Oral Aversion in the Breastfed Neonate
Linda Killion Healow, BSN, IBCLC and Rebecca Sliter Hugh, IBCLC
from Breastfeeding Abstracts, August 2000, Volume 20, Number 1, pp. 3-4.
Infants are incredibly oral creatures. Not only is the mouth the preferred route of caloric nourishment (although essential in some circumstances, gastric feeding tubes and IVs are less-than- ideal substitutes), but it is also the way newborns most acutely sense and come to know their new environment. Infants' mouths can make sounds to let their needs be known. The mouth serves to satisfy hunger and thirst. The simple act of suckling can relieve newborns' tension and calm their fears. The gratification and safety an infant feels when suckling is immense. Newborns' mouths are their first consistent avenue to access extrauterine bliss. Mobbs states, "The mouth is the most sensitive organ and the one over which the infant has the most control."1 As needs are met, a budding mastery over the environment emerges, and newborns learn that the world is a good place and they are safe. Thus, newborns' mouths provide the key first step to learning about love and trust.
The oral experience is also an integral part of how the newborn learns to recognize his or her mother. As Ruth Lawrence observes, "Comfort sucking and formation of nipple preference are genetically determined behaviors for imprinting to the mother's nipple. The recognition of the mother is at first through the distinctive features of the nipple. Although imprinting is multisensory and varies from species to species, it is oral/tactile for the human and other higher mammals."2 Thus newborns' mouths are "virgin" territory. Although the fetus experiences taste and possibly finger sucking in utero, nothing "foreign " enters the mouth before birth. A noxious oral experience in the early days of life is likely to leave a more damaging impression than a similar experience taking place later in a baby's development. Based on clinical observations, Klaus and Kennell state that "affectional ties can be easily disturbed and may be permanently altered during the immediate postpartum period."3 Widstrom found that gastric suction disrupted prefeeding behavior in healthy term infants.4 In addition to the introduction of an object into the mouth, other sensory experiences may also be harmful. Herbst has shown that taste, odor, and visual stimuli all have an effect on suckling.5 Because of this, a newborn's mouth and feeding behavior must be treated with the utmost respect. While procedures such as inserting a feeding tube or suctioning a newborn may be necessary to provide quality health care, they are, nevertheless, invasive. And while any oral intervention is less than ideal, a procedure that is roughly done, however inadvertently, qualifies as an invasion. Some lactation consultants, faced with the challenges of persuading justifiably reluctant newborns to take the breast, have described this type of oral invasion as akin to rape.
One consequence of any type of poorly tolerated oral contact can be oral aversion, also referred to as oral-tactile hypersensitivity.6 This outcome is a very real possibility when a baby's mouth has been traumatized. Wolf and Glass state that oral-tactile hypersensitivity and aversive responses can be caused by immaturity and illness, delayed introduction of oral feeding, and by unpleasant oral-tactile experiences.6 Oral aversion leaves the baby in actual danger. An infant with oral aversion may not take anything into the mouth;not the breast, a pacifier, bottle nipple, spoon, or finger. Some infants also will not tolerate anything touching their lips, such as a cup. Infants with an aversion response go through a period of relative oral deprivation until the aversion subsides. This is a serious situation, and an ounce of prevention is worth far more than a pound of cure. The infant's oral aversion may also adversely affect the mother's perception of her abilities. The infant's strong negative response to oral stimuli may lead the mother to feel that her baby is rejecting her. The intricate bonding feedback process in which mother and newborn learn to recognize each other via oral, tactile, and olfactory modes is short-circuited. Klaus and Kennell note that these disruptions to mother-infant bonding may affect the mother's behavior for the first year of the infant's life, even when the infant's aversive behavior has ceased.3
Oral aversion and the potential for maladaptive imprinting are rarely discussed in conjunction with infant feeding and newborn care. However, in many cases the development of oral aversion can be prevented. One of the most common practices newborns encounter immediately following delivery is suctioning of the airway. NICU nurses have identified suctioning as noxious and possibly painful because it involves potential tissue damage and often elicits responses that resemble pain. 7 In one study of low birthweight babies, 75 percent of infants displayed all 4 of the specified signs of pain when suctioned, and 100 percent of the infants displayed 3 of 4 signs of pain.7 In newborns, any oral discomfort may cause an aversion to subsequent stimuli touching the mouth or lips, possibly causing more pain.6
Lawrence notes that aggressive suctioning may be related to the development of conditioned dysphagia. Conditioned dysphagia is learned, acquired, and maintained when a negative stimulus is associated with the act of swallowing.15 The diagnosis of conditioned dysphagia may be difficult to make and requires thorough testing, which may in turn aggravate the problem. The neonate may have negative responses to the taste of a barium swallow or invasive exams.8 Intubation for diagnostic study has the potential to cause damage to the infant's delicate anatomy, causing pain-related responses to oral stimuli or dysphagia.7,9 Aggressive suctioning and nasogastric feeding tubes in the NICU have also been associated with conditioned dysphagia.2 Birth history is highly relevant.
In addition to suctioning of the newborn airway and naso-or orogastric feeding tubes, other potential causes of oral aversion include gastric suctioning, inappropriate use of rubber nipples, and the inappropriate use of fingers in finger feeding, assessment of the newborn's mouth, and in attempts to alter sucking motion. In some cases, it is not possible to avoid interventions at birth that involve the baby's mouth. Some infants do need suctioning to open the airway and/or intubation to initiate and sustain respiration. Infants born prematurely or with congenital anomalies are unavoidably at an increased risk of developing oral aversion because of the many procedures necessary for life support. Infants with feeding difficulties whose mouths must be checked carefully for physical anomalies are also at risk. If suck assessment is indicated, the evaluation should be performed by a practioner specifically trained in this procedure, as this again is a situation where an object other than the mother's nipple is being placed in the baby's mouth.
The evaluation, assessment, and treatment of feeding difficulties in newborns all carry the potential of exacerbating the problem. For instance, in some hospitals finger cots must be used for finger feeding an infant. Infants do not always respond well to the taste and feel of rubber in their mouths, and thus reject this feeding method.10 Other artificial methods of feeding may also meet with rejection due to taste and feel.6 Infants may also reject the taste of certain fluids such as artificial baby milks or glucose water.5
Supportive breastfeeding protocols such as the Baby Friendly Hospital Initiative and the American Academy of Pediatrics' policy statement "Breastfeeding and the Use of Human Milk" recommend early initiation of breastfeeding, uninterrupted feedings, and avoidance of artificial nipples and procedures that have the potential to traumatize the infant, in particular, the oral cavity, esophagus, and airways. 11, 12 Adherence to these recommendations would greatly decrease the occurrence of oral aversion. The potential for problems is decreased by allowing the infant to establish suckling first at the breast, not on a finger, pacifier, or artificial nipple. Many studies have demonstrated a negative impact on the initiation and duration of breastfeeding when artificial nipples, pacifiers, and finger sucking are introduced early in life.13,14
The cardinal rule of medicine is "first, do no harm." Procedures considered routine in some facilities, such as suctioning, supplemental feeds, and introduction of pacifiers or dummies, have proven to be not as risk-free as is widely assumed. Not only do these procedures have a potential negative effect on breastfeeding initiation and duration, they may in fact cause real harm to the baby or in some cases prevent successful breastfeeding.
Fixing a problem once caused may be difficult and costly. The cost of a lost breastfeeding relationship cannot be measured in dollars alone or even in days of hospitalization. It may have long-term negative emotional, developmental, and health effects on both mother and baby.
Linda Killion Healow lives in Billings, Montana, where she works privately as a nurse/lactation consultant. She is a long-time La Leche League Leader and coordinator of continuing education events for La Leche League International and the United States Western Division of LLL.
Rebecca Sliter Hugh, editor of BREASTFEEDING ABSTRACTS , is a lactation consultant in Geneseo, Illinois, a long-time La Leche League Leader, and a frequent continuing education speaker.
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