When breastfeeding is not going smoothly, most mothers seek help. By the time a breastfeeding pair—mother and infant—comes to see me in my office, they have usually already seen several health care practitioners: the pediatrician in the hospital, their own pediatrician, the nurses in the hospital, and one or more lactation consultants. Often, the mother reports having received large amounts of conflicting information. She tries to follow all of the instructions and advice, but there is still a problem. Or, sometimes, the mother struggles through long feedings and pain, but is told that everything is fine because the baby is gaining weight. If a mother complains that her baby is frustrated at the breast and causing her pain with nursing, telling her everything is “fine” or advising her to “to wait it out” or “just give the baby a bottle” will set her up for failure.

This chapter describes how to use a detailed medical and breastfeeding history to evaluate a mother—infant pair. This is the first half of the evaluation. Chapter 6 describes what to look for in a physical examination. Taken together, these two chapters provide health care providers—especially those on the front lines—with a thorough understanding of what portions of an evaluation are necessary and sufficient in assessing whether breastfeeding is working correctly so that timely intervention can be offered.

As with medicine in general, most of the diagnosis of a problem with breastfeeding comes from the history, with confirmation coming from the clinical examination. A physical exam alone cannot predict success or failure of breastfeeding because there are three exams—the mother/breasts, the baby, and the two of them together. For breastfeeding to succeed, the baby and the breast have to lock together in a very specific way. External observation alone, such as watching a baby nurse, cannot indicate a “good latch,” since we can’t observe what is happening inside the infant’s mouth.

The questions listed here are meant to be comprehensive enough to provide a clear picture of the state of breastfeeding. It’s important to note that eliciting too much information can be confusing to a practitioner and new mother alike. For example, mothers often keep detailed diaries of feeding times and length of feedings, but they have no sense of how much the infant is actually drinking. Similarly, it is not enough to ask whether a baby is gaining weight. It is also important to know how that weight gain is being achieved. If a baby must nurse every hour in order to gain weight, there is a breastfeeding problem that must be addressed.

NOTE: This Breastfeeding History questionnaire is a tool for the health care provider, not a form to be completed by the mother in isolation. It should only be used to guide the clinical evaluation conversation.

How old is the baby?

This first question sets the context for all questions that follow. When it comes to breastfeeding, the infant’s age is everything. How a baby behaves at 1 week is very different from how he will behave at 4 or 11 weeks.

During the first week, every day can be different, but patterns can develop as quickly as 2–3 days. The most variation in breastfeeding happens in the first 4 weeks. Because the baby’s stomach expands as the mother’s milk supply increases, there can be periods of catch up when the baby cluster feeds. The baby can also be sleepy at first and not hungry because they retained extra fluid from birth and produce extra cholecystokinin (CCK), so they do not wake up to nurse on a regular schedule. In very efficient nursers and if mothers have a large milk supply, nursing times can be shorter but just as efficient. The optimal nursing schedule is 10–15 min of nursing on each breast every 2–3 h. Even if the baby does not feed every 2–3 h, the mother should be emptying her breasts with a pump at least this often during the first 4 weeks so her breasts can meet their milk making potential.

Conversely, just because a baby is breastfeeding and gaining weight at age 4 weeks, that doesn’t mean that all breastfeeding issues have been resolved. Frequent, prolonged feedings with current or resolved nipple pain means the baby has an inefficient latch. If the mother has a large or oversupply, she can compensate during the first 6–10 weeks because her milk production is regulated by her hormones. There will be a waning effect, however, and her supply will slowly decrease over time. After 6–10 weeks, milk production transitions to local control by breast emptying and removal of FIL. So if the baby has an inefficient latch when the mother has oversupply, the negative effects are often not noticed until much later, sometimes when it is too late. In these circumstances, babies often go on “feeding strikes” and refuse the breast concurrent with the mother losing her supply. The mothers might have thought everything was fine because the baby was gaining weight, but when questioned about the experience of breastfeeding, it’s simple to see that the clues to a problem were there all along.

How was the birth experience? Did the baby spend time in the NICU?

Does the baby have any medical problems?

Was the baby premature?

Is the baby a twin?

The answers to these questions are often interrelated, so they will be considered as a group.

The birth history is important not merely for the physical effects it has on the baby. The medications used and the type of birth can impact or delay lactogenesis. Ahluwalia et al. (2012) studied the relationship between breastfeeding and method of delivery using data from the Longitudinal Feeding Practices Study (n = 3026). They compared rates of breastfeeding (to any degree, not just exclusive) in spontaneous vaginal, induced vaginal, emergency cesarean, and planned cesarean. They found no significant association between delivery method and the initiation of breastfeeding. However, there was great variation in breastfeeding duration depending on delivery method. According to the article, median breastfeeding duration was 45.2 weeks among women with spontaneous vaginal, 38.7 weeks among planned cesarean, 25.8 weeks among induced vaginal and 21.5 weeks among emergency cesarean deliveries (Ahluwalia et al. 2012).

Vaginal birth can result in deformities in the skull, as with vacuum or forceps deliveries, or from the skull bones overlapping to fit through the birth canal. This can affect the movement of the skull structures and/or create compression of the hypoglossal nerve at the craniocervical junction (see Chap. 7, Cranial Osteopathy section for more information).

Cesarean section delivery is a known risk factor for delayed breastfeeding and possibly a 10–20 % reduced overall rate of breastfeeding (Zanardo et al. 2010; Dewey et al. 2003; Rowe-Murray and Fisher 2002). One study (Kutlucan et al. 2014) found that general anesthesia caused an increase in post-birth prolactin in the mothers, and also delayed initial latch because of the need for maternal recovery. Similar delays were found by Zanardo et al. (2010). Post birth oxytocin levels were highest in vaginal births, and there was no delay in breastfeeding with epidural or spinal anesthesia. At one time, breastfeeding post-anesthesia was delayed for 12–24 h, but Kranke et al. (2011) demonstrated that a single dose of common anesthetics results in “vanishingly small” concentrations in colostrum compared to transplacental exposure. They found no reason to delay breastfeeding once the mother is sufficiently awake. The American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) concur (American Academy of Pediatrics 2013).

Traumatic or prolonged birth can result in maternal exhaustion, which may delay nursing. Babies who spend time in the NICU also often have a delay in nursing. Anemia, retained placenta, and post-partum bleeding or hemorrhage can also compromise lactation.

Intrapartum pain medications can make breast milk unsafe for babies, but it can also have a sedative effect on the infant. In the United States, 83 % of mothers receive labor pain medications. Lind et al. (2014) showed that 23.4 % of mothers in the study who took these medications experienced a delay of lactation of more than 3 days, regardless of delivery method.

A note about pain medications: Meperidine is lipophilic and has a long half-life in newborns, so it can accumulate. Morphine is also transferred to milk, but less so because it is hydrophilic. Nalbuphine and butorphanol both have low excretion in milk and a short half-life, so they are preferred.

Postpartum pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, are considered safe because extremely low amounts are secreted into breast milk. (Aspirin is an exception because infants cannot secrete it quickly—it should not be taken by nursing mothers.) Oral narcotics are considered compatible with nursing at the lowest possible dose and for the shortest possible duration, usually less than 3 days (American Academy of Pediatrics 2013). However, Madadi et al. (2009b) developed guidelines for maternal use of codeine during breastfeeding, arguing that newborns are more sensitive to opioids than older infants. Also, some women are hypermetabolizers of codeine so their body converts 20 % of it to morphine (as opposed to 7–10 % by normal metabolizers). Hydrocodone is a safer alternative because it is metabolized through a different pathway (Hale and Rowe 2014).

Maternal exposure to oxycodone has been shown to result in 20 % rate of CNS depression in infants (Lam et al. 2012), resulting in a very sleepy baby with limpness and poor weight gain. Usually the CNS depression symptoms are most obvious at day 4 of codeine use and continuous nursing (Madadi et al. 2008, 2009a). The mother herself will have CNS depression symptoms that correlate strongly with her infant’s symptoms (Madadi et al. 2009a). Also, since opioids decrease the mother’s pain, she may not seek to correct a painful latch until the medication wears off.

Signs of neurological impairment are not always obvious at birth. Sometimes the process of trying to nurse makes the impairment apparent. The baby cannot seem to coordinate his tongue movements with swallowing. He cannot form a seal on the breast or bottle. He doesn’t seem to exhibit early hunger cues or reflexes. The whole process of feeding is difficult no matter what the source (bottle, breast finger, etc.). These babies are special cases and need proper evaluation by a feeding specialist.

If the baby was premature, then consideration should be given to the gestational age of the baby. Preterm babies may not have fully developed nursing reflexes (Smithers et al. 2003). However, one of main barriers to breastfeeding preterm infants is lack of breast milk (Callen et al. 2005), because the mother’s breasts may not have had enough time to develop sufficient glandular tissue (Lactogenesis I). In addition, the mothers’ brains may not be secreting prolactin and oxytocin in amounts that are beneficial and necessary for breastfeeding.

Twins are often born premature, and require more milk from the mother and more time to nurse two babies. They can also provide an excellent comparison, if one twin seems to be nursing more effectively than the other.

Does the baby have appropriate weight gain?

How many wet/soiled diapers does the baby make a day?

Has the baby experienced dehydration or jaundice?

How long does the baby take to nurse at each feeding?

How often does the baby nurse in a 24-hour period?

After nursing, do you have reason to believe that the baby is still hungry?

This set of questions is about quantifying and qualifying the baby’s experience at the breast.

Most health care providers focus on weight gain alone as a measurement of successful nursing. If the baby is gaining weight, it is assumed that everything is “fine.” If a baby is not gaining weight, then the mother is told either to supplement with formula or to nurse more often to improve the baby’s weight gain. But these suggestions can result in poor outcomes if they are presented without a complete look at the baby’s breastfeeding history.

A baby’s weight gain is a result of the whole process of nursing. It takes into account the mother’s supply and the baby’s willingness and ability to transfer milk from the breast. The process should be effortless for the baby and painless for the mother. It should also happen in quick bursts that are adequately timed so maternal hormonal and local regulators can work in sync with breast emptying. If it takes the baby an hour to nurse and he is hungry an hour later, or if the mother is having pain with nursing, it is lucky that the baby is gaining weight. It is never normal for a baby to nurse every hour. It is also not normal for a baby to nurse for long periods of time and remain hungry, even during the first few days when there is only colostrum. In these situations, either the mother is not making enough milk, or the baby cannot transfer the milk from the mother’s breast, or both. These are early indications of a problem that could eventually lead to breastfeeding failure.

During the first month, babies should nurse an average of 10–15 min every 2–3 h. They may nurse more frequently in the first week in the early morning hours between 3:00 am to 9:00 am. (No one knows exactly why this happens, but maternal hormone regulation follows this pattern early on, as well.) They may go for longer periods without nursing later in the day, but feedings should average out into that pattern, which equates to 8–12 feedings in each 24-hour period.

After the first month, the baby’s stomach stretches to hold more milk. Once this happens, the baby can take more milk from the breast with each feeding, and may therefore nurse less often. As the baby drains more from the breasts, the mother’s milk supply grows to meet the extra demand. As time goes on, babies become more efficient nursers, so they may actually nurse a shorter amount of time while getting more milk at each feeding.

The cadence of output is another crude measure of intake. Mothers are often told to count the number of wet diapers, which, with today’s highly absorbent diaper technology, can be misleading. These diapers are so absorbent that it takes a lot of output to make them appear wet. Soiled diapers should occur 3–4 times a day in the first few days and increase as the days go on, They should progress from seedy yellow to dark and soft in consistency. Hard stools may mean dehydration, and runny stools may mean excess foremilk and oversupply with inefficient milk transfer.

Jaundice and dehydration are also indicators of poor intake. Usually these problems are a result of infrequent nursing, but not always. Jaundice will be easily recognizable as the infant’s skin and eyes take on a yellow color. Dehydration can result in a sleepy baby and excessive weight loss. Recommendations are often made to increase the frequency of nursing, assuming it will increase intake. However, if a baby nurses continuously and develops jaundice or dehydration, that indicates a problem with milk production, transfer, or both.

Can he/she open her mouth wide to latch on?

Gape is always mentioned but never fully discussed in breastfeeding literature, yet it is the single greatest cause for failure to latch.

At birth, babies gape as wide as they possibly can. They must be able to gape so wide that they almost dislocate their jaw to fit as much breast tissue in their mouths as possible. If the gape is not there at birth, it will not magically appear, stretch, or grow without intervention or specific positioning. The problem is not due to a “small mouth,” and babies will never develop a wider gape on their own.

A small gape will always result in a shallow latch. If a baby cannot open his mouth wide enough, the breast (teat) cannot “lock” into position at the back of the baby’s throat, and the palate will not fill with sufficient breast tissue to elicit a normal suck reflex. With a small gape and shallow latch, the baby has to work much harder to transfer milk and sometimes cannot transfer milk at all. The tongue sometimes cannot reach the palate to sufficiently compress the breast tissue. As a result, the nipple gets caught in the front of the mouth, where the suck reflex causes abrasion and damage because the nipple moves around in the baby’s mouth.

Even first-time mothers can identify a small gape as a problem, especially when they try (and fail) to follow the recommendations of breastfeeding guidebooks and lactation consultants. Mothers are often told to hold the baby’s jaw down or flip the upper lip up to artificially create a gape. They are also taught different breast compression methods or ways to hold the baby to encourage him to get as much breast in the mouth as possible, with variable success.

Conversely, a baby with a wide gape can fit almost any shaped breast into his mouth. Some women have nipple shapes that fit more easily to many different mouth openings. I once had a mother claim that, although her baby was unable to latch successfully onto her breasts, he was able to easily nurse on her friend’s breasts. Which brings us back to the notion of fit. The mother’s breast must fit her baby’s mouth. We cannot change the shape of the breast, but now there are safe interventions to release the structures of the infant’s mouth so that the baby can reach the appropriate gape. This will be discussed more in Chap. 7.

How does the baby behave at the breast?

Is he/she fussy?

Does he/she fall asleep often?

Does he/she get frustrated?

Does he/she fall off the breast and need re-latching?

Does he/she reject the breast (i.e. nipple confusion)?

The baby’s behavior at the breast provides valuable clues to breastfeeding problems. He should exhibit early hunger cues, such as turning toward the breast, increased alertness, flexion of the extremities, rooting, cooing, and putting his hands and fingers in his mouth. Babies that cry to be fed, especially in a panicked state, are likely working too hard for their food and feeling too hungry. If they are working too hard, usually from a poor latch and/or low supply (which go hand in hand), they will become frustrated at the breast. They will latch and relatch. They will fall off the breast and require repositioning. They may get so frustrated they hit the breast and cry even when brought near it.

One common and damaging myth is that the mother’s temperament or behavior is the cause of the baby’s frustration. A mother of a frustrated baby is often told that she is transferring her own stress to the baby, that she is overthinking nursing and therefore hindering the baby’s reflexes and natures course. It is not that simple. In some cases this may be true, but it is rare. The baby is usually frustrated because he cannot latch. If the baby can’t latch, there will be frustration for both mother and baby. Since poor latching and frequent relatching usually also causes maternal pain or a feeling that her baby is rejecting her, the mother can develop a negative association with nursing her baby, so her stress does feed back to the baby. Do not underestimate the pain and suffering a mother will endure to nurse her baby. Encouraging her to continue through the pain and blaming her for her baby’s frustration is not only cruel, it is setting her and her baby up for failure in the long run because it is not correcting the underlying problem.

Babies do not inherently reject their mothers, but there are instances where the baby won’t latch on at all. No one knows why this happens. In my experience, it is mostly because babies cannot gape wide enough to latch. If the gape is corrected early enough, the baby’s reflexes can be used to get them back onto the breast. It can be corrected later as well, and I have had 6- and 7-week-old babies latch for the first time after the gape was corrected. But the earlier the problem is addressed the better.

A common scenario that can develop when babies are frustrated at the breast is nipple confusion or aversion. Here’s a common scenario for how that can happen: The baby tries to nurse at the breast immediately at birth, but cannot latch on efficiently. He nurses every hour for the first few days. After several days, he falls off the breast easily and has to relatch often, sometimes screaming and hitting the breast. It can take hours of struggling to latch the baby on, and once he does latch, he falls asleep from exhaustion after a few sucks. The mother or health care provider may interpret this behavior as breast rejection or colic. The mother may feel as if her baby is rejecting her and her milk, but what is really happening is the baby cannot transfer milk from the breast. The baby is given a viable food source but is unable to get the food out, leading to frustration. It’s common for babies to simply give up due to conditioned behavior after continually being offered an inaccessible food source. The baby “learns” that his mother’s breast will not feed him.

If the baby is quickly given an easy food source, such as a bottle, he will become further conditioned away from the breast. This situation is often called nipple confusion, but it is really breast aversion. Studies trying to define nipple confusion or breast aversion are inconclusive and offer little insight to health care providers because the mechanism of causation is not well understood or defined in the literature. Regardless, alternative feeding methods, other than the bottle, are frequently recommended (Neifert et al. 1995). In truth, it doesn’t matter what the easy food source is, only that it is not the mother’s breast. Nothing else feels or smells like a mother’s breast. Spoon, finger, cup or syringe feeding may prevent the baby preferring the bottle, but they won’t make the baby any more or less averse to the breast. I once had an infant patient who would only finger feed. She rejected all other food sources, including a bottle, because she had learned what fed her. She was not confused at all. If a baby smells his mother and is able to transfer milk from the breast, he will prefer her as a food source. If he smells his mother but is unable to transfer milk, he will learn a negative association, sometimes as quickly as the first day of life (Neifert et al. 1995).