Conditioned dialling up with breastfeeds: diagnosis + management

What are the diagnostic signs of a conditioned dialling up at the breast?

Sometimes, the mother can identify a particular feed when a helper used force to bring the baby on, and from then on the baby dialled up at the breast. Often, the mother has been worried about the baby's milk intake or weight gain, and has been accidentally coercing the little one to the breast. Also very commonly there is an underlying positional instability, which may explain the initial breastfeeding problems that the mother has been trying to deal with.

Conditioned dialling up with the breast occurs as a pattern of infant behaviour over time. The infant shows one or more of the following signs:

• Dials up when mother lies baby back to come to the breast

• Dials up as mother brings baby to the breast

• Dials up when in contact with the breast

• Dials up and pulls off after a short time at the breast

• Dials up and pulls off regularly throughout a breastfeed

• Frequently back arches whilst breastfeeding or whilst coming off the breast

• Remains dialled up at the end of the breastfeed instead of having dialled down with the breastfeed.

Management of a mother-baby complex adaptive system when baby has a conditioned dialling up at the breast

Please find out about management of a baby with conditioned dialling up at the breast, and what doesn't usually work, here. This article is currently in the parent-facing BSB section of this module.

NDC verbal scripts for helping a breastfeeding woman whose infant has a conditioned dialling up at the breast

Script 1

"Human babies want to breastfeed. Even when your baby has developed a conditioned dialling up (sometimes referred to as breast aversion or breast refusal), it's not that your baby actually hates breastfeeding, though it can seem that way. A love of breastfeeding, a powerful drive to breastfeed, is hardwired into your baby's nervous system for many months after the birth.

"It's the other way around, actually. The longing to breastfeed is so intense, so ancient, so powerful, that when things don't go well, your little one can develop a habitual (or conditioned) sensitivity or distress at the breast. In this situation, the sympathetic nervous system is conditioned to dial up so high at the breast that it overrides the powerful drive to suckle from the breast.

"It's not uncommon for a baby with conditioned dialling up with the breast to start crying the minute you even lie your little one back and begin undoing your bra. This can be terribly upsetting!"

Script 2

This story is told in the third person, as we are demonstrating our complete understanding of what might have been happening for the parents to be using pressure or even some force with feeds (without using the word force). We are normalising their response. This is extremely sensitive matter for parents, who can't bear to think they've been forcing feeds or forcing the breast onto the baby in a way that has caused a conditioned dialling up - and yet this is commonly the case. We want to normalise this so much, that the woman or parents feel that they can identify has having done this without incurring any judgement from you, as their health professional, or indeed their own inner critic.

"The upset feelings that accompany weight gain worries can be incredibly powerful. It's as if our mind is hardwired, from an evolutionary point of view, to tell us: "If my baby doesn't feed, my baby's going to die." This is why it's normal for a breastfeeding mother whose baby has weight gain worries, or isn't breastfeeding well, to find herself accidentally trying very hard to persuade her little one to feed.

[You might act this out a little.] "She might find herself saying: 'Come on sweetheart, you need to keep going, you need to get more milk in or you won't grow (or you won't sleep, or you'll get sick - whatever it might be that you guess the woman's mind is telling her.)' 'Come on darling, let's try again. Take a little bit more.'

"But unfortunately, quite unexpectedly, this can backfire with some babies, and actually make them more likely to dial up with breastfeeds."

Script 3

"Your little one has become very sensitive at the breast. Another baby probably wouldn't have reacted in this way, but your little one for whatever reason right now has become very sensitive with breastfeeds."

A nipple shield might help when the baby has conditioned dialling up at the breast and has been using the bottle

Sometimes a nipple shield can help in this situation, particularly if it is severe. Make sure though that the shield is not simply compensating for breast tissue drag and positional instability. You can find comprehensive steps for management of a conditioned dialling up at the breast here.

But if a baby has become accustomed to taking milk from a bottle, and has a conditioned dialing up at the breast, the shield mimics the bottle teat and can be a very helpful way to help a baby with a conditioned dialing up remember that the breast is the loveliest place to be, at the same time as the breastfeeding woman works with fit and hold.

In a case like this, returning to the breast or enjoying breastfeeds is a wonderful outcome for the mother and her baby, which as a clinician we need to facilitate as quickly as possible to avoid worsening of the conditioned dialling up. A nipple shield can prove to be a very positive aid in this situation.

The mother may be able to stop the shield use down the track, but many women very happily breastfeed indefinitely using the shield. The most important thing is that she and her baby grow many experiences of dialled down enjoyable and effective breastfeeding. Weaning off the shield is not something to think about until much further down the track. Trying to hasten weaning off the shield can worsen a conditioned dialling up which has only just settled down.

You can find out about nipple shield use here (under development).

Recommended resources

You can find out about conditioned dialling up as a novel concept developed in NDC's neurobiological model of infant crying (2013) here.

Conditioned dialling up in the first 16 weeks of life

When does a baby have a conditioned dialling up with the bottle and what to do about it?