Breastfeeding the Hypotonic Infant

Publication Date: January 1, 2016
Last Updated: March 14, 2022


Prenatal care

Healthcare providers should encourage all mothers to breastfeed, whether the infant has a high risk of hypotonia or not. Encouragement can make a significant difference as to whether a mother decides to breastfeed or not. (, )
(II-2, II-2)
A breastfeeding history should be obtained as part of prenatal care, and identified concerns and risk factors for breastfeeding difficulties should be communicated to the infant’s healthcare provider(s). (III)
If it is known during pregnancy that the infant will have hypotonia, mothers should be referred to breastfeeding medicine specialists and/or lactation consultants with expertise with hypotonic infants. (, )


  1. All mothers should be educated about the advantages for themselves and their infants of breastfeeding and of providing human milk. A significant proportion of hypotonic infants can feed at the breast without difficulty.
  2. Infants with hypotonia should be followed closely both before and after discharge from the hospital to assess further needs.
(, )

Facilitation and assessment of feeding at the breast in the immediate postpartum period

The first feed should be initiated as soon as the infant is stable. There is no reason this cannot occur early, for example, in the delivery room, if the infant is physiologically stable. Extra support and supervision may be required. (, )
Kangaroo (skin-to-skin) care should be strongly encouraged. As with all infants, when infants with hypotonia are being held skin-to-skin, care should be taken to ensure the mother is fully awake and infant’s face is visible and airway remains open. If the infant does not feed well, the touching may be stimulating so that the infant is easier to arouse for feedings. Skin-to-skin care has also been shown to help increase mother’s milk supply, and, in addition to eye contact and touching, can assist with bonding that may be especially important for these families. (, )
(II-2, II-2)
Assessment of the infant’s ability to latch, suck, and transfer milk should involve personnel specifically trained in breastfeeding evaluation and management. (, )
For attempts at breastfeeding, particular attention should be given to providing good head and body support for the infant since he/she needs to spend effort sucking, not supporting body position. Use of a sling or pillows to support the infant in a flexed position allows the mother to use her hands to support both her breast and the infant’s jaw simultaneously (Dancer hand position). Skin-to-skin contact will facilitate frequent attempts at breast. (, )
The ‘‘Dancer hand’’ position (Fig. 1) may be helpful for the mother to try as it supports both her breast and her infant’s chin and jaw while the infant is breastfeeding. The mother cups her breast in the palm of her hand (holding her breast from below), with the third, fourth, and fifth fingers curling up toward the side of her breast to support it, while simultaneously allowing the infant’s chin to rest on the web space between her thumb and index finger. The thumb and index finger can then give gentle pressure to the masseter muscle, which stabilizes the jaw. In addition, pulling the jaw slightly forward may allow the infant to better grasp the breast and form a seal. The other hand is free to support the infant’s neck and shoulders. (, )
(II-2, II-2)
Other strategies to help the infant latch and transfer milk may also be effective. Some mothers facilitate milk transfer by using hand compression in conjunction with breastfeeding. Instead of placing the thumb and index finger on the infant’s jaw for support (Dancer hand position), the fingers are kept proximal to the areola, and milk is hand expressed as the infant suckles. A thin silicone nipple shield may be useful if milk production is generous (>500 mL/day) and mothers learn how to keep the reservoir filled by synchronizing breastfeeding with hand compression or using a nursing supplementation device simultaneously inside the shield.
By making the mother aware of various techniques, aids, and ideas, she can experiment and discover the best ways to fit her and her infant’s individual needs.
More time may be necessary in the early weeks to complete a feeding. Mothers, and the family that supports them, should also know that in many cases the infant’s ability to feed will improve over the first weeks to months. (, )
Trained personnel should reassess the infant frequently (a minimum of once every 8 hours) as these infants must be considered at high risk of breastfeeding difficulties, similar to the late preterm infant (see ABM Protocol #10: Breastfeeding the Late Preterm Infant). Encourage frequent breastfeeding throughout the day as the ability to sustain suck may be impaired. Infants should go to breast as often as possible, aiming for at least 8 to 12 times per 24 hours. Prolonged periods of skin-to-skin contact will facilitate these frequent attempts at breast. Assessments should include state of hydration and jaundice to identify possible complications of poor oral intake. (, )
Once transitional milk is present, test weighing with an appropriate digital scale may be an option to assess adequate milk transfer for these infants. Infants are weighed immediately before the feed on an electronic scale with accuracy at minimum ±5 g, and then reweighed immediately after the feed under the exact same circumstances: diaper (nappy), clothing, blankets, etc. Intake during the breastfeed is reflected by weight gain, 1 g = 1 mL. Infants with Trisomy 21 may gain weight more slowly than normal full-term infants. New growth charts for infants with Trisomy 21, introduced in 2015, are designed to more accurately reflect normal growth for these infants. (II-3, )
Consider alternative modes of feeding such as a cup, spoon, or syringe, if the infant is unable to breastfeed or sustain adequate suckling. The use of a nursing supplementation aid alone (without a nipple shield) may not be as helpful, as it works best with an infant who has an effective latch and infants with hypotonia often have difficulties with latch. (I, )
If supplementation is necessary, see Academy of Breastfeeding Medicine Protocol #3 (Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Infant). If the infant is attempting to suckle, follow each breastfeeding encounter with breastmilk expression and then feed expressed milk to the infant by spoon, cup, or other device. This provides more stimulation to the breasts and more milk to the infant. (, )
At times, some of these infants may have issues with dysphagia and aspiration of feedings of any type. There is some evidence that thickening of feedings in these circumstances can decrease the risks. Close communication with the team managing these feeds is crucial for the breastfeeding mother who will be providing breastmilk to be used with the thickening substance. (, )
(I, III)

Preventive measures to protect a milk supply

If the infant is unable to successfully and fully breastfeed, or if the mother is separated from her infant (e.g., NICU admission), lactation should be initiated and/or maintained through milk expression by hand or pump.
  • Mothers should be encouraged to express milk shortly after the birth, ideally within the first hour, and approximately every 3 hours thereafter.
Older recommendations suggested expressing within the first 6 hours of birth. (II-3)
The mother should aim to remove milk at least eight times in a 24 hour period, mimicking the stimulation of a vigorous term breastfeeding infant. Even if the infant shows some ability to go to breast, latch, and transfer milk, the mother will benefit from expressing extra milk in the early weeks to build and maintain her milk supply.
Most of the research on initiating and maintaining milk supply by expressing milk has been conducted on mothers of preterm infants. The strongest determinant of duration and exclusivity of breastfeeding the preterm infant is the volume of milk produced by the pump-dependent mother, whereas insufficient milk production is the most common reason for cessation of efforts to provide milk for these infants. (, )
(II-3, II-3)
As milk transfer begins to improve with the infant developing sucking rhythms, and showing feeding cues, expressing can be tailored to these signs (i.e., breast emptying by expression after each attempt at breast). This pattern should continue until the dyad is reunited and/or the infant is able to sustain full breastfeeding. It is critical that mothers be instructed on effective milk removal, including expressing with the use of a hospital-grade electric pump, if available, and hand expression.
  • Combining mechanical pumping and hand expression can increase both milk volume
  • and the caloric content.
Extrapolating from preterm research for guidance in feeding the hypotonic infant, breastmilk production of 500 mL/day is commonly cited as the minimum volume enabling premature infants of less than 1,500 g to transition from tube or bottle feeding to successful, exclusive breastfeeding. (III)
Until studies are done in infants with hypotonia, this is a minimum volume from which mothers can start to reduce any supplementation and can be adjusted based on calculations of intake necessary for growth.
When an electric breast pump is used, simultaneous expression of both breasts with a hospital-grade pump is more effective than single breast expression. Hand expression while pumping improves expressed milk volume and milk caloric content in pump-dependent women. Thus, in contrast to the usual practice of passively depending on the pump to remove milk from the breast, hand expression, massage, and compression, used in conjunction with mechanical expression, enable mothers to enhance breast emptying. (, )
(II-2, I)
Mothers should consider keeping an accurate expressing/feeding log to enable her and her healthcare providers to track milk supply and intervene if there is concern about milk volume. (III)

At discharge and in the neonatal period

If the infant remains hospitalized, the mother’s milk supply should be assessed daily. That assessment should include time at the breast, expression frequency, 24 hour milk total by expression, and any signs of breast discomfort. The infant’s weight gain should be carefully monitored and supplementation considered as necessary. (, )
Monitor the length of breastfeeds (e.g., limit to 1 hour) to ensure the infant is not becoming overtired from feeding. (, )
Inform mothers that sucking efficiency frequently continues to improve over the first year, so that the breastfeeding experience may ‘‘normalize’’ and expressing, supplementation, diary keeping, and other interventions may no longer be necessary. (, )
If breastfeeding does not continue to improve, assess the infant for other causes of breastfeeding difficulties (e.g., ankyloglossia). (, )
Provide information about local support groups for breastfeeding and for specific diagnoses such as Trisomy 21. Because of the additional patience and time that are sometimes required to breastfeed these infants, support and encouragement are particularly important for mothers and families. (, )
If maternal milk supply does not equal or exceed the infant’s needs, or begins to slow despite optimal breastfeeding and/or expressing, the use of galactogogues to enhance maternal milk supply may be considered. See Academy of Breastfeeding Medicine Protocol #9 (Use of Galactogogues in Initiating or Augmenting Maternal Milk Supply).
Supplementation with pasteurized donor milk is an option if supplementation becomes necessary and donor milk is available.

Recommendation Grading



Breastfeeding the Hypotonic Infant

Authoring Organization

Publication Month/Year

January 1, 2016

Last Updated Month/Year

August 1, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

To promote, support, and sustain breastfeeding in infants and young children with hypotonia.

Target Patient Population

Mothers breastfeeding hypotonic infant

Inclusion Criteria

Female, Male, Adult, Infant

Health Care Settings

Ambulatory, Home health, Hospital, Outpatient

Intended Users

Dietician nutritionist, counselor, nurse, nurse practitioner, physician, physician assistant


Counseling, Management

Diseases/Conditions (MeSH)

D001942 - Breast Feeding, D007225 - Infant Food, D009123 - Muscle Hypotonia


Breastfeeding, infant nutrition, infant trisomy 21, hypotonia, infant hypotonia


Number of Source Documents
Literature Search Start Date
January 1, 1983
Literature Search End Date
December 31, 2016
Description of External Review Process
Yes. The draft protocol is peer reviewed by individuals outside of contributing author/expert panel, including specific review for international applicability. The Protocol Committee's sub-group of international experts recommends appropriate international reviewers. The Chair and/or protocol resource person institutes and facilitates this process. Reviews are submitted to the committee Chair and resource person. The contributing author/expert panel and/or designated members of protocol committee work to amend the protocol as needed. The draft protocol is submitted to the Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. The Chair, resource person and protocol contributor(s) amend the protocol as needed. Following all revisions, the protocol has the final review by original contributor(s) to make final suggestions and ascertain whether to maintain contributing authorship. The final protocol is submitted to the Board of Directors of ABM for approval. A two-thirds majority of Board members' positive vote is required for final approval.
Specialties Involved
Endocrinology, Medical Genetics And Genomics, Obstetrics And Gynecology, Pediatrics, Pulmonology, Neonatology And Perinatology, Pediatric Endocrinology, Pediatrics, Pediatrics
Description of Systematic Review
The protocol is a review of the evidence.
Description of Search Strategy
Yes. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English.
Description of Study Selection
Yes. See methods below.
Description of Evidence Analysis Methods
Yes. Consensus-based. Led by Chair.
Description of Evidence Grading
U.S. Preventative Services Task force Recommendations. An expert panel is identified and appointed to develop a draft protocol using evidence-based methodology. An annotated bibliography (literature review), including salient gaps in the literature, is submitted by the expert panel to the Protocol Committee.
Description of Funding Source
Topic does not lend itself to bias.
Company/Author Disclosures
Topic does not lend itself to bias.