Positioning and Latch-on

We spend an awful lot of time discussing latch-on and positioning. I recently looked at the wording in a pamphlet that was explaining how to "properly position" an infant for breastfeeding...the standard cradle, cross-cradle, football and side lying positions were explained along with all the directions, "elevate feet to ensure legs are level and turn infant tummy to tummy...place baby in crux of arm...hand must be placed behind head...etc, etc..."Really?! I was exhausted after reading all the rules and regulations of breastfeeding. I am also not surprised when the formula companies patiently describe the above scenario and take great satisfaction at using directions from lactation experts in their written material. We supply many of the information used by the companies trying to paint breastfeeding as difficult and exhausting.

When infants and moms are left skin-to-skin following birth, often spontaneous breastfeeding occurs within and hour to 90 minutes. No panic, no readjusting, no mandatory pillows...just baby and breast in proximity. Remind mom to stay in her comfortable, "laid back" position and place baby vertically on her body. We see a "baby crawl" and latch. http://www.youtube.com/watch?v=B2p6T8ewu9I. Yet, when well-meaning attendees attempt to "position" the baby, they often interfere with the natural progression and bonding time. Reclined breastfeeding is not anything new. Lactation books explained this years ago, but somehow we lost contact with our instincts and tried to control the experience, or perhaps the medications administered during labor inhibited instincts. More about the laid back position and biological nurturing can be found at http://www.biologicalnurturing.com/

With that said, there are situations and scenarios when assistance is necessary and imperative. A baby with Down Syndrome will definitely benefit from the Dancer Hold.

If poor muscle tone makes it difficult for your baby to latch on well, try supporting your baby's chin and jaw while nursing using the "Dancer Hold." (The name of this position was coined by Sarah Coulter Danner, RN, CPNP, CNM, IBCLC and Ed Cerutti, MD. "Dancer" comes from the first letters of their last names (Dan + Cer).) Hold your baby with the arm opposite the breast you'll be offering. Using the hand on the same side as the breast you are offering, cup your breast with your thumb on one side of the breast, palm beneath, index finger pointing outward, and the other three fingers on the other side of the breast. Use your index finger to support your baby's lower jaw while nursing. As your baby's muscle tone improves through breastfeeding and maturity, he will become able to support himself and breastfeed more effectively.http://www.llli.org/faq/down.html

Although laid-back is effectively used with cesarean births, some moms are concerned about the feet touching the incision. If a mom wants the baby on her side, there is nothing wrong with instructing on the "football hold." Remember, as lactation consultants, we desire to protect the breastfeeding relationship and construct a plan that is agreed upon with the mother. She is autonomous and we must respect that.

As the baby ages, there is little talk about positioning and latch. Babies will eat in any position and adjust well to change. The initial information we give mom should include the point that breastfeeding is natural and babies know how to do it...place baby skin-to-skin following delivery and enjoy the bonding time...position the baby vertically and use your hands to guide and direct as he begins to crawl to the breast. Also, timing is not that crucial. Babies have spent the hours leading up to birth at the "all-you-can-eat buffet." They do not come out starving. Allow the baby time to adjust to the new surroundings and relax.

Moms do need to know that breastfeeding should not be painful. Latch is an issue if no milk transfer is occurring or if mom is experiencing pain. Lactation Consultants can help by observing a feed. Observe a complete feed. Watch mom's breast, the position of the areola in the infant's mouth, the rhythm of the feed, listen for swallows, check to make sure the infants lips are flanged and then observe mom's nipple following the feed (it should be round and symmetrical and not pinched or wedged).

Observation is a lactation consultant's best tool. Look for clues to the mystery of pain like where the nipple is damaged, how severe the damage is, the length of the feeding, the baby's demeanor following the feed--all of these are clues.  Lactation Consultants are detectives. Watch, look and listen--a phrase we all learned in kindergarten--is the best advice I can offer anyone in or entering the field of lactation.

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Christy Jo Hendricks, IBCLC Doula

Birthing, Bonding & Breastfeeding

Infant Physiology and Milk Transfer

This topic is too broad to be thoroughly addressed in a blog, but I can definitely comment on the area and encourage those in the learning mode to continue to examine this very important discipline.  

Ascertaining that the infant actually breast feeds is very crucial to the role of the Lactation Consultant.  It sounds pretty elementary, but it is amazing how many infants wind up with jaundice or failure to thrive due to mismanagement of breastfeeding.  It's not actually breastfeeding that is the problem in most of these cases, but starvation.

When a mom delivers, she has a wonderful synergy of hormones that are adjusted perfectly for bonding and breastfeeding.  The two hormones that are present for only a short time are oxytocin and estrogen--a combination that assists in bonding (Uvnas-Moberg, The Oxytocin Factor, 2005).  While pregnant, the mother has progesterone which inhibited milk production, but with delivery, a  radical withdraw of progesterone and estrogen gave way to high levels of prolactin which enabled milk production (this is another reason to have a mom examined for retained placenta if she does not enter lactogenesis II and has heavy bleeding beyond the 3-4 day).  

The prolactin is the milk producing hormone, but nipple stimulation releases oxytocin which is the milk ejection hormone.  Oxytocin is often referred to as the "love hormone" since it is elicited through stimulation.  Initially, stimulation is necessary to release the milk, but over time, stimulation is less relied on.   If we allow Baby to turn oxytocin on (baby led attachment)  The following timeline is observed: (Matthiesen, Birth, 2001)

Minutes:

  6:  Baby opens eyes

11:  Massages breast

12:  Hand to mouth

21:  Rooting

25:  Moistened hand to breast

        Nipple becomes erect

27:  Tongue stretches & licks nipple

80:  Breastfeeding

Other hormones necessary for the production of breast milk include: insulin, cortisol, thyroid hormone, parathyroid hormone, parathyroid hormone-related protein, and human growth hormone.

Once the hormonal process is well underway, we must turn our attention to the act of breastfeeding. Milk transfer is necessary to feed the baby and to ensure mom continues to make milk. If baby is unable to empty the breast, mom should be encouraged to hand express to finish the process. If the breast is not emptied, it is in jeopardy of slowing production. A full breast not only will not make more milk, it can even inhibit milk production (this is a good time to refresh your memory on the FIL or feedback inhibitors of lactation). 

Often babies will self-latch and feed within a few hours after delivery. Medications and interventions can alter the schedule, but ideally a mom and infant left together to bond will have a successful time breastfeeding (remember the laid-back technique for easy and biological breastfeeding).

Measuring milk transfer can be as easy as noting the babies behavior. Is baby having 1 wet diaper on day 1 (24-hour period), 2 on day 2, 3 on day 3...6-8 on day 6 and beyond? That is one indicator of milk transfer.
The scale is also a good tool to use (especially for the premature infant). Pre and post test weights can assure milk transfer has occurred.

The infant test-weighing procedure should be performed using an electronic digital infant scale with accuracy to at least 2 grams. The infant is weighed clothed pre- and postfeeding without changing the diaper between weight measurements. The prefeed weight is subtracted from the postfeed weight, and the difference represents the volume of milk consumed, where 1 gram of weight is equivalent to 1 mL of milk intake. Milk is slightly denser than water, so in theory this calculation overestimates the test weight results, which is countered by insensible water loss during feeding.

Milk transfer is an area of concern and we must make sure early on that the infant is being fed. Know signs and symptoms of dehydration and make sure early follow-up appointments are kept. Unfortunately, I have to say, many lactation consultants, including myself, have witnessed mismanagement of feeding to a point of readmission to the hospital. Let's educate parents and keep our eyes open to possible warning signs.

For more detailed description of oxytocin and prolactin visit http://www.breastfeedingbasics.org/cgi-bin/deliver.cgi/content/Anatomy/physiology.html

For visible cues of milk transfer, visit http://www.letsbreastfeed.com/research/visible-cues-of-poor-milk-transfer/