A lthough exclusive breastfeeding isassociated with significant healthbenefits, British mothers are some of

the least likely in Europe to sustainbreastfeeding (Hamlyn et al 2002).Knowledgeable support may be crucial inovercoming the problems that prompt early,unintended breast weaning (Renfrew et al2005). Current breastfeeding supportapproaches suggest a fixed system of routineand early breastfeeding management usingverbal instruction to enable mothers tolearn correct positioning and attachmentskills. The following points have beenrecently reported as best practice. Tobreastfeed, mothers should:

● sit in a chair with an upright back, at rightangles to their ‘almost flat lap’● use a footstool (if needed) to support theirfeet ● swaddle the baby (if necessary), ensuringbaby’s arms are lying at the sides, not acrossthe body ● support the baby on a pillow with nose

and mouth in line with mother’s nipplebefore beginning the feed ● attach the baby correctly, holding thebreast, if necessary, but keeping the breast still ● elicit a mouth gape, by moving the babyagainst the breast and enabling the mouthto touch the nipple● aim the baby’s bottom lip as far away aspossible from the base of the nipple to enablebaby’s tongue to scoop in as much breast aspossible (Inch et al 2003a).

The theory for this kind of instructionappears to originate from three primarysources:1. Research examining the anatomy andphysiology of infant sucking (Weber et al1986, Woolridge,1986a; 1986b).2. Research differentiating sore nipple typesand expert clinical practice (Gunther 1945,1973).3. Experts’ practice in English problem-solving hospital/community feeding clinics(Woolridge 1995).

Infant sucking and sore nipplesA recent systematic review highlights thatpoor positioning and breast attachment areassociated with low milk supply, nippletrauma, breast engorgement and earlyweaning (Renfrew et al 2000). These riskfactors were first identified throughlandmark research carried out by Woolridgein the 1980s. Studying the mechanisms ofsucking through ultrasonic examination ofthe buccal cavity during breastfeeding,Woolridge (1986a, 1986b) replicated andfurther developed earlier cineradiographicstudies made of both breast- and bottle-feeding episodes (Ardran et al 1958a,1958b). Using video recordings ofultrasound scans to examine patterns andcoordination between sucking, swallowingand breathing, Woolridge (1986a, 1986b)studied six breastfed and six bottlefed infantsbetween the second and sixth postnatal day.

Maternal breastfeeding positions: Have we got it right? (1)

Suzanne Colson reviews the theory

supporting routine teaching of

breastfeeding positioning and

attachment skills, and considers

unexpected research results that

challenge current practices

Although traditionallymothers are advisedto breastfeed inupright seatedpostures, there doesnot appear to be anyresearch evidencesupporting thisinstruction

Below: This mother, pictured latching her baby as she was taught in hospital, was unable to sustain this posture. The baby was also unable to sustain thelatch for longer than one minute, even when the baby’s arm was stretched around the mother’s midriff (below right).

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Maternal breastfeeding positions: have we got it right? (1)

Mapping the anatomy of infant sucking andexamining the aetiology of sore nipples, thisresearch has been cited widely, informingpractices concerning the positioning andattachment of the baby at the breast.

Woolridge’s (1986a) description ofnormal infant sucking patterns,culminating in the finding that milk transferinvolves an almost frictionless processbetween neonatal tongue action andmaternal nipple, made good physiologicalsense, since experiencing pain duringbreastfeeding always appeared incongruentwith a biological process. Woolridge (1986a,1986b) set the gold standard forbreastfeeding education. Clinical applications centred onrecommendations for teaching midwives toteach mothers optimum attachment andpositioning skills to ensure effective milktransfer, breast emptying and painless feeds(Woolridge 1986a).

Challenging theoryThe aim of Woolridge’s (Weber et al 1986,Woolridge 1986a) pioneering research wasto clarify the organisation and physiology offeeding events that occur inside the baby’smouth during a feed. Generating theoriesabout how an infant becomes attached tothe breast, Woolridge (1986a: 169)reiterated that babies are born with twoprimitive reflexes, the innate rooting andsucking responses enabling them to ‘obtainthe nutrients essential for survival’.However, mothers appeared to lack anyinstinctive responses, unable innately tobreastfeed. Mothers, concluded Woolridge(1986a), need to learn and developbreastfeeding skills.

This theory can be challenged because itdoes not appear to take into account howmothers might sit or lie instinctively. Anysystematic examination of neonatalpositioning and attachment in relation tospontaneous maternal postures appears tohave exceeded the scope of the Woolridgeresearch (Weber et al 1986, Woolridge,1986a; 1986b).

In the earlier cineradiographic studiesmade of both breast- and bottlefeedingepisodes (Ardran et al 1958a, 1958b),maternal research postures are clearlydescribed: the breastfeeding mothersobserved were asked to lean over a couchwith their bodies twisted so as to allow one

breast to project clear from the chest wall. Anurse then ‘adjusted the baby to themother’s nipple and when active suckingwas established the radiographic exposurewas made’ (Ardran et al 1958b: 156).Although care was taken to ensurematernal comfort, these postures –suggested purely as part of a researchprotocol to enable close observations ofbreast attachment and the neonatal buccalcavity during feeds – could hardly increaseknowledge about spontaneous maternalfeeding postures.

Back straight, chest out!Traditionally, in any body of literature,mothers are often shown sitting uprightunsupported or upright on nursing chairs tobreastfeed. Both Mavis Gunther, anobstetrician in the UK, and Karen Pryor, anAmerican marine biologist, fervent andrespected breastfeeding authorities in the1950s to 1970s, suggested that in sittingpositions mothers should sit ‘bolt upright orlean slightly forward’ and ‘not leanbackwards’ (Gunther, 1973: 49; Pryor,1973: 167). Two such upright seatedpostures are still widely used and promotedas the only correct way to breastfeed. Theseare:

● Sitting upright and holding baby in acradle or cross-cradle position● Sitting upright and holding baby in theclutch, rugby ball or football position.

Mothers are also advised that they canbreastfeed lying down. The lying downposition is usually recommended forinitiating breastfeeding, especially after acaesarean section or for night feeds. Lyingdown, even in the artistic literature, iscommonly represented in postures whereboth mother and baby are on their sidesfacing each other.

Bad for the back?I have carried out an extensive literaturesearch and have been unable to find anyresearch data supporting these suggestions.However, there are some interestingpostural descriptions from osteopaths.Definitions of good or correct postureemphasise alignment of the body organsthat allows them to function properly. Bad orincorrect posture is that which places undue

strain and pressure on any of the organsleading to their abnormal functioning withresultant pain or general bad health. Theosteopathic literature is unambiguous: anupright posture where the back is at rightangles to the lap is the most uncomfortableof any position, and usually becomespainful; traditionally, it is called ‘the typist’sposition’. The typist’s position is well-knownamong osteopaths whose treatments forpredictable effects of tense trapezius andneck muscles and the tendonitis oftenassociated with repetitive stress injuryinclude manipulations and massage(Kapandji 1974).

Learning to breastfeed has beencompared with learning how to type(Renfrew et al 2004). The argument goessomething like this: when you sit straight, inan upright posture, you are well positioned;therefore, you will look better, feel better, beless tired and more accurate. In fact, theseclaims are unsubstantiated. It may be thatsitting upright is not the most comfortable,most accurate or least tiring position fortyping or for breastfeeding.

Postures where mothers are leaning backslightly, semi-reclined or flat lying are largelyresting postures, not erect. Promotingrelaxation and recovery, they may have adistinct advantage in that head, neck andshoulders can be fully supported. Semi-reclined postures can be just as well-alignedand balanced as erect postures, enabling fulllung expansion, preventing sagging of theinternal organs and exaggeration of thelumbar curve of the spine. The aim is to bestable, supported and comfortable, avoidinghunching and slumping.

Some breastfeedingexperts maytraditionally haveinsisted on uprightsitting posturesbecause of etiquette,leaning back perhapsbeing associated withslouching or anunkempt appearance

REFERENCESArdran G M, Kemp F H and Lind J (1958a). ‘A

cineradiographic study of bottle feeding’. Br Jof Radio, 31: 11-22.

Ardran G M, Kemp F H and Lind J (1958b). ‘Acineradiographic study of breast feeding’. Br Jof Radio, 31: 156-162.

Gunther M (1945). ‘Sore nipples, causes andprevention’. Lancet ii: 590-593.

Gunther M (1973). Infant Feeding, revisededition, Harmondsworth: Penguin Books.

Hamlyn B, Brooker S, Oleinikova K and Wands S(2002). Infant Feeding, London:TSO.

Inch S, Law S and Wallace L (2003a). ‘Hands off!The Breastfeeding Best Start Project (1)’. ThePractising Midwife, 6 (10): 17-19.

Kapandji I A (1974). The Physiology of the Joints,Vol.3: the Trunk and the Vertebral Column, 2nd

edition, Edinburgh, London, NY: ChurchillLivingstone.

La Leche League (1958). The Womanly Art ofBreastfeeding, La Leche League International,9616 Franklin Park, Il 60131, USA.

Pryor K (1973). Nursing Your Baby, New York:Harper and Row.

Renfrew MJ, Woolridge MW and McGill HR(2000). Enabling Women to Breastfeed,London: TSO.

Renfrew M, Fisher C and Arms S (2004).Bestfeeding: How to Breastfeed Your Baby,Berkeley, CA:Celestial Arts.

Renfrew M, Dyson L, Wallace L, D’Souza L.,McCormick F and Spiby H (2005). TheEffectiveness of Public Health Interventions toPromote the Duration of BreastfeedingSystematic review (1st ed), London: NICE.

Royal College of Midwives (1996). Breastfeeding:Coping With The First Week (videotape), Mark-It Television, 34 Gadshill Drive, Meade Park,Stoke Gifford, Bristol BS12 6UX.

Royal College of Midwives (2002). SuccessfulBreastfeeding, London: RCM.

Woolridge MW (1986a). ‘The “anatomy” ofinfant sucking’. Midwifery, 2: 164-171.

Woolridge MW (1986b). ‘Aetiology of sorenipples’. Midwifery, 2: 172-76.

Woolridge M W (1995). ‘Baby controlledbreastfeeding’, 217-242, in P Stuart-Macadamand K A Dettwyler (eds), BreastfeedingBiocultural Perspectives, NY: Aldine de Gruyter.

Woolridge MW, Baum JD (1986). ‘Anultrasonographic study of the organization ofsucking and swallowing by newborn infants’.Dev Med Child Neurol, 28:19.

One reason that has been given for sittingupright for breastfeeding is that women’sbreasts will ‘point downwards and outwards’if they are lying back, making it difficult tolatch the baby on to the breast (RCM 2002:44). Renfrew et al (2004) also argue thatlying down postures are problematic,suggesting that semi-reclined seated posturescould inhibit the milk supply or cause nipplesucking. These statements are unreferenced,suggesting that this is professional opinion;authoritative statements such as these areoften illustrated by a series of pictures ofmothers sitting starkly upright with both feetflat on the floor and head, neck and shouldersunsupported, illustrating how to attachbabies correctly to the breast using thecorrect seated posture.

After that, there is often a series of mothersin semi-reclined postures that are crossedout, indicating that leaning back or lying flatto breastfeed is wrong or incorrect. Again,this is unsubstantiated. However, theseconstant visual displays throughout thebreastfeeding literature not only reinforce thewidespread belief that upright sittingpostures are the only correct way tobreastfeed when seated, but they also assumethat mothers (or, sometimes, midwives) aresupposed to attach the baby to the breast.

It may be interesting to explore why somebreastfeeding experts have traditionallyinsisted on upright sitting postures.Speculation suggests that it might have to dowith etiquette, leaning back perhaps beingassociated with slouching or an unkemptappearance. Upright can also mean decent,honest and of good moral conduct. Or,

maybe, bolt upright postures were originallythought to strengthen bone development,preventing malalignment or nerve injury; thetheory could have originated at a time whenthe benefits of vitamin D were unknown andrickets was prevalent. Chair design isconstantly changing and evolving; maybestraight-backed chairs were the only onesavailable in the hospital or clinical setting.Finally, it may have been thought that ifbreastfeeding mothers leaned back in semi-reclined or semi-flat postures, the milk couldnot flow upwards and out and down into thebaby’s mouth. Thinking in terms ofbottlefeeding, and considering the effects ofgravity, logically this makes sense. Equipped,however, with the understanding of themechanisms of maternal milk release andhow the baby applies ‘negative suctionpressure’ during sucking bursts (Woolridge1986a: 164), we can start to look beyond anyassociation between maternal postures andthe effectiveness of milk transfer.

Creating a ‘problem’ A third primary source that underpins theroutine verbal instruction of breastfeedingmanagement cited above appears to originatefrom the nature of knowledge and clinicalexpertise gained during feeding clinics.Woolridge (1995: 221) reports that hospitaland community clinics offer ‘women withseemingly intractable breastfeedingproblems’ the opportunity to be taughtspecific positions and attachment skills toovercome them. When there are problems,his response makes good sense – a consistentapproach to reorganise is probably exactly

what is needed. However, to regard theinitiation of any breastfeeding as problematicis culturally loaded. For example, abreastfeeding promotional video suggeststhat mothers must acquire coping skills to beable to breastfeed during the first postnatalweek (RCM 1996). The word ‘cope’ comesfrom middle English via the French ‘coper’,meaning to meet in battle or give a blow withthe fist. Today, coping is still associated withsuccessful confrontation of problems: somecoping synonyms are ‘managing’, ‘gettingby’, ‘surviving’ and ‘muddling through’– hardly words conjuring up images ofpleasure and satisfaction.

There is a good argument to be made that itis not the act of breastfeeding that isproblematic, but rather fixed attitudes andcultural beliefs that obscure the biologicalchoice (La Leche League 1958).

ConclusionIn today’s consumer world, to promote andsupport breastfeeding it may be moreproductive to encourage natural positionsand introduce the concept of nurturing andenjoyment – to ‘market’ breastfeeding,inspired by the positive energy coming fromtestimonials of mothers who take pleasure inbreastfeeding. That is what biologicalnurturing is about. TPM

Suzanne Colson is a research midwife andsenior lecturer at Canterbury Christ ChurchUniversity

NEXT MONTH: Biological nurturing – a newapproach to breastfeeding.