overview understanding breastfeeding behaviors · ©2016 n.mohrbacher & t. nesbitt 6 sitting...

Understanding Breastfeeding Behaviors

©2016 N.Mohrbacher & T. Nesbitt 1

Understanding Breastfeeding

Behaviors

~Nancy Mohrbacher,

IBCLC, FILCA

Overview

• A brief history

of positioning

• Where we are

now & why

• Basics checklist

• Our best role

Positioning Key

to Top 3 Issues:

• Nipple Pain

• Milk Worries

• Latch Struggles

Odom, et al. Pediatrics 2013; 131(3):e726-32

Key to comfort

& milk transfer

To mother’s feelings of

competence

To mother-baby

relationship

Why Is This So Tricky?

• Many grew up in a bottle-feeding culture

• Many don’t see breastfeeding

• We’re still learning

Advice Circa 1980

Photo: The Breastfeeding Atlas



The End Result

Photo: The Breastfeeding Atlas

Wait 4 to 6 weeks

and the pain will go away

Pain and

trauma

happen when

mothers

do not “toughen”

their

nipples enough

‘Blame

the

Victim’

Mentality

At about the same time, three experienced breastfeeding counselors:

– Kittie Frantz, USA

– Chloe Fisher, UK

– Maureen Minchin, Australia

Came to the same conclusion:

“We…could significantly

reduce or eliminate the pain

of sore nipples by

altering mothers’ techniques

to match those of the mothers

who were not experiencing pain.”--Kittie Frantz,2

Major Shift #1

For comfortable feeding & effective milk transfer, the nipple must

go deeper into baby’s mouth

Jacobs, et al. J Hum Lact 2007; 23:52-59



Assumptions Then

• Use upright or side-lying positions

• Mother determines depth of latch

• Teach all mothers “proper” position & latch

• Suppress baby’s arms

Techniques to Achieve a Deeper

Latch

Photo: Mary Jane Chase, RNC, MN, CCE, IBCLC

Managing Nipple Problems

• Use cradle hold

• Turn baby on side

• Keep fingers away

• Support breast (C)

• Tickle lips lightly

• Center nipple

• Pull baby in close

Kittie Frantz, PNP, LLLI, 1982; www.geddesproduction.com

Video: Positioning Your Baby (1989) by Chele Marmet, MS, IBCLC, Medela

Image: Bestfeeding (2004)

Asymmetrical Latch

Chloe Fisher, RN, RM, MTD

When baby attaches off-center,

nipple extends further back in baby’s mouth

Sandwich Analogy • For

asymmetrical

latch

• Compress

breast into oval

• Roll in

areola first, nipple last

• “Working” lower jaw takes more underside

Wiessinger. J Hum Lact 1998; 14(1):51-56



Positional Stability

Baby well-supported

• Torso, hips, chin touching mother

• No gaps between mother & baby

Photo: Rebecca Glover, RM, IBCLC

Rebecca Glover, RM,

IBCLC

Photo: Catherine Watson Genna, BS,

IBCLC

“Instinctive

Feeding Position”

Head back,

chin thrust forward to open throat for easier swallowing

Video: Follow Me Mum (2005) by Rebecca Glover, RM,

IBCLC; Available from www.ibreastfeeding.com

“Nipple-Tilting” for asymmetrical latch

Understanding Baby’s Role

What Nature

Builds into

Babies

1. Birth cry: Lungs expand

2. Relaxation: Relaxed hands, no mouthing

3. Awakening: Small head & shoulder movements

4. Activity: More head & shoulder movements

5. Rest: May occur between any stages

6. Crawling: Movement to the breast

7. Familiarization: Licks nipple, touches breast

8. Suckling: Latches & suckles

9. Sleep: Falls into restful sleep

Breast Crawl: 9 Instinctive Stages after Birth

Widstrom, A-M, et al. Acta Pediatr 2011; 100:79-85; N=28Girish, et al. J Perinatol 2013; 33(4):288-91; N=100

Video: “Breastfeeding in the First Hours After Birth” (2015);

www.globalmedia.org Baby-Led Breastfeeding

Saw similar responses

among babies

Smillie, C. In Supporting Sucking Skills in Breastfeeding Infants,

2nd ed. by C.W. Genna. Boston: Jones and Bartlett, 2013, pp. 83-104

Christina Smillie, MD, IBCLC



Baby’s frontal

contact releases breast-seeking

behaviors

Reflexes hardy,

long-lasting

Smillie, C. In Supporting Sucking

Skills in Breastfeeding Infants, 2nd ed., ed. by C.W. Genna.

Boston: Jones & Bartlett, 2013,

pp. 83-10425

Triggering feeding

behaviors resolves

– Tight latch

– Sore nipples

– “Dysfunctional” suck

– Breast refusal

Inborn behaviors long-lasting;

full frontal contact main trigger

Fewer problems when baby takes

active role

Major Shift #2 Biological Nurturing®Suzanne Colson, RM, PhDwww.biologicalnurturing.com

• Videotaped feedings of 40 mother-baby pairs

• Identified 20 primitive neonatal reflexes

• PNRs work for or against breastfeeding, depending on position

Colson, et al. Early Hum Dev 2008; 84(7):441-49

20 Primitive Neonatal Reflexes Include:• Rooting• Suck• Swallow

• Hand to mouth• Mouth gaping• Tongue licking

• Jaw jerk• Arm & leg cycling• Head lifting

• Head bobbing• Stepping, crawling

More PNRs led to breastfeeding when

mothers lean back with baby on top (p=<0.0005)

Colson, et al. Early Hum Dev 2008; 84(7):441-49; N=4030



Sitting up, PNRs

made latching difficult

Pull of

gravity caused gaps,

head-butting, arching

31

Pressure to back

of baby’s head causes baby to push back

32

Babies hardwired to be “tummy feeders”

Colson. et al. Early Hum Dev 2008; 84(7):441-49

Breastfeeding innate &

reciprocal

Mothers’

stroking “appeared to trigger

instinctively the right reflex

at the right time”

• Calm & stabilize • Communicate

Baby’s Hand MovementsGenna & Barak. Clinical Lactation 2010; 1(1):15-20

• Help find breast & move to it• Stimulate milk flow

Matthiesen, et al. Birth 2001; 28:13-19

Major Shift #3

Early breastfeeding easier with baby

tummy down, hands free,

gravity helping



Approach to newborn

breastfeeding includes all this,

insights from

The Prague School& more

www.NaturalBreastfeeding.com

Natural Breastfeeding after Birth

• Undisturbed skin-

to-skin contact

• No time constraints

• Mother & baby

well supported

• Baby’s hands free

• If help needed,

keep it simple

Schafer & Genna. J Midwif Womens Health 2015; 60(5):546-53

A newborn’s

curved spine

makes her flail

like a turtle

on its back

Flip baby over & she has much more body control

Baby’s Pressure Buttons

Theresa Nesbitt, MD; www.drtheresa.com

Adjust Your Body, Baby, Breast

www.YouTube.com/NancyMohrbacher



Adjust Your Body

Mother’s arms supported, like baby’s nest

Adjust Your Baby

Think

Clock

Baby Heads Up Frog Legs


If mother

lifted her arms,

baby would

roll away

What’s

adjustment might make

this

position easier?

Adjust Your Breast,Think Sandwich

• Compress breast

into an oval

• Fingers parallel to baby’s lips

• Like hamburger, not taco

Wiessinger. J Hum Lact 1998; 14(1):51-56



Less to Know & Remember

• Feeding cues

• Calm, engage baby

• Innate feeding behaviors

• Positional stability

• Asymmetrical alignment

• Depth of latch

Like Watching TV


In Any Chair, Sofa, Bed


• Less nipple pain

& trauma

• Fewer

latching struggles

• Fewer milk

production worries

The Big 3

Girish, et al. J Perinatol 2013; 33(4):288-91; N=100

Deep latch for comfortable, active feeding & effective milk transfer

Jacobs, et al.

J Hum Lact 2007; 23:52-59

Gravity & the Comfort Zone




What we are used

to seeing feels normal & natural

The Challenge

We need to replace

the old images with new ones


Learning New Skills

57

No pressure on tender perineum

Mother

fully relaxed, no muscle strain

With baby’s help, less focus on

mechanics

Gravity deepens latch

Benefits Mothers

More Natural for Newborns

Video: Positioning Your Baby (1989) by Chele Marmet, MS, IBCLC, Medela

Basics Checklist

� Is baby upset, need to be calmed (arousal state)?

� Is mother fully supported, relaxed & partly reclined, not upright or completely flat?

� If mother lifts her arms, does baby stay in place?

� Is baby tummy down (frog legs) & head higher than bottom?

� Tried varying direction of baby’s body (clock)?

� Baby’s feet touching mother or something else?

� Tried breast shaping (hamburger not taco)?60



Assumptions

THEN NOW

Use upright or side-lying

feeding positions

Baby rests tummy down

on mother, so gravity

helps

Mother determines

depth of latch

Gravity ensures

a deeper latch

Teach all mothers

“proper” position & latch

Reserve latch instructions

for problems

Suppress baby’s arms Free babies’ hands, act as

GPS & enhance milk flow

Our

Best

Role

• We want to help

• But doing too much

has drawbacks

• Mothers learn by

watching & doing

“Hands-on help is associated with a more negative experience

of the first breastfeeding session.” – Cato, et al. Breastfeed Med 2014; 9(6):294-300; N=879, Sweden

64

Demonstrating without touching

• More positive

• More effective at teaching competence

Weimers, et al. Int Breastfeed J 2006; 1:20; N=10, Sweden

In NICU, mothers felt hands-on help

– Slightly brutal, unpleasant

– Violated integrity

Squeezing breast into baby’s mouth

– Negative

– Not want repeated

Photo: Lena Weimers

Weimers, et al. Int Breastfeed J 2006; 1:20; N=10, Sweden



Hands-Off Help Linked to Higher Rates of Exclusive Breastfeeding

1st Week 4th Week 8th Week

Hands- Off Help 71% 62% 48%

Hands-On Help 48% 26% 9%

Baghany, et al. Life Sci J 2013; 10(12s):202-07; N=124, Iran

“Trying to attach infant to breast with a grip

around the neck & a grip around the breast [may]

inhibit baby’s inborn

rooting-tongue reflex….

[T]this kind of

forceful help could be one underlying factor

for infants’

latch-on problems.”--Svensson, et al. Int Breastfeed J

2013; 8:1; N=103, SwedenPhoto: Lena Weimers

Help without

touching linked to significantly

– Longer

breastfeeding

– More exclusivity

at 2 & 6 wk

– Fewer “not

enough milk”

Ingram, et al. Midwifery 2002; 18:87-101; N=395, UK

Example of Hands-Off Help

Babies are

hardwired to

breastfeed

With gravity

helping, many

early problems

can be avoided

[email protected]

www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC

Pinterest.com/nancymohrbacher@BFReporter


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overview understanding breastfeeding behaviors · ©2016 n.mohrbacher & t. nesbitt 6 sitting...

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