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TRANSCRIPT
The Best Start
©2017 Nancy Mohrbacher 1
The Best Start: Strategies to Reduce Early
Feeding Problems
Nancy Mohrbacher, IBCLC, FILCA
Overview• A brief history
of positioning• Where we are
now & why• Basics checklist
Positioning Key to Top 3 Issues:• Nipple Pain• Milk Worries• Latch Struggles
Odom, et al. Pediatrics 2013; 131(3):e726-32
The Best Start
©2017 Nancy Mohrbacher 2
Key to comfort & milk transferTo mother’s feelings of competenceTo 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
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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
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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 #1For comfortable feeding & effective
milk transfer, the nipple must go deeper into baby’s mouth
Jacobs, et al. J Hum Lact 2007; 23:52-59
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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
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Video: Positioning Your Baby (1989) by Chele Marmet, MS, IBCLC, Medela
Image: Bestfeeding (2004)
Asymmetrical LatchChloe 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
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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
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1. Birth cry: Lungs expand2. Relaxation: Relaxed hands, no mouthing3. Awakening: Small head & shoulder movements4. Activity: More head & shoulder movements5. Rest: May occur between any stages6. Crawling: Movement to the breast7. Familiarization: Licks nipple, touches breast8. Suckling: Latches & suckles9. 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, 3rd ed. by C.W. Genna. Boston: Jones and Bartlett, 2017
Christina Smillie, MD, IBCLC
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Baby’s frontal contact releases breast-seeking behaviorsReflexes hardy, long-lasting
Smillie, C. In Supporting Sucking Skills in Breastfeeding Infants, 3rd ed., ed. by C.W. Genna. Boston: Jones & Bartlett, 2017
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
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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=40 30
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Sitting up, PNRs made
latching difficultPull 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”
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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 #3Early breastfeeding
easier with baby tummy down fully resting on mother,
hands free
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“…contemporary theories of
breastfeeding initiation have shifted away from
mechanical position-and-attachment models
toward a focus on supporting a
relationship-centered breastfeeding
experience incorporating innate
breastfeeding abilities.”Schafer & Genna. J Midwif Women’s Health 2015; 60(5):546-53
Approach to newborn
breastfeeding includes all of this
& moreSuggest favoring these positions
for first 4 to 6 wkwww.NaturalBreastfeeding.comFree 38-min. video with narration
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 simpleSchafer & Genna. J Midwif Womens Health 2015; 60(5):546-53
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A newborn’s curved spine
makes her flail like a turtle on its back
Flip baby over & she has much more body control
Adjust Your Body, Baby, Breast
www.YouTube.com/NancyMohrbacher
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Adjust Your Body
Maternal body slope: 15 to 63 degreesArm support, so mother relaxes all muscles
Why 15-to-63 Degree Body Slope?Efficacy: Better
activates baby’s GPS Comfort: No straining
Safety: Mother can easily see baby
Adjust Your Body
Small adjustments in body slope matter
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Adjust Your Baby
Think Clock
Baby Heads Up
Frog Legs & Foot Contact
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If mother lifted
her arms, baby would
roll awayWhat’s
adjustment might make
this position easier?
Baby Controls Latching
Mother’s arms act as baby’s head support Deeper latch when baby is in charge
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
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Less to Know & Remember
• Feeding cues• Innate feeding behaviors• Positional stability• Asymmetrical alignment • Depth of latch
Like Watching TV
www.YouTube.com/NancyMohrbacher
In Chair, Sofa, Bed
www.YouTube.com/NancyMohrbacher
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• Fewer latching struggles
• Fewer milk production worries
• Less nipple pain & trauma
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
www.YouTube.com/NancyMohrbacher
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©2017 Nancy Mohrbacher 20
As Baby Nurses…In traditional
holds, as hormones relax muscles, latch gets shallower
In starter positions, as mother and
baby relax, latch gets deeper
Learning New Skills
59
When mother is
skilled, can use any position
When not skilled, starter
positions foster better
dynamics
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No pressure on tender perineum
Mother fully relaxed,
no muscle strainBaby in charge, less focus on
mechanics Gravity
deepens latch
Easier for Mothers
Easier 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)? 63
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AssumptionsTHEN NOW
Use upright or side-lying feeding positions Baby rests tummy down on mother, so gravity helpsMother determines depth of latch Gravity ensures a deeper latchTeach all mothers “proper” position & latch Reserve latch instructions for problems
Suppress baby’s arms Free babies’ hands, act as GPS & enhance milk flow
Babies are hardwired to breastfeedWith starter
positions, many early problems can
be prevented
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©2017 Nancy Mohrbacher 23
Overview• A brief history
of positioning• Where we are
now & why• Basics checklist
www.NancyMohrbacher.comwww.NaturalBreastfeeding.com
Facebook.com/NancyMohrbacherIBCLCPinterest.com/nancymohrbacher
@BFReporterwww.YouTube.com/NancyMohrbacher
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