overview understanding breastfeeding behaviors · ©2016 n.mohrbacher & t. nesbitt 6 sitting...
TRANSCRIPT
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 2
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 3
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 4
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 5
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 6
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 7
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 8
Adjust Your Body
Mother’s arms supported, like baby’s nest
Adjust Your Baby
Think
Clock
Baby Heads Up Frog Legs
www.YouTube.com/NancyMohrbacher
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 9
Less to Know & Remember
• Feeding cues
• Calm, engage baby
• Innate feeding behaviors
• Positional stability
• Asymmetrical alignment
• Depth of latch
Like Watching TV
www.YouTube.com/NancyMohrbacher
In Any Chair, Sofa, Bed
www.YouTube.com/NancyMohrbacher
• 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
www.YouTube.com/NancyMohrbacher
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 10
What we are used
to seeing feels normal & natural
The Challenge
We need to replace
the old images with new ones
www.YouTube.com/NancyMohrbacher
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 11
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
Understanding Breastfeeding Behaviors
©2016 N.Mohrbacher & T. Nesbitt 12
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
www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC
Pinterest.com/nancymohrbacher@BFReporter
www.YouTube.com/NancyMohrbacher
~