Could a laid-back approach to breastfeeding help your baby latch on?

baby_cryingAlthough it’s perfectly feasible to feed your baby any way that feels comfortable, four positions are commonly recommended. These are the cradle hold, the football hold, lying on your side, and the cross-cradle hold. This last position requires you to sit up with a straight back, hold your baby sideways on, and carefully position him with his nose opposite your nipple so he has a large mouthful of breast when he latches on. It can seem like quite a complicated process for a beginner, particularly when a crying baby is added to the equation. Nevertheless, it is particularly recommended to new mothers, as it is apparently the best position in which to ensure your baby is latching on correctly – something that many women (and babies) can find quite difficult.

Despite the strong recommendation of these feeding positions, there appears to be virtually no scientific evidence to justify their use. In practical terms, it is easy to see why being able to discreetly breastfeed whilst sitting up is a useful skill to master, but for a new mother, simply being able to comfortably nourish her baby may be a more immediate priority.

A recent study conducted at hospitals in the UK and France calls into question the idea that the traditionally recommended feeding positions are automatically the best ones1. During the study, 40 women whose babies were less than a month old were videotaped breastfeeding in a series of recording sessions. As long as feeding was going well, mothers were not advised or guided in any way: they were simply left to get on with it in whichever was most comfortable for them. In the ‘best’ recorded feeding session 21 of the mothers sat upright to feed their babies, one lay flat on her back, and one lay on her side; the remaining 17 were semi-reclined with their babies lying on their tummies (a behaviour termed ‘Biological Nurturing’).

There were some striking differences in the feeding process when mothers adopted a reclining position, as opposed to sitting upright. When babies lay on their mothers’ tummies, their mothers’ hands were free to gently guide them. Stroking their babies’ feet seemed to be particularly helpful, as it released mouth and tongue reflexes that helped them to latch on. By contrast, when babies were held in their mothers’ arms, their legs and feet were left in thin air, and the foot-to-mouth connection was lost.

The reclinining group did not need to line up the nose and nipple, and make sure the baby’s mouth was open wide enough before initiating the latch: as the baby was on top, gravity pulled his tongue and chin forward, allowing him to attach himself, even when he was sleepy. Gravity also automatically ensured a close fit between the baby’s chin and the mother’s breast, facilitating deep suckling and producing the ear and jaw movements that indicate successful feeding.

Perhaps the most interesting result, however, was that babies exhibited reflexes that helped feeding when their mothers were reclined, but hindered it when their mothers were upright. When they were lying on their mothers’ tummies, head-righting and -lifting reflexes allowed the baby to orientate himself for successful latching on. When mothers were upright however, these irregular, jerky head movements had the opposite effect: the head bobbing that resembled ‘nodding’ when a mother was reclined was perceived as ‘head butting’ when a baby was held sideways against an upright mother. The gravitational forces that had helped attachment in reclining postures dragged babies away from their mothers when they sat up. It was harder to keep the baby latched on, and mothers reacted by tightening their grip, resulting in back arching and arm and leg cycling that appeared like thrashing or flailing.

It is important to view these results in context: this was an observational, rather than a controlled study, so the data cannot ‘prove’ that one feeding method is better than another. Many of the mothers who participated fed quite happily whilst sitting upright – as do many women every day – so it’s clear that a reclining posture is not required for successful feeding.

Nevertheless, this research does call into question the idea that a position like the cross-cradle hold is the best one to recommend to new mothers. Innate early breastfeeding behaviours were observed to help attachment when a mother lay back with her baby lying on her tummy, but not when she sat up;  reflexes and gravitational forces which aided latching on when a mother reclined, hindered it when she was upright. If, as this study suggests, women can just lie back and let nature take its course, the often fraught early days of breastfeeding could potentially be a much more relaxed affair.

  1. Early Hum Dev. 2008 Jul;84(7):441-9.
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Milk stasis – not infection – is the main cause of mastitis

holding_babyPrior to my brush with it, I thought that mastitis was caused by a bacterial infection. This is not completely unreasonable, given that this is precisely how numerous ‘health’ websites define it (FreeMD, eMedicineHealth, HealthSquare to name just a few). When you consider that the symptoms of mastitis can include a fever as well as redness, lumps and pain in the breasts, and treatment can involve antibiotics, the definition seems to make sense.

Unfortunately, it turns out to be somewhat misleading. Whilst bacterial infection may play a part in mastitis, it is in fact inflammation of the breast tissue that is at the root of the condition, and causes the majority of the symptoms. The World Health Organization describes mastitis as ‘an inflammatory condition of the breast, which may or may not be associated with infection’1. They summarize the uncertain relationship between bacterial infection and mastitis as follows:

Many lactating women who have potentially pathogenic bacteria on their skin or in their milk do not develop mastitis.
But:
Many women who do develop mastitis do not have pathogenic organisms in their milk.

This basically means that you can be carrying the bacteria associated with mastitis – and even have it in your milk – without developing the condition, and conversely, you can succumb to mastitis when there is no evidence you’re carrying the bacteria.

So, if mastitis isn’t due to an infection, what does cause it? It appears that the inflammation that characterizes mastitis is a consequence of ‘milk stasis’: milk is produced, but then remains in the breast, rather than coming out during feeding. Milk stasis can occur for many reasons, including blockages in the ducts, a decrease in feeding frequency and poor attachment1,4. It’s also possible that stress might play a role, by both increasing milk production and delaying the letdown reflex2. Why milk stasis goes on to cause inflammation isn’t so clear, though it could result from inflammatory substances found in milk irritating the breast tissue, or an immune reaction to certain milk proteins3.

Although bacterial infection is not often the primary cause of mastitis, it is sometimes thought to exacerbate the symptoms3. Determining the precise role it plays, however, is a tricky business. Firstly, it is very hard to ensure that milk cultures are sterile, so it isn’t always possible to know that the bacteria found in a woman’s milk haven’t in fact come from her skin when the sample was taken1. Secondly, as stated above, harmful bacteria can be found in the milk of women who don’t have mastitis, indicating that there is not a simple cause and effect relationship between the two. One possibility is that mild changes initiated by milk stasis may be exacerbated by bacterial activity: symptoms could be considered to be on a scale, from a reduction in milk output but no pain (known as subclinical mastitis), to breast abscess and severe pain, with increasing amounts of bacterial involvement as you move from one end to the other3.

What does all this mean if you find yourself suffering from mastitis? Perhaps the most important thing to remember is that the symptoms are probably due to a milk flow problem, so your top priority should be to address any causes of this. This might include making sure your baby is properly latched on, feeding more frequently and emptying the breast properly at each feed. Many doctors also choose to treat mastitis with antibiotics, although there is a lack of consensus as to which ones to use, and even whether it’s appropriate to use them at all (see when should mastitis be treated with antibiotics?). Whether or not you take medication, the most important thing is to keep the milk moving. Whilst feeding with mastitis doesn’t appear to pose a risk to you or your baby, stopping could well do: not only will it make the symptoms worse, but it will almost certainly jeopardize your milk supply5. Mastitis is a common reason for giving up breastfeeding, but it needn’t be – focus on sorting out your feeding technique and you should hopefully make a rapid recovery.

  1. Mastitis: causes and management. World Health Organization; 2000.
  2. Mediators Inflamm. 2008;2008:298760.
  3. Arch Dis Child. 2003 Sep;88(9):818-21
  4. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458.
  5. Am Fam Physician. 2008 Sep 15;78(6):727-31.

Nipple nightmares 1: bleeding

mother breastfeedingThe first couple of days at home were pretty breezy. Before I left hospital I was assured by two midwives that C was latching on properly – cheeks puffed out, chin pumping, ears wiggling – so I was confident we had the technique sorted. Family visited and I assured them everything was going well, demonstrating our successful feeding on several occasions. By the time I got to day four, however, things weren’t quite so easy. Accompanying the hormone-induced plunge into despair inadequately named ‘the baby blues’ (that coincides with the start of proper milk production) was a serious deterioration of my nipples.

The ‘initial soreness’ quietly mentioned in some of the leaflets just didn’t cover it. Not only did feeding result in agony extending minutes beyond the approved first 10-15 seconds, but I was starting to display serious war wounds. The first time that C vomited blood I was frantic with worry, and straight on the phone to the maternity unit. But, as the midwife reassured me (!), the blood was my own, swallowed by C while she fed. Bleeding!? No one had told me about this. Well, no one except for my friend Zara… Surely it couldn’t be normal? It certainly wasn’t according to the copious NHS breastfeeding resources.

And this was a major part of the problem. Everywhere I looked I was told that nipple soreness, cracks and bleeding were caused by the baby failing to latch on correctly: these problems were my own fault, caused by a poor technique. The thing is, when I talked to the health professionals, I was told I was doing it right, and fortunately, C seemed to be getting plenty of milk.

When the midwife next visited, I voiced my concerns. She checked my attachment – again, it seemed fine – and then admitted that she had had the same problem. Apparently, people with fair skin have a much harder time of it when it comes to breastfeeding. My nipples hadn’t darkened at all during pregnancy, so I could be particularly susceptible to problems. Hearing this was a massive relief. Ironically, being told that I might find it more difficult because of my inferior nipples made it easier to carry on (see the post on skin colour and nipple pain for more info on this). The midwife suggested I grit my teeth, and within two to three weeks it would be ‘a piece of cake’.