mohrbacherbeststart2017 75 min - emory department of ... · pdf file7kh %hvw 6wduw 1dqf\...

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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


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


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”

The Best Start


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

The Best Start


“…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

The Best Start


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

The Best Start


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

The Best Start


Adjust Your Baby

Think Clock

Baby Heads Up

Frog Legs & Foot Contact

The Best Start


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

The Best Start


Less to Know & Remember

• Feeding cues• Innate feeding behaviors• Positional stability• Asymmetrical alignment • Depth of latch

Like Watching TV


In Chair, Sofa, Bed


The Best Start


• 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


The Best Start


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

The Best Start


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

The Best Start


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

The Best Start


Overview• A brief history

of positioning• Where we are

now & why• Basics checklist

[email protected]

www.NancyMohrbacher.comwww.NaturalBreastfeeding.com

Facebook.com/NancyMohrbacherIBCLCPinterest.com/nancymohrbacher

@BFReporterwww.YouTube.com/NancyMohrbacher

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