74 BIRTH 16:2 June 1989

Resources

Royal College of Midwives. Successful Breast- feeding. London, Royal College of Midwives, 1988. 86 pp manual, essential for perinatal care- givers. 22.50 plus postage from 15 Mansfield St., London, W 1M OBE England.

Michaelson KR. Breastfeeding Basics for Busy Moms and Dads. 25 slides and manual; avail- able for $25 plus postage from Therapeutic Media, Box 21056, Santa Barbara, CA 93121 USA. Some clear slides of good and bad posi- tioning.

A video on this subject will soon be available from the Queen Victoria Hospital Foundation, Fullarton Rd., North Adelaide, SA 5006, Aus- tralia.

Commentary: Another Look at Positioning for Breastfeeding Marsha Walker, RN, BS, BA, ACCE, IBCLC

The first part of this article examines the infant’s oral patterns as they relate to removing milk. Sev- eral studies are discussed, but the interpretations of their implications for breastfeeding are somewhat subjective. For example, Ardran, Kemp, and Lind (1) used radiographs to study sucking mechanics. This showed the correct configuration of tongue, lips, and so on, but required positioning the baby on a couch with the mother leaning over the couch so the breast cleared her chest wall. Not many mothers use this position. In the line drawing of the radiograph the baby’s chin does not touch the breast because that is how the study was con- ducted. The authors stated that according to Gunther, the baby’s chin must “drive” firmly against the breast, but is this to avoid nipple problems? Are the mothers in the study experi- encing nipple problems with the chin away from the breast?

Another confusing interpretation arises from the

Marsha Walker is director of the breastfeeding support program at Harvard Community Health Plan in Wellesley, Massachu- setts, and a partner in Lactation Associates, 254 Conant Rd. , Weston, M A 02193.

statement about the study sample being experi- enced breastfeeding mothers with protractile breasts, and older babies, but none of these terms is defined or confirmed from information provided in the study. The study used 41 infants with ages ranging from a few days to several months, but does not specify exact ages. Nor does the topic of nipple trauma appear. Was it experienced in any of the sample in spite of the chin being away from the breast?

Two other groups (2,3) used real-time ultrasound and described an anterior-to-posterior peristaltic motion of the tongue during sucking. One scan was done of babies two to six days after birth through one plane. It is interesting to note that the artist’s rendering of the ultrasound picture shows the in- fant’s chin well away from the breast, as in the criti- cized Figure 3. Maybe some of the questions re- garding positioning come from the kinds of artwork that try to translate ultrasound scans.

The author mentions descriptions for Figure 4 that do not appear on my copy of the figure chart but are clearly stated in the paper. There are no written explanations of the differences between Figures 4, 5 , and 6 of the artificial nipple. It is easy to see, however, that the tongue rests well behind

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the lower gum and bears no resemblance to the human tongue, in either a static or dynamic situa- tion. This particular paragraph of the paper wanders a little off the topic. The research on babies learning to breastfeed more quickly than bottle feed (4) is a study conducted on preterm in- fants. It is an exciting and important study with great implications in that preterm babies may be maturationally and neurologically prepared to breastfeed before they can handle the rapid flow of milk from preemie nipples. However, term babies may have matured enough to control the flow of milk from an artificial nipple or to adjust them- selves to the faster flow rate.

The next section discusses the shape and tension of the breast as it relates to feeding efficiency. I find no evidence that the shape of the breast in Figure 7 reflects “a particular curve” in pregnancy and the postpartum. This looks more like Lawrence’s (5 ) il- lustration of a developing, young, prepregnant breast. I have seen thousands of breasts over 13 years of clinical work and am always amazed by their variety. This outline reminds me more of a lactating breast several months postpartum or after weaning, or of an older woman, not necessarily of a full breast during the early weeks of lactation. Ne- ville and Neifert (6) described more glandular tissue in the upper outer quadrant of the breast. I am not sure that the “effect of prepartum and postpartum breast changes is to present the lower milk sinuses more directly to the baby’s mouth, enabling him to milk the breast more efficiently.” In my practice, I have not seen that a rounded breast makes latch-on any more difficult unless the roundness and firm- ness are due to engorgement. The shape of the breast as it meets the baby’s mouth is also deter- mined by how it is held and supported during feeding. Many mothers are currently being taught to support the breast with four fingers underneath to keep its weight from pulling the nipple out of the baby’s mouth. This changes the contour and can elevate the breast tissue so it makes contact with the infant’s chin without “driving” the chin anywhere.

The compressed nipple or one with a stripe across it after feeding is indicative of both poor po- sitioning and the way the baby nurses. A baby can be correctly positioned and still bite the nipple due to reasons unique to the baby.

Infant posture is certainly one of the keys to suc- cessful and enjoyable breastfeeding. The author de- scribes positioning with the infant’s head slightly extended, yet sucking is considered a flexor pattern (7). Braun and Palmer (8) described that “. . . the mouth reflects for the most part the patterns that

occur in the body. . . . The head must be observed in relation to the hips, pelvis, trunk and shoulder girdle.” If we do not pay attention to maintaining flexion of the baby’s trunk and hips, the baby’s mouth and face may be close enough to the breast (chest to chest) but his back and hips can be in ex- tension. This can contribute to stimulation of primi- tive reflexes that cause arching off the breast. It can also press the baby’s nose into the breast, and cause the chin to tip upward with the tongue falling back. When the tongue falls back a baby may fix it to the roof of his mouth to maintain the airway or simply come off the breast. The author is quite right in explaining that pushing the baby’s head for- ward results in his pulling away from the breast- but not necessarily in anger. It is a protective re- flex. This is also different from providing support to keep the head from falling back in extension. She also reminds us that the infant’s head is not to be turned sideways to reach the nipple.

When the baby is held across the lap, mothers can be taught to “wrap” him around their waist, and hold him high up with his mouth at the level of the nipple. The crook of the arm is in front of the nipple where baby’s head will rest and the mother will lean back, not forward into the baby. The mother’s index finger can be slipped under baby’s chin for further support, especially if the infant shows a tendency to wide jaw excursions or biting. The four fingers under the breast support the weight of the breast not the baby’s jaw. Symmetric nipple placement in the mouth is rightly empha- sized. There is a range of what works best for a particular mother and baby, and each situation must be managed individually.

Seven variations are next mentioned on how the baby’s mouth contacts the breast. Item 5 describes improper conditioning of the mouth by bottles or pacifiers. This, as well as older age, is used to ex- plain why an ultrasound study in the United States reported different results from those previously discussed. This group (9) conducted the imaging through two planes rather than one, and studied 16 infants 60 to 120 days old. Their interpretation showed milk being ejected from the nipple 0.03 seconds after maximum nipple elongation, and sug- gested that nipple compression drew milk into the lactiferous sinuses, but the actual stimulus for re- lease of the milk was a vacuum generated by the rapid enlargement of the oral cavity. The undulant motions of the tongue were not credited with as much significance as by Weber and Woolridge. However, Morris and Klein (7) pointed out that “. . . babies often have more active closure of the lips and less up-down jaw movement during the

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first weeks or month of life because of the in- creased flexor activity in the entire body. ” These authors also described two distinct phases of the suck: “suckling,” which is the earliest pattern in infants, involving an anterior to posterior move- ment of the tongue, and “sucking,” which is seen at several months of age and shows a raising and lowering action or more of an up-down direction of tongue movement. Perhaps this may be why younger babies use the tongue in a peristaltic fashion while the older infants in the Smith study relied more on an up-and-down jaw movement pat- tern. Sucking, like many other body functions, may grow, mature, and change from a reflexive pattern to one with more voluntary control. There is prob- ably a range of oral behavior between a newborn and older baby, only a small part of which we have begun to glimpse.

Protractility of breast and nipple tissue is cer- tainly important to proper latch-on and in avoiding nipple damage. If a combination of a short nipple on an inelastic breast is present, not all babies will suckle successfully once milk is flowing. This is a simplistic answer to a more complex situation. I could not agree more, however, on the manage- ment of engorgement. Telling a mother whose breasts are overfilling with milk not to remove it because she will just make more milk, sets her up for sore nipples, decreased milk supply, and a hungry baby.

Noisy feeders may be incorrectly positioned, but babies who make smacking sounds at breast may also have excessively wide jaw excursions (10) that separate the tongue and jaw from working as a unit. This is a baby-related problem, and other measures may have to be taken besides proper positioning. Babies who feed constantly or who demonstrate in- adequate weight gain may indeed be poorly posi- tioned; however, this is not the only reason for these problems. Again, they may be baby related as a result of disorganized or dysfunctional sucking.

In the section on signs that suggest poor posi- tioning, “prissy” lips are often accompanied by dimpled cheeks or dimples at the corners of baby’s

mouth. This shows a tongue drawn back behind the lower gum and a sucking action like on a straw. I am not sure how colic, frequent regurgitation, and profuse loose stools relate to improper positioning unless they refer to the baby not taking in enough fat-rich hindmilk because he did not stay at the breast long enough, or was so poorly positioned that he could not suck properly. These signs can also be related to intolerance and allergy. Perhaps the author was referring to a 1988 study (11) on switching the baby to the second breast too soon.

Positioning is crucial to successful breastfeeding but must be studied and managed in relation to both what the mother and baby bring to the experience. We must appreciate the differences among mothers and infants and take knowledge from many sources as contributing small parts to the whole.

References

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Ardran GM, Kemp FH, Lind J. A cineradiograph study of breastfeeding. Br J Radio1 1958;31: 156-162. Woolridge MW. The “anatomy” of infant sucking. Mid- wifery 1986;2: 164- 171. Weber F, Woolridge MW, Baum JD. An ultrasonographic study of the organisation of sucking and swallowing by newborn infants. Dev Med Child Neurol 1986;28:19-24. Meier P, Anderson GC. Responses of small pre-term in- fants to breast- and bottle-feeding. Maternal Child Nursing

Lawrence RA. Breastfeeding: A Guide for the Medical Profession, 2nd ed. St. Louis: C.V. Mosby, 1985:26. Neville MC, Neifert MR. Lactation: Physiology, Nutrition and Breast-Feeding. New York: Plenum Press, 1983:23. Morris SE, Klein MD. Pre-Feeding Skills. Tucson: Therapy Skill Builders, 1987:28-29. Braun MA, Palmer MM. Early Detection and Treatment of the Infant and Young Child with Neuromuscular Dis- orders. New York: Therapeutic Media, 198352. Smith WL, Erenberg A, Nowak A. Imaging evaluation of the human nipple during breast-feeding. Am J Dis Child 1988; 142:76-78. Morris SE. The Normal Acquisition of Oral Feeding Skills: Implications for Assessment and Treatment. New York: Therapeutic Media, 1982. Woolridge MW, Fisher C. Colic, “overfeeding,” and symptoms of lactose malabsorption in the breast-fed baby: A possible artifact of feed management. Lancet 1988;28:

1987;12:97-105.

382-384.

Author’s Response Maureen K. Minchin, M.A. (Hon.), I.B.C.L.C.

Two main areas need discussion. Walker rightly as- serts, as I concluded, that not only positioning, but also matters relating to maternal and infant

anatomy and behavior affect the feeding process. In a fuller presentation (such as the pamphlet from which this article was excerpted), these will be dis-