The Study I've Waited for Is Finally Here!

Is there a specific approach to early positioning that nursing families can use to reduce by half the incidence of nipple and breast problems? Yes, according to THIS brand-new randomized controlled trial from Italy.

This New Italian Study

For years, when giving talks to lactation supporters, I asked aspiring researchers to please study the impact of using the Natural Breastfeeding (NB) approach to early positioning (aka “biological nurturing” and “gestalt breastfeeding”) on the incidence of nursing problems. The NB approach involves using relaxed, semi-reclined feeding positions (see photos) rather than sitting upright to nurse. From what I knew from experience and previous studies, its impact was huge.

Finally, the study I was hoping for is here, and its conclusions are just what I expected. Its research team randomized 188 pregnant women to one of two groups. Before delivery, the usual-care group was taught to nurse sitting upright. The intervention group watched videos of families using the NB approach. After birth, both groups had skin-to-skin contact with their newborns, were encouraged to nurse on cue, had 24-hour rooming-in, and as needed, were helped in the hospital with the approach to positioning that was consistent with their group.

During the first 4 months of nursing, the researchers found significant differences between the two groups. Compared with the usual-care (upright) group, those using the NB (semi-reclined) approach experienced about half the incidence of nipple and breast problems, such as nipple pain and cracks, engorgement, and mastitis. Before hospital discharge, the NB group had fewer latching struggles. Although not statistically significant, the study team noted a trend toward more exclusive breastfeeding among those in the NB group.

The study’s authors concluded that the NB approach was effective in a real-life hospital setting and that anything that cuts in half the incidence of nipple and breast problems “has the potential to become an important public-health measure for the promotion of breastfeeding.” These conclusions were the same I reached more than a decade ago.

The Natural Breastfeeding Approach

My own “aha moment” about early positioning came in 2009, when I happened upon a UK STUDY that challenged my assumptions and changed my practice. As I began to use this new positioning strategy, I saw many families quickly overcome some of the thorniest nursing challenge simply by making small changes in their nursing positions. There will never be an intervention that works 100% of the time, but because this one takes advantage of the innate feeding behaviors present in healthy babies at birth, I’ve found that in most cases, it makes a great starting point.

When I promoted this approach during my talks to clinicians, sometimes my colleagues were willing to give it a try—often only as a last resort—but more often they weren’t or told me later, “I tried it once and it ‘didn’t work.’”

An entrenched practice such as upright positioning can sometimes be difficult to change. But I kept honing my message and developing new teaching tools, because I saw with my own eyes what a night-and-day difference it made for so many families struggling to nurse their newborns.

NB Digital Teaching Tools

As I attempted to find the words and images that made this approach easier for parents and professionals to use, I partnered with OB Dr. Theresa Nesbitt. We named this approach Natural Breastfeeding and created a simplified vocabulary and easily accessible visuals. We included a free demo video on the home page of our Natural Breastfeeding website HERE, so families can become familiar with this approach both before and after birth. We hoped that watching a diverse group of mothers with different body types discussing the adjustments that worked for them might get the message across in a format many of today’s parents prefer. I created an ad-free YouTube channel HERE, where families and colleagues can watch short clips of mothers and newborns using the NB approach.

For providers, we created the Natural Breastfeeding Professional Package (NBPP) HERE, which offers licensing rights to use our teaching videos and images in hospitals, public-health departments, and private practices. (See also our short video about the NBPP HERE.) A subscription to the NBPP allows providers to give an unlimited number of families access to our 6-module NB digital program. A perfect educational option during a pandemic, families can view this lactation course (and its more than 60 short videos) before and after birth at their own pace on their phones, tablets, and computers. The NBPP also includes staff training materials and handouts.

For those who still think that nursing upright during the newborn period is best, it’s time to rethink this assumption. Please read this new study, watch our videos, and give the NB approach a try. For a more detailed, fully referenced explanation of the NB approach, see Chapter 1 of my new book for lactation supporters, Breastfeeding Answers, Second Edition.

Introducing Natural Breastfeeding

All mammals are born with responses that Mother Nature builds in to enable them to get to their food source and feed. Yet today, the way most mothers are taught to breastfeed ignores what our babies bring to the table, making early breastfeeding harder than it needs to be. It’s no wonder then that during the first week after birth, 92% of the nursing mothers in one study reported major breastfeeding challenges.

Instead of tackling individually each breastfeeding issue—latching struggles, milk supply concerns, sore nipples--what if there was a single way to address many challenges at once? That’s what Natural Breastfeeding is all about.

What are the roots of this innovative new approach to early breastfeeding? To create the Natural Breastfeeding program, obstetrician Theresa Nesbitt (“Dr. Theresa”) and I drew from the work of many: the Swedish breast-crawl researchers, UK scientist Dr. Suzanne Colson, international brain-science experts, the Prague School, and Americans Dr. Christina Smillie and Dr. Brian Palmer. When we put together these diverse-but-related puzzle pieces, what emerged was our new prenatal preparation program, Natural Breastfeeding: For an Easier Start.

Every baby is born with her own internal GPS, so baby knows where she is and what to do. If a mother knows how to activate and use her baby’s GPS, she can avoid many common early breastfeeding struggles. At the same time, Natural Breastfeeding allows a mother to relax completely, so she can nurse in comfort and rest while baby feeds. In most cases, she can even breastfeed hands free. By taking full advantage of an infant's inborn feeding behaviors, even a brand-new baby can be the active breastfeeding partner Mother Nature intended.

The Natural Breastfeeding program prepares pregnant women for breastfeeding with more than 60 short videos and 100 images of diverse women learning about and using Natural Breastfeeding. This interactive program, which mothers can access on their tablets, computers, and smartphones, is mother-friendly, jargon-free, and fun.

Amazingly, science has already weighed in on this 21st century innovation. One 2015 study found that tablet-based prenatal breastfeeding education can increase breastfeeding initiation, duration, and exclusivity. In other words, this modern, high-tech approach works and can help more mothers reach their breastfeeding goals.

Before a pregnant woman gives birth, the demonstration videos and simple exercises in the Natural Breastfeeding program make its concepts clear and integrate its moves into her body memory. Even if her birth attendants are unfamiliar with this approach, after completing this program, a mother should be able to make it work on her own.

Natural Breastfeeding is like the training wheels on a bicycle. While mother and baby are learning, it helps them avoid unnecessary pain, strain, and struggle. By making the most of what baby can do, Natural Breastfeeding helps mothers use the behaviors built in by Mother Nature to successfully feed and nurture their newborn.

Intrigued? To view some of our basic videos, see our 38-minute video on our NaturalBreastfeeding.com website HERE, go to my YouTube playlist HERE, or browse the videos on my YouTube channel HERE.

If a pregnant woman wants to prepare for breastfeeding rather than just planning to breastfeed, she can download this program at www.NaturalBreastfeeding.com.

Please help us spread the word.

Coping with Fast Milk Flow

Mother's question: "I need help! My daughter is a week old tomorrow and I can’t seem to get my milk flow under control. It just pours out and she chokes. What do I do to make it easier for her?"

During the early weeks, while your milk supply is adjusting to your baby’s needs, your feeding position can make all the difference. If you sit straight up during feedings, your milk flows downhill into your baby’s mouth, which makes coping with milk flow more difficult for her. Instead, use positions like those pictured here. Move your hips forward and lean back with baby’s whole body resting on yours so your baby’s head is higher than the breast. In these positions, gravity makes milk flow easier for her to manage. Many mothers also find these positions much more comfortable.

You can read more about these positions at this post.

Lying on your side to breastfeed can also help because baby can let overflow milk dribble out of her mouth rather than having to swallow fast to prevent choking. (Lay a towel under baby first!)

Most important is never to hold your baby’s head to your breast when she wants to pull off and catch her breath. Fingers crossed these tips help!

Doing It Right

Today my guest blogger is one of my favorite people in breastfeeding, Diane Wiessinger, coauthor of the new The Womanly Art of Breastfeedingand author of the seminal article “Watch Your Language,” which forever changed how we think about the “benefits” of breastfeeding. 

I took my young son to a Chinese restaurant for lunch years ago.  I asked our waiter to show us the right way to use chopsticks.  “Well,” he said, scanning a nearby table of Chinese waiters, all busy eating lunch, all with chopsticks, “None of them are doing it right.”

Whether we’re eating, walking, or putting on socks, we don’t have to do it “right”; we just have to do it so it works for us.  So why are there so many rules about breastfeeding?  And why don’t they work very well? 

More than 30 years ago, when my first child was born, there were no rules at all about how to make a baby take the breast (there was no such thing as The Latch).  All anyone knew was that if a baby’s cheek is touched when he’s hungry, he responds by turning his head with a wide, searching mouth.  It was the height of the natural childbirth movement, and many of us who were interested in breastfeeding also had medication-free births, which meant our babies were competent from the start.  Skin-to-skin was unheard of, our babies were kept in central nurseries, often they had a bottle before their first nursing… but most of them latched with little or no difficulty.  It didn’t occur to us that they might not.

Trouble is, we were sore, often for weeks.  So the field of Lactation Consultants began – not to help babies latch, but to figure out what caused the pain.  We LCs looked carefully at each tiny piece and realized that the pain was usually from holding the baby as if for bottle-feeding.  But we broke everything into tiny steps, created rules about how to do each step “right”… and the whole thing worked even less well.  Now we began seeing non-latching babies!  So we added more rules, and more, and mothers’ confidence eroded.

When a baby learns to walk, he’s pretty awkward.  He falls a lot, he wobbles, but no one says, “Oh dear, if you don’t take that baby to a specialist, he’ll never walk right.”  Everyone knows he has the basics built in, and just needs time.  Making him follow a detailed set of rules would probably drive him back to crawling! 

That’s what happened with breastfeeding.  We laid down rules for something that had never had any, and we left mothers feeling incompetent and babies feeling totally confused. 

So try this:   lean back comfortably, your baby’s whole front on you, and let gravity take care of the holding.  Your baby lies there with his cheek against your breast.  If he’s hungry, he turns toward his cheek, and there’s that wonderful nipple right nearby.  You’ve done nothing in particular (in fact, any fumbling that you do probably helps), and he chooses the moment that suits him best.  What a concept! 

Are you doing it right?  Well… if both of you are comfortable and the milk is flowing, what else could possibly matter?  Let the Lactation Consultants save their problem-solving for if you have a problem. 

Some Ins and Outs of Laid-Back Breastfeeding

In an earlier post I explained why it’s time to change the way we teach breastfeeding.  I described research findings indicating that early breastfeeding is easier when mothers lean back with their babies’ weight resting on their body.1  (See my new Blog History category “Laid-Back Breastfeeding” in the right column for a link to all my posts on this subject.)  These laid-back positions not only make breastfeeding less work for mothers, they also make it easier for babies to take the breast deeply, especially during the early weeks.  That’s because in these positions gravity helps rather than hinders babies’ inborn feeding reflexes, which can make a huge difference when babies are at their most uncoordinated. 

After decades of teaching mothers to breastfeed sitting upright or lying on their sides, many have difficulty visualizing this new approach.  One common question I am often asked is whether these positions are practical after a cesarean birth.  The answer is most definitely yes.

A number of adjustments can be made to help a mother customize laid-back breastfeeding (also known as “Biological Nurturing”) to her body type and situation.  As you can see from these line drawings, one adjustment is changing the direction of the baby’s “lie” on her body.  In all laid-back positions, baby lies tummy down on mother, but this can be accomplished in many ways.  The baby can lie vertically below mother’s breast (as on this website’s banner), diagonally below the breasts, across her breasts, at her side, even over her shoulder.  As Suzanne Colson explains in her DVD, “Biological Nurturing: Laid-Back Breastfeeding,” the breast is a circle, and the baby can approach it from any of its 360 degrees, except for positions in which the baby’s body covers mother’s face.  So after a cesarean birth a mother can use many laid-back positions without baby resting on her incision.

Another possible adjustment is the mother’s angle of recline, or how far the mother leans back. In laid-back positions, the mother leans back far enough so that her baby rests comfortably on her body without needing to support her baby with her arms but is upright enough so she and her baby can easily maintain eye contact.   Because most hospital beds are adjustable, finding their best angle of recline is especially easy during the hospital stay.  At home, I suggest mothers imagine the positions they use to watch their favorite television show.  Most of us lean back on a sofa, chair, or bed, using cushions or pillows so we can relax our shoulders, head, and arms.  Colson says the best laid-back breastfeeding positions are those that mothers can easily and comfortably maintain for up to an hour.

When using laid-back breastfeeding, ideally each mother finds her own best variations by trial and error.  In light of these insights, I think the time has come for us to stop naming and teaching specific breastfeeding “holds.”  (After all, no one teaches bottle-feeding mothers how to hold their babies during feedings!)  That way, mothers will no longer waste their time trying to duplicate feeding positions taught in classes or pictured in books that may not be right for them or--even worse--may even make early breastfeeding more difficult. Instead, each mother’s focus will stay exactly where it belongs: on her and her baby.

Reference

1 Colson, S. D., Meek, J. H., & Hawdon, J. M. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development 2008; 84(7):441-449.

Changing How We Teach Breastfeeding

We are experiencing a sea change in breastfeeding.  But how quickly can we change our approach?  At a breastfeeding conference last weekend, I summarized breastfeeding teaching strategies since 1980, how our understanding has evolved, and how this affects the way we help mothers. 

In 1980, I was told to breastfeed my first baby by holding him in my arms with his tummy facing the ceiling, which I realize now was a bottle-feeding position.  Over time, these instructions changed.  Instead, we recommended mothers hold their babies “tummy to tummy.” To make latching easier, we suggested breast support using the “C” hold and “U hold.”  We incorporated a variety of techniques for helping babies achieve an asymmetrical—or off-center—latch.  

However, in 2008, U.K. researcher and midwife Suzanne Colson published an article indicating that some of our fundamental assumptions had been wrong.  Not surprisingly, our “latching” or “attachment” instructions had been influenced by what we grew up seeing.  Generations of bottle-feeding had convinced us that mothers needed to sit upright or lie on their sides to breastfeed their babies.  

What changed?  In her research, Colson identified 20 inborn reflexes that help babies breastfeed.  And surprise!  Like baby piglets and other newborn mammals, Colson found that these reflexes work best when our babies feed on their tummies.  It turns out that all those years of teaching upright and side-lying breastfeeding positions may have been wrong-headed.  Although our tried-and-true methods make sense in some situations, rather than using them sparingly, we taught all new mothers to breastfeed this way.  As a result, gravity pulled babies away from their mothers’ bodies and made breastfeeding more challenging.  Colson noted that as “positioning and attachment” techniques became more widely taught in the U.K., more new mothers gave up on breastfeeding early. 

Colson’s research demonstrated that when mothers simply lean back and rest their babies tummy down on their semi-reclined bodies, most of our complicated latching instructions are no longer needed.  In “laid-back” positions, gravity keeps mothers and babies touching and helps rather than hinders breastfeeding. 

Last week I spoke to a mother with a 5-day-old baby who at first had decided to formula feed because her baby wouldn’t take one breast and breastfeeding was just too hard.  But then she felt her milk increase and decided to give it another try.  Her goal was to do some breastfeeding and some formula-feeding.  I told her about laid-back breastfeeding positions and steered her to http://www.biologicalnurturing.com/ to watch Suzanne Colson’s video clips.  When we spoke again yesterday, her 10-day-old baby was now exclusively breastfeeding and she told me how much easier laid-back breastfeeding had been for her. 

After my conference talk, many of my listeners—most of whom work with breastfeeding mothers every day—struggled to accept this new approach.  Clearly much thought and reflection was needed before many could translate this knowledge into practice.  Major paradigm shifts are never easy.  But for the sake of mothers and babies, here’s hoping this one doesn’t take too long! 

For more on laid-back breastfeeding, see my earlier post: /blog/2010/7/18/laid-back-breastfeeding.html

Reference

Colson, S. D., J. H. Meek, et al.  Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev 2008; 84(7): 441-9.

Laid-Back Breastfeeding

One reason breastfeeding has gotten the reputation of being so much work is that many mothers use feeding positions that cause muscle strain and require supporting baby’s weight with their arms for long periods. Now there is an alternative. 

In the research she conducted for her PhD thesis, British midwife Suzanne Colson analyzed the effects of gravity on breastfeeding in 93 videotaped feeding sessions of British and French mothers during the first month of life.  After scrutinizing these videos, Colson identified 20 inborn reflexes babies use to get to the breast, latch on, and feed.  These reflexes are triggered best when baby feels light pressure against her chin, torso, hips, legs, and feet.  They can be triggered when a mother breastfeeds sitting up or lying on her side—the breastfeeding positions traditionally taught—but Colson’s research found that in these positions, gravity makes breastfeeding more challenging.

When the study mothers tried to breastfeed sitting up or lying on their sides, gravity pulled their babies’ bodies away, creating gaps between them. Many babies became frustrated and upset when their feeding triggers were missing. One baby of an upright mother began batting at the breast, a reflex Colson refers to as “arm cycling.”  This mother finally gave up, assuming her baby did not want to breastfeed. The pull of gravity caused other babies to arch away and fuss, making attachment difficult. More upright or side-lying mothers found breastfeeding to be a struggle.

When mothers used what Colson calls laid-back breastfeeding(mothers leaning back with all body parts well supported and their babies lying tummy down on their semireclined bodies), the dynamics were very different. Gravity kept their babies’ bodies securely against theirs so no gaps could form and feeding triggers were continuous rather than interrupted. There were far fewer breastfeeding struggles, and the mothers perceived breastfeeding more positively. One reason may be that in laid-back positions, mothers were freed from supporting their babies’ weight with their arms. One of these mothers said, “Breastfeeding is so easy. I wish more of my friends were doing it.”

Colson concluded that human babies, like hamsters and puppies, feed best on their tummies.  From a practical standpoint, breastfeeding in laid-back positions is a lot less work. Thanks to gravity, baby’s chin, torso, legs, and feet automatically stay in contact with mother’s body and mother’s body supports baby’s weight throughout the feeding.

Especially during the early weeks, using laid-back positions reduces the steps mothers need to remember about getting their baby latched on deeply.  Good breastfeeding dynamics occur almost automatically, allowing mothers to focus on their baby instead of what they need to do next.  With gravity helping instead of hindering breastfeeding, the same reflexes (such arm cycling) that can get in the way in other positions actually make it easier for baby to get to the breast and attach deeply. Having at least one hand free also makes it easier for mothers to help their newborn or just to stroke and enjoy her. If desired, variations of laid-back breastfeeding can also be used when mother and baby are out and about.  Mothers can just scoot their hips forward in their chair and lean back.

For more information, see Colson’s website at www.biologicalnurturing.com and see her DVD, “Biological Nursing: Laid-Back Breastfeeding.”

Reference

Colson, S. D., Meek, J. H., & Hawdon, J. M. (2008). Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449.