Positioning, Latch-On, and the Baby’s Suck – [Latch-On] – Part 3

Positioning, Latch-On, and the Baby’s Suck – [Latch-On] – Part 3

LATCH-ON—HOW THE BABY GOES ON TO THE BREAST

Support the Breast When Needed

The purpose of supporting the breast is to make it firmer for easier latch-on and to keep its weight off the baby’s chin during feedings so that he stays latched-on well.

Even a mother with small breasts may find that during the early weeks of nursing some breast support helps her achieve better positioning and latch-on. Most mothers find that their breasts are at their largest during the early weeks of nursing and that some support is helpful.

The C-Hold of the breastThe C-hold—thumb on top and four fingers underneath—allows the mother to gently support her breast without distorting the nipple. It also makes it easier to keep her fingers well behind the areola so that they will not be in the baby’s way as he latches on to the breast.

Because a mother cannot easily see where her fingers are in relation to the underside of her areola, suggest that as she begins to support the breast she check carefully to be sure her fingers are far enough back so that they are not covering any part of the areola.

Suggest the mother with large breasts concentrate her efforts on supporting only the part of her breast near the areola. She does not need to be concerned about supporting the rest of her breast, although some large-breasted mothers find it more comfortable to put a rolled- up baby blanket or small towel underneath the breast to raise and support it slightly.

Although it has been used for centuries and is often seen in breastfeeding photos or paintings, the “cigarette” or “scissors” hold—with the breast held between the mother’s index and middle fingers—has disadvantages. Because the mother’s fingers cannot stretch as far apart as the thumb and the fingers in the C hold, they may get in the baby’s way as he tries to latch on, preventing him from taking the breast far enough into his mouth, which can contribute to sore nipples. Some mothers using this hold actually restrict the amount of breast tissue that the baby can take. The extra pressure the fingers put on the breast may cause plugged ducts.

Barbara Heiser, a La Leche League Leader, registered nurse, and board-certified lactation consultant, developed a technique she calls the “nipple sandwich,” which makes latch-on easier for some mothers.

Nipple Sandwich

The mother first uses the C-hold to support the breast, with her fingers under the breast and her thumb on top. Both fingers and thumb need to be well behind the areola (Step 1).

The mother then gently squeezes her fingers and thumb slightly together. This makes the areola area oblong, instead of round. This means that there is now a narrower part for the baby to latch on to (Step 2).

The mother then pushes in toward her chest wall or ribs. This helps the nipple protrude farther, which makes it easier for the baby to grasp (Step 3).

Finally, the mother pushes in with her thumb more than with her fingers. This makes the nipple point slightly upward toward the roof of the baby’s mouth (Step 4).

After making the “nipple sandwich,” the mother encourages the baby to open wide and pulls him in close, as described in the following sections.

Mothers with large breasts may need to support their breast throughout the feeding until their baby is older, so that the weight of their breast does not rest on the baby’s chin. Supporting and lifting the breast also helps the mother with large breasts to keep her breast from covering the baby’s nose and keeps the breast in the baby’s mouth. Unsupported, the weight of the heavy breast would put pressure on the baby’s mouth, making it difficult for him to stay well latched-on. If the baby slips down to the nipple, he won’t get as much milk for his efforts and may damage the mother’s nipple.

Encourage the Baby to Open His Mouth Wide

After the first day of breastfeeding, it is normal for a mother’s nipple to feel a little tender at the beginning of a feeding when the baby’s first sucks stretch the nipple and areolar tissue far back into his mouth. This temporary tenderness usually diminishes once the milk lets down and disappears completely within a few days.

Aside from this normal tenderness, breastfeeding is not supposed to hurt. Sore nipples usually indicate that the breast needs to be farther back in the baby’s mouth where it cannot be gummed or chewed. If poor latch-on is the cause of the soreness, breastfeeding should be comfortable within a day or two after latch- on is corrected.

If the soreness does not improve after three days of consistently working to correct the cause, it may indicate a sucking problem in the baby, which may mean he is not receiving enough milk. (See the later section “The Baby’s Suck.”)

When the mother and baby are positioned comfortably, the baby should already be in front of the mother’s nipple. Then he will need to open his mouth wide as he latches on and is pulled in close.

How wide is wide? Descriptions vary. In some parts of the world, breastfeeding counselors tell mothers their baby should open wide, “like a yawn.” Because most mothers have seen their babies yawn, this gives them a useful comparison (as well as confidence that their baby can open wide). Although there are important differences between a baby yawning and a baby with a mouth open wide for breastfeeding (tongue placement, for one), this image clearly conveys the idea of “how wide” to many mothers. In England, the expression “wait for the gape” is used to describe not only “how wide” but also the need to wait. It could also be described as “open wide like a baby bird waiting for the worm.” Whatever description is used, however, the basic idea is the same. For a good latch-on, the baby needs to open very wide, and the mother needs to wait until he does before pulling him in close.

Opening wide is vital because in order to breastfeed effectively the baby must take the breast far back into his mouth. To release the milk, the baby must compress the milk sinuses which lie well back from the nipple within the breast (about an inch to an inch-and-a-half). To do this, the baby’s gums need to bypass the nipple completely and take in a large mouthful of breast. While the baby is opening wide, as the mother pulls him onto the breast, she should center the nipple in the space between the tongue and the baby’s upper lip. Since the baby’s lower jaw does most of the work during feedings, the baby’s lower jaw should be as far back as possible from the nipple and his chin pressed into the breast.

Good latch-on is also important for the mother’s comfort. Barbara Heiser suggests an easy way to explain to the mother the importance of proper latch-on. Ask the mother to put her index finger in her mouth just back to the first knuckle and then suck on it. She will feel how her tongue rubs the end of her finger. This is what happens to her nipple when the baby does not get enough of the breast in his mouth. Now ask the mother again to put her index finger in her mouth, but farther back, between the first and second joint, and suck as she did before. This time there is no rubbing. The tongue comes up under the finger, compressing it against the roof of the mouth, and does not touch the end at all. This vividly illustrates why getting the breast farther back into the baby’s mouth can make the difference between sore nipples and comfortable breastfeeding.

Babies are born with a reflex that causes them to open their mouths wide when properly stimulated. To trigger this reflex, suggest the mother lightly tickle or brush her baby’s lips with the tip of her nipple and wait until the baby opens his mouth. (If the mother uses too much pressure, this will not produce the same response.) For some babies this may take some time, so encourage the mother to keep tickling or brushing and be patient. Some babies respond more quickly if just their bottom lip is lightly brushed or tickled.

The mother can teach her baby other cues to encourage him to open wide. By saying the word “open” as she tickles or brushes the baby’s lips and then opening her own mouth wide, he will learn to associate the word “open” and the mother’s open mouth with the desired behavior. Rewarding him with the breast will reinforce this.

If the baby doesn’t open his mouth, or doesn’t open wide enough, the mother can open the baby’s mouth wider by gently but firmly pulling down on the baby’s chin with the index finger of the hand supporting the breast as he is opening. It is important to pull down as the baby is opening because the baby’s jaw muscles will be relaxed at that time. If the mother has a helper, suggest the helper pull down on the baby’s chin as the mother is latching him on.

Pull the Baby in Close and Keep Him Close

When the baby’s mouth is opening wide, encourage the mother to pull him in quickly and gently so that he takes the breast deeply into his mouth. With a good latch-on, a baby’s lower jaw (which does most of the work of nursing) should be as far back from the nipple as possible. Although the mother probably will not be able to see this herself, a helper may notice that more of the bottom than the top of the areola is covered (Royal College of Midwives, p. 18-19).

The baby should be pulled in so close that his chin is pressed into the mother’s breast. His nose may rest on the breast as well. Some mothers are afraid to pull their babies in this close, because they worry that the baby won’t be able to breathe. But a baby’s nostrils are flared so that he can easily breathe even when his nose rests against the breast.

If the baby’s breathing seems to be blocked by the breast, this is an indication that her positioning probably needs some adjusting. Rather than pressing down on her breast (which could pull the breast to the front of the baby’s mouth), the mother should try lifting her breast and dropping her shoulder or pulling in the baby’s legs closer to her.

Timing is very important. In order to get the baby latched-on well, the mother needs to pull him in quickly when he opens wide. If she pulls him in while his mouth is closing or before it opens fully, he may not latch on well.

During the early days and weeks of breastfeeding—while mother and baby are both still learning—it may take time and patience for the baby to latch on well. If the baby goes on the breast and the mother feels some discomfort or the baby does not seem to be sucking properly, encourage her to gently take the baby off the breast and try again. Allowing the baby to stay on the breast if it hurts the mother or if the baby is not sucking well may result in sore nipples and ineffective breastfeeding. To remove the baby comfortably, suggest the mother break the suction by using one of the techniques listed at the end of this section under “Coming Off the Breast” so that baby cannot clamp down on her nipple as she removes it from his mouth.

Assure the mother that with time and practice, latching the baby on well will get easier and more automatic.

If the mother is using the cradle hold, the baby should be on his side with his whole body facing hers. If they are breastfeeding lying down, the baby’s knees should be pulled in close to the mother’s body. In the football hold, the baby’s knees should be tucked under mother’s arm along her side. Being pulled in close will enable the baby to take the breast deeply into his mouth without his nose being blocked.

To breastfeed well and prevent nipple soreness, the baby will need to keep the breast deeply in his mouth throughout the feeding. Good positioning and support (pillows, cushions, or other props) will help the mother keep the baby at breast height without fatigue or muscle strain.

Without support, the mother’s arm muscles may become tired. If the baby gradually drops below the height of the mother’s breast, the breast will pull forward in his mouth, where his jaws will chew or gum the nipple.

Some babies have a more difficult time than others in latching on and staying on the breast (for example, the baby with a weak suck, low muscle tone, a short tongue, or a short frenulum). For a baby like this, once the baby has opened wide and latched on to the breast, the mother may need to apply steady pressure on the baby’s back or his head (see “Cross-Cradle Hold”) to help him keep his mouth open wide and the breast deeply in his mouth.

The “Dancer Hand Position” (which is pictured and described in “Cleft Lip and/or Palate” in the chapter “The Baby with Special Needs”) gives extra jaw and chin support and is another way to provide extra help for the baby who needs it.

Signs of a Good Latch-On

If the cradle hold or side-lying position is used, the baby should be on his side with his shoulders, hips, and knees facing mother. In the football hold, as well as the other holds, the baby’s mouth should be directly in front of or slightly below the nipple.

The baby needs to take a large mouthful of breast—not just the nipple—into his mouth. Although some recommend that the baby take in “all or most of the areola,” this is not necessary or practical for women with very large areolae, who may achieve a good latch-on with some of the areola still visible. The suggestion that the the baby take in “an inch or more” of the areola has also been called into question because in mothers with very small areolae, the baby may need to take in some of the surrounding breast tissue as well as the areola to achieve a good latch-on.
With a good latch-on, a baby’s mouth should be pulled onto the breast so that the lower jaw is as far back from the nipple as possible, so a helper may notice that more of the bottom than the top of the areola is covered (Royal College of Midwives, p. 18-19). (The mother probably will not be able to see this herself.)

When a baby is latched-on well, his chin should be pressed into the breast. His nose may be lightly resting on the breast. If the breast blocks his breathing, suggest the mother adjust her positioning by pulling the baby’s knees closer to her or by slightly lifting her breast.

If the baby’s chin and nose are away from the breast, it is likely that the baby does not have enough breast in his mouth. Suggest the mother break the suction, take the baby off the breast, and try again.

If the mother (or her helper) sees that the baby’s upper or lower lip are pulled in rather than flanged out, suggest she gently pull the lip out or take him off the breast and latch him on again with his mouth open wider.

If the baby sucks in either of his lips while nursing, it can cause nipple soreness.

If nursing is going well and the mother is comfortable, there is no need to check the baby’s tongue.

If nursing is uncomfortable and the tongue cannot be seen, the baby may be sucking it along with the nipple or using it incorrectly. It will probably be difficult for the mother to see her baby’s tongue while he is nursing, but if she is feeling discomfort, suggest she ask a helper to gently pull down the baby’s bottom lip and see if the tongue can be seen between her breast and the baby’s gum.

If the baby is retracting his tongue, suggest the mother take the baby off the breast and restart him, being sure his mouth is open very wide and his tongue is down when he latches on (Righard and Alade 1992). (See the later section, “Tongue Sucking, Retracted Tongue, or Tip of Tongue Curled Up.”)

Coming Off the Breast

Mothers are sometimes told to limit feedings in the early weeks of breastfeeding to help prevent sore nipples, but if the baby is positioned and latched-on well, there is no advantage to watching the clock. Encourage the mother to watch her baby for cues that he has finished the first breast before offering the other. When the baby has finished that breast, he will come off spontaneously or fall asleep.

Although babies usually nurse for a total of twenty to thirty minutes at a feeding, some babies nurse for shorter periods and others for longer periods. The same baby may nurse longer at one feeding than another.

Allowing the baby to determine when he’s finished will ensure that the baby receives the right balance of the watery foremilk and high-calorie hindmilk. The milk increases in fat content as the feeding progresses, and only the baby knows if he’s had the right amount of both and is satisfied.

If the mother decides to take her baby off the breast before he is finished, suggest she first break the suction to avoid damage to sensitive breast tissue. There are several ways to break the suction:

  • press down on her breast near the baby’s mouth,
  • pull down on the baby’s chin,
  • insert a finger into the corner of the baby’s mouth.
Summary In Points

Support the Breast When Needed

  1. During the early weeks, most mothers find breastfeeding goes more smoothly if they support their breast while latching on and throughout the feedings.
  2. Suggest the mother support her breast with the C-hold—thumb on top and four fingers underneath— making sure her fingers are well behind the areola, especially underneath the breast.
  3. The “nipple sandwich” is another technique that makes latch-on easier for some mothers.
  4. Mothers with large breasts may need to support their breast beyond the learning period.

Encourage the Baby to Open His Mouth Wide

  1. When the baby is latched-on well, the mother should feel little or no nipple soreness.
  2. The baby needs to open wide and take the breast deeply into his mouth for a good latch-on.
  3. To encourage the baby to open wide, suggest the mother lightly tickle or brush the baby’s lips with her nipple.
  4. Other ways to encourage the baby to open wide are to say the word “open,” have the mother open her own mouth, and gently pull down on the baby’s chin as he begins to open.

Pull the Baby in Close and Keep Him Close

  1. If the baby goes on to the breast well, he will take a large mouthful of breast and be pulled in so close that his chin will be pressed into the mother’s breast. His nose may rest on the breast.
  2. If the baby does not go on the breast well, encourage the mother to gently take him off and try again.
  3. The baby’s body should be tucked in close to the mother.
  4. Good positioning and support will help assure the baby stays well latched-on throughout the feeding.
  5. Some babies need extra help in staying on the breast.

Signs of a Good Latch-On

  1. The baby’s body is facing the mother so that he doesn’t have to turn his head.
  2. The baby has taken the breast deeply into his mouth.
  3. The baby is pulled in so close that his chin is pressed into the breast and his nose may rest on the breast.
  4. Once he is latched-on, the baby’s lips are flanged out and relaxed.
  5. The baby’s tongue is cupped beneath the mother’s breast.

Coming Off the Breast

  1. Encourage the mother to let the baby finish the first breast before offering the other breast.
  2. Before taking her baby off the breast, suggest the mother first break the suction.