I have followed the rough treatment topic and the much earlier discussions
about self attachment with great interest, asking myself where do my
practices fall on what I see as a continuum of 2 extremes here.  As with so
many things in life, I think I fall in the middle.

I do see this as a continuum.  At one end, (A) we have the belief that
babies (perhaps all?) should self attach and the faith that they will do so
in a way that yields an adequate milk intake, enhances mother's supply and
doesn't cause nipple trauma.  At the other end, (B) we have rough treatment
with mouths pulled open, faces shoved into breasts, aversive babies and
upset mothers.  I truly believe there is a middle ground of assisted
attachment and that is where I often practice.

I started as an LC in private practice, seeing many 1 - 3 week old babies
who had poor weight gain and/or mothers with traumatized nipples.  These
babies did a lot of self attaching, in ways that would make you shudder.
For them, drawing from many mentors, I found the following, very detailed,
remedial & interventionist moves help.

1) Use a position that gives some control of the baby's head to mom
(football or cross cradle) - line the baby's mouth up to a line coming out
of the breast/nipple and pointing straight into the baby's mouth.  Don't
move the breast to the baby.
For football, make room for baby's feet by turning mom slightly away from
the side being nursed and/or with a firm pillow behind her back, slightly
off centered and away from the side being nursed.  Baby should wrap around
mom on his side, not be sitting on his bottom.
2) Tickle the lips to get the mouth open with the nipple, baby should be
close but not smashed in.  Don't tickle with fingers.  Don't allow a
slightly open  mouth "crawl on".  Keep tickling until baby seeks the breast
with an open mouth.
3) Use pillows to support the weight of the baby, ("V" with point at mom's
front for cross cradle and wrapped around her side + the one off center for
her back for football). Stack pillows to the height of the nipple and be
sure they are parallel to the floor, not slanting downward on one side.
This helps with mothers who are used to holding baby's head.  Lots of
pillows gives them the security to use finger tips only on base of baby's
head and to hold shoulders and neck, not head.
4) The hand holding the baby must have heal of hand between the shoulders
and finger tips supporting the base of baby's head, never cup baby's head
with hand.  Teach mom to avoid "chin on chest or shoulder to ear"
positioning of the baby.
4) Be prepared to move quickly, the wide open mouth usually closes again
quickly.
5) "Hug" the baby in, don't say "RAM".
6) "Nipple sandwich" when needed to get more in.  Be sure to compress the
"sandwich" the way the baby's mouth opens, nose to chin, not check to check.
Lay the nipple over the tongue and lift baby up and over to attach upper
lip.  Must have your grasp of the baby at the shoulders, not the head to do
this.
7) Don't release the sandwich until baby has had a full suckle/pause/suckle
cycle then release slowly, thumb first, then "walk" the fingers out (to
avoid pulling the breast out of position).  Most moms don't have to support
the breast the entire feeding.  Stop releasing the hold on the breast if
pain increases.
8) Don't press on the breast to make an airway, pulls nipple forward and up
in baby's mouth.  Readjust baby if needed, not breast.  Note the easy way
the baby breathes with nose, chin and checks all touching breast.  Note
triangles formed from cheek, nose and breast where air flows.  Adjust head
if needed to open both triangles.
9) Use a footstool to raise knees after rhythmic suckling starts, slide
mom's bottom forward and lean her back, keeping baby hugged in while you do so.

ALL THESE DETAILED (and written) INSTRUCTIONS and sometimes I still have to
"do it" for Mom before she can finally feel what a good latch is like.  I am
not willing to stand back and watch more trauma, more frustration when I
KNOW if I do it once or twice they will see how different a good latch is.
Then, with that confidence instilled, we can work on getting the mom
independent.

If I "do it" for them I give them a few minutes to settle in then we take
the baby off and on and practice EVERYTHING (I even take the pillows away)
until mom can "do it" for herself.  If I wasn't willing to be "hands on"
some of these moms wouldn't even attempt another latch.  With a good enough
latch, almost all of the severely traumatized nipples hurt less, much less.

At a mom's home I try to get behind her to assist so my hands will be at the
same angles as her hands.

Coming from this background I then became a hospital based LC.  Enter the
sleepy 8 to 48 hour old, non-feeding baby who must be supplemented (by
hospital policy) if he doesn't get to the breast....TA DA.... add some
assertive (not aggressive) wake up techniques and the same interventions
work!  Except I can't get behind the moms with our hospital furniture.  A
tip for all hospital helpers.....raise those electric beds while doing hands
on help - it really saves your back.

To wake a sleepy baby:
1) Skin to skin - mom bare to waist and baby in a diaper only - blankets
over baby's back.
2) Massage the baby - don't pet the baby, use moderate pressure that pinks
up the skin.  Remember goal is to wake, not to soothe.
3) Move baby up and down - elicits the "doll's eye" response and wakes them
up.  Support baby well at diaper and shoulders/neck then lift up and down
with your arms or bend at your waist, taking baby up and down.  Bending baby
at the waist "baby sit ups" doesn't work as well as moving the entire baby's
body.
4) Tickle the lips with nipple, entice with expressed colostrum, dry the
mouth and nipple if skin is too slick for baby to feel the tickle.
5) If baby was awake then dozes off, take him slightly away from mom's body
and start over with stimulation.

I am aiming for a baby in a quiet, alert state, not a screaming, upset baby.
I don't use foot flicks or wet wash clothes for this reason plus I don't
enjoy torturing babies and more pragmatically - crying babies have the
tongue on the roof of their mouth, not good for breastfeeding.  I point this
out to parents, "we need to wake the baby but we can do it in a gentle, yet
assertive way".
quickly

I have issues with the need to wake a sleepy baby in these hours, but until
*I* am put in charge babies at my hospital WILL BE FED every 6 hours, at the
breast or by supplement.  I deal with this by being a gentle yet assertive
baby waker-upper, by pumping moms and dropper feeding expressed colostrum,
by using assisted attachment and by being very hands on.

I always have mom's permission to touch her breast, I don't assume it.  I
ask if my pressure is too hard, I look for and back off at subtle signals.
I approach babies gently and with mom's permission.  If I put a gloved
finger in their mouth it is after much lip tickling, gum massage and "asking
permission" of the baby too.

Still, I feel I am put between a rock and a hard place, needing to get these
babies on the breast to prevent the cascade of complication that
supplementing (even with expressed colostrum) can cause while wanting to
instill confidence in the mom in her own abilities.  I bring the subject up,
knowing most moms are thinking "how will I do this on my own?" even if they
don't say it out loud.  I acknowledge the wish to be independent and assure
mom baby's sleepy state is temporary.  I point out to her that when baby is
more awake s/he will be a more active partner and the baby will be her
helper, not me.  I often teach mom's significant other to be a hands on
helper if needed.  This is with mom's permission as well.

I also point out, it is OK to be needy now and talk about societies where
new mothers are supported for long periods of time as opposed to our culture
where moms are expected to be super women and get back to work in 4 weeks,
pumping and smiling while they leave the baby with a sitter.  I may not be
able to change the culture but I want the mom to know the culture is what is
crazy, not her.

So, I do assisted attachments and I will keep doing them.  I'll be careful,
I'll be gentle.  I don't believe in either extreme.



-- Carla (just north of Washington, DC)