I read the article a few days ago and noticed the same thing -- scissor [sic]
grasp is prominently shown in the illustration as the preferred hold.  The
C-hold or palmar grasp is indicated to be incorrect.

The article's text emphasizes that with the C-hold or (as Lawrence states in
her textbook BREASTFEEDING: A GUIDE FOR THE MEDICAL PROFESSION on p. 251 of
the 5th ed.) the Palmar Grasp the thumb is apt to press into the breast
thereby pointing the nipple upward which is indicated to be a disadvantage.

Also in her textbook it is emphasized that the scissor [sic] grasp "is the
placement of the thumb and index finger above the areola and the other three
fingers below the breast for support, thus allowing some compression of the
breast."  She goes on to say that the scissor [sic] grasp "has been used for
centuries and was shown in sketches and paintings even before the Christian
era.  If the hand is large or the breast small, it may not work as well as
the palmar grasp."  The scissors grasp is presented first in her textbook.

As for the palmar grasp Lawrence states in her textbook on p. 251 , "If too
much pressure is exerted by the thumb, the nipple will be tipped upward,
causing abrasion of the underside."  This may be the reason the illustration
in the JAMA article indicates the palmar grasp to be incorrect.  But Lawrence
in her text goes on to tell when the palmar grasp is useful.  It would seem
that the JAMA article is presenting a limited and therefore inaccurate view
of breast holds.

I have a number of comments about this article and what Lawrence writes in
her book. (I do not have the article in front of me as my daughter moved it
and I cannot find it, so I hope I am accurate.)

1.  After having worked for over twenty years with slightly older infants and
over four years with newborns in a hospital I have come to realize that no
single hold works for all mothers and babies.  I think we do women and their
infants a disservice when information is given to health professionals that
limits the ways to grasp the breast.

Over and over again I have observed that a mother often instinctively uses a
grasp that works for her breast's degree of softness and her nipple's
reaction to being presented.  The very problem indicated with the palmar
grasp in the article of the nipple being directed upward can be a component
of a successful latch depending upon how the breast is presented.

 Some mothers with large soft breast and receding nipples pinch up some skin
medial to the areola which seems to compress and stabilize the areolar nipple
complex, and they then allow their fingers to enter the baby's mouth,
releasing the hold when the baby starts to suckle in order.

If one follows the recommendation in Best Feeding positioning a baby so that
the lower lip is further from the nipple than the upper, lip having the
nipple pointing slightly upward as the baby comes onto the breast can work
fine.  In fact this method of latch is the one I use most successfully with
two day-old babies who have been referred to me for a consultation.

I also see mothers using a scissors hold and the only thing I do is point out
to them how to keep their fingers far enough away so as not to block the
baby's access.


2. The article includes a description of an infant's tongue when feeding from
an artificial teat.   Michael Woolridge's 1987 article is attributed to be
the source for a description of how a baby suckles at a feeding bottle.
Every time I hear this description of a baby using an artificial teat and
using his tongue to stop the rapid flow of milk from the hole in the teat and
thereby a totally different tongue motion from that of a breastfed baby I
cringe.  I have viewed many times the cineradiographic films that Michael has
shown at conferences as well as the ultrasound studies. I've even discussed
with him that fact that the baby on the artificial teat has a normal front to
back wave motion of the tongue and I believe Michael Woolridge agreed with
me.   Every time I see the film of the baby feeding from the bottle and
drinking the barium it is clear that that baby is using a front to back wave
motion of the tongue -- very similar if not identical to the baby at the
breast.  I think this "baby using his tongue to stop the flow" description is
one that has been passed on repeatedly without much critical thinking and
needs to be reexamined.

There are a number of factors that might influence how a baby suckles on an
artificial teat:  the length of the teat, how much of the teat is placed in
the infant's mouth, the infant's ability to produce suction, the shape of the
teat, the shape of the nipple hole, the diameter of the nipple hole.  We know
that many holes are now laser cut and more consistent in diameter.  See the
book on infant sucking and swallowing disorders for an analysis of these
factors.

3.  Interestingly this JAMA article tells us that the mother who case is
presented sought help for what was diagnosed as mastitis and insisted she did
not want to use antibiotics.  Instead she used some herbal preparations and
the mastitis resolved quickly and without sequela.  I appreciated how that
information was presented in a matter of fact way, but the fact that
antibiotics were not used is never addressed in the rest of the article.  But
it is food for thought.  Chloe Fisher has told us in lectures that in England
mastitis is first considered and treated as only an inflammation of the
breast tissue due to leakage of milk from between the cells that produce milk
whose tight gaps have not yet been established.  The milk acts as an irritant
to the tissue and inflammation ensues.

I'm glad that this article appeared in JAMA and I hope it stimulates
discussion in many HCP circles.

Mardrey Swenson

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