Dear Friends,

I've been intrigued with the *smooshing* discussion, and here's the reason
why.

Some of you remember that I developed a 10-point Apgar-type scoring tool for
breastfeeding that was published in the Journal of Human Lactation in 1992.
It's called the MBA or Mother-Baby Assessment, and my intent was to track the
behavior of a mother and baby who are learning to nurse and find a shorthand
way of identifying the elements of breastfeeding with which they still need
help.

The MBA divides a feeding into five steps: signaling, positioning, fixing (or
latching), milk transfer, and ending.  Each partner of the dyad has certain
jobs to do at each step, or so I thought when I developed the tool...except
perhaps for the third step. I knew even then that some babies will latch
themselves on once mom gets them into position, so there wasn't always
something that mom was obliged to do in order for the baby to latch on well.
In the original MBA, the instructions say to give mom her point for Fixing
even if she didn't need to DO anything to get the baby on.

But now here we are in 2002, discussing whether or not a mom DOES need to DO
anything, once her baby is in good position...and that means nose to nipple,
entire ventral surface of body facing mom's body, butt tucked in close to her
body (hips slightly flexed), chin touching breast (head slightly extended),
well-supported from head to toe (no body parts are dangling).  And I think
the correct answer is...sometimes.

Maybe the mom uses a hand to steady her breast and keep it from flopping
around while baby roots his way towards it.
Maybe she expresses drops in order to give the baby some tactile, taste, and
smell cues of where he's going and why.
Maybe she compresses the breast slightly along the baby's ear-to-ear axis
(the hoagie technique) to fit into his mouth better.
Maybe she aims the breast onto his tongue once he has opened wide, trying to
gain a few millimeters' deeper latch.
Maybe she snuggles him in closer with her baby-holding arm as he lunges for
the breast.

If we could fast forward to watch this same nursing pair two months later
(...or perhaps as little as two weeks later), we probably wouldn't see her
doing any of these things, because by then she and the baby will be
experienced old hands at nursing, and the baby will be hitting the target
100%---latching himself on once mom has made the breast available.

So my question is this: SHOULD we be teaching mothers any of these little
"tricks" for helping a baby latch on?  Or is it always sufficient just to get
the baby into a perfect position, when the baby is in the perfect mood...or
to get the baby into a perfect position and WAIT for the baby to be in the
perfect mood?  Or does being in the often-imperfect environment of the
hospital require nurses, LCs, and other helpers to have a Bag of Tricks ready
to use for couples who aren't getting it yet?

My common sense tells me that the Bag of Tricks is the LC's stock in trade.
Just the way a midwife or a doula or a good labor nurse knows all sorts of
ways to help a laboring mother get more comfortable and assist the natural
forces of birth, the LC needs to know lots of ways to help a mom and baby
learn to breastfeed.  Of course midwives have to pay attention to the
environment for birth as well; the better environment they can provide for
the mother, the less they may need to reach into the Bag.  But there will
always be *natural circumstances* that call on the midwife's skills---a
difficult presentation, moms who begin labor in varying states of
rest/fatigue, emotional needs of the mom and her previous experience with
labor...many, many variables. What makes a good midwife is experience and
judgment about WHEN to intervene, good skills in her interventions, ability
to evaluate whether her interventions are helping or hurting, knowing her
limitations and resources, and ability to communicate about what she does so
that others can learn and understand.

And isn't it the same for LCs?

So, to get back to the question of smooshing: is it EVER acceptable to smoosh
a baby onto the breast?

Well, my answer is....that depends on your definition of *smoosh.*  And it
also depends on the circumstances.  If the blood sugar clock is ticking, and
you know someone else is going to come at the mom and baby with a bottle of
formula if he doesn't nurse, and you can see that he's almost there but
something just isn't pushing his buttons, then to give him a gentle boost
onto the breast, with mom's permission, might be one of the LC's options from
her Bag of Tricks.  It's a matter of skill and judgment to decide whether
this intervention is more likely to contribute to long-term breastfeeding
success than another intervention, which could be letting someone give the
baby formula from a bottle and trying again later, or could be leaving the
baby skin-to-skin with mom and coming back in half an hour.

In the hospital where I worked for 19 years, support for breastfeeding was
variable.  Motivation of moms and families was variable.  There was lots of
medication use.  Sometimes I smooshed, and it worked.  Sometimes it didn't
work.  Sometimes I didn't smoosh, and that worked.  Sometimes moms gave up
anyway, no matter what I did.  Sometimes they succeeded, no matter what I
did.

It's a big job to collect the evidence that we need in order to establish an
evidence base.

Very interested in Swarthmore  PA (eastern USA)
Chris Mulford

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