Yesterday, in my reply supporting Marie Davis's earlier comments about the
problems with the aggressive approach to teaching latch,I was fairly
inarticulate about my criticism of the RAM technique, and didn't describe
very well what I do instead. I did paste in my handout for moms, but it lost
a lot by losing its formatting as a text file for lactnet.
And a brief overview handout for moms is just not enough to explain what we
do in our office.
Below I've distilled some of what I've put into talks for medical residents
and LLL leaders, etc. to explain our technique and its rationale. I've left
out all the neuroendocrine, biobehavioural and psychobiological background
to all of this, although it's facinating.
Causes of latch refusal, tight painful latch, etc.
Problems with the current way latch is taught:
Sometimes baby is taken from crib and put straight to breast, no cuddling
with mom first: Baby hasn't gotten aclimated to being back in mom's arms,
and immediately gets the sense of an agenda.
We usually start with some horizontal "breastfeeding position" which mom may
or may not be awkward with, arms uncomfortable. But babies we know usually
prefer to cuddle vertically: So we already start out with a tense baby,
"hypertonic," those arms in the way.
Then we just put that head and mouth straight to nipple: Causing the baby,
not yet ready to latch, to respond defensively: mouth shuts down, closes
"too small"
Then we try to "tease" baby's mouth with nipple: Baby gets more defensive,
tenses up, including tense tongue, which I think can cause later "suck
dysfunction" if baby actually gets onto the nipple in this tense condition.
Then we ask moms to push their babies onto the breast with "Rapid Arm
Movement": Mothers describe this as "they shoved the baby onto my breast"
parents universally shudder as they describe this.
If the baby doesn't latch, we keep trying and trying, over and over,
mobilizing the baby's defensive sympathetic nervous system, and all the
epinephrine and norepinephrine, glucocorticoids, etc-- tense baby, in no
condition to eat. To feed, we need to be relaxed, our vagal and
parasympathetic systems paramount, not in "fight of flight" mode.
So baby's instincts have been violated, and parents' instincts have been
violated: Everyone feels incompetent-- and we end up with baby crying, mom
crying, dad crying
· How babies can learn to latch
First we start with a calm, relaxed baby baby. Mom can help this by what she
does instinctively: talking, eye contact, communicating, socializing,
enjoying baby
Baby is skin on skin, chest on chest, vertical position, up between breasts.
We're on "Baby time": no agenda, time to socialize, enjoy each other
Wait for baby to begin search for breast
Follow baby's lead, as baby twists one way, mom can help move rump up toward
opposite breast
Mom can help by making sure mouth is NOT over nipple, but to one side, "Nose
to nipple," head tilted slightly back
Baby knows breast by feel, not by sight, so mom can help by allowing
infant's cheek or face to remain in contact, touching breast
Baby, not mother, initiates latch, with chin touching breast, baby will
reach up and over nipple
Mom follows infant's lead, helps, keeps chin to breast, head tilted back,
keeps baby calm
Mom's instincts-listen to them.
Keep baby calm, happy.
Move baby back to vertical position, or just face up on top of breast above
nipple like a pillow, if baby shows tension. Talk to baby, let baby calm by
sucking on finger.
Our (professional) role in facilitating latch
Help mom feel calm, relaxed, competent
Help baby feel calm, relaxed, competent
Encourage mom to talk to infant
Encourage mom to enjoy process of learning, that it will take time
Interpret baby's behavior, show her how competent he is
Model patience and calm.
If a baby has already been "shoved to the breast" and is already pretty
defensive about latch, when you put the baby vertically to breast, and keep
everyone calm, etc as above, if baby is at all hungry, the infant will
usually move straight to breast as orchestrated by his instincts, but as
soon as he gets there, he tenses up, cries, being there has already caused a
learned response to the negative experiences there.
Luckily, babies have short memories, and such a baby needs only a few hours
or a few days, sometimes a week, off, from trying. But, during that time,
lots of skin on skin cuddling, when he's not hungry (so he won't search for
the breast and repeat that tension when he gets there), and pretty soon the
breast will be a safe haven for him again, and then he will be able to
return to his instincts and latch comfortably. And with this time off, too,
no hurry, no agenda, baby time.
Tina Smillie, MD, IBCLC
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