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From:
Rachel Myr <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 3 Apr 2007 11:08:18 +0200
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Gonneke asks what, in our opinion, is the cause of arching or
over-stretching when being offered the breast **in the first week of life**.

In the first week, I think it is almost always a result of forceful
so-called help, and secondarily a result of vigorous suctioning.  We don't
routinely suction babies here, happily.  Rarely it may be due to a fractured
clavicle, or torticollis, but poor help in the first couple of days is by
far the most common cause I see.  It is also the easiest to deal with, by
giving the initiative back to the baby through skin-to-skin on mother's
unclothed upper body, with mother lying flat on her back.  It almost never
takes more than a couple of sessions before there is great progress and a
much happier mother and baby.

Arching and general tension at the breast in an older baby, in my
experience, starts more insidiously and is harder to deal with because the
longer a problem exists, the more difficult it is to solve.  There may have
been small difficulties with latching from the start, but things seem to go
sort of all right for weeks, even a couple of months, before mother calls,
exhausted, distraught over her obviously unhappy but rapidly growing baby.
Sometimes mother has tendonitis in wrists and shoulders from the bizarre
positions she has resorted to in order not to elicit the arching, or to hold
the baby close enough to complete a feed.  The prime feature is the mother's
lack of self-confidence because she is getting very little positive feedback
from the baby, and nearly all their waking time together is spent physically
struggling to get baby situated for a feed.  The babies are high-tone, and
arch very exaggeratedly and with little or no provocation, usually only to
one side.  Some of them spit up a lot, but that is rare.

Typical for these mothers is that they never report that breastfeeding was
going excellently, only all right, and then it deteriorates as baby grows.
A lot of them report jaw-clenching latch at the start with marginal
improvement as milk supply builds.  The well-child follow up system here has
no scheduled contacts with babies from the age of about ten days, to six
weeks.  Mothers go home on day three or thereabouts, and there will be one
home visit by the health visitor, at some point in the first ten days after
that, and then it is up to the mother to make contact if she thinks she
needs it.  The baby may be asleep during the entire home visit so is never
observed feeding.  IME the mothers who really need it are the least likely
to get in touch.  By six weeks things are really rocky, although since these
babies are usually gaining weight like gangbusters and weighing and
measuring and a once-over by a doctor are the focus of the six week visit,
their unhappiness is trivialized to the tune of 'it's normal for babies to
cry some every day'.  By the time they come back to me, after a couple of
months, they often have visibly misshapen heads, flattened on one side
because they are always turning the same way, and the breastfeeding problems
are extremely pronounced on the side requiring the baby to adopt what is for
him an unnatural and difficult, if not impossible, position.

There is a theory from Germany, about a syndrome abbreviated as KISS which
on a Norwegian website about the condition is translated as 'Kinematic
imbalance due to suboccipital strain' but when I translate the German term I
get 'upper cervical vertebra-induced symmetry disturbance'.  It is gaining
credence here, fortunately, because without recognizing that this is a
physical problem, it is impossible to get help.  When I see these features I
have now stopped trying to help with positioning until baby has been seen by
an osteopath, specially trained physiotherapist, or craniosacral therapist.
And, wonder of wonders, there are such people in my community, and the
treatment works.  The baby starts relaxing more and feeding better and there
may not be any need for further breastfeeding support.  This is because it
isn't a breastfeeding problem, it is a physical problem which manifests
itself very visibly during feeding.  I think that's why it has taken time
for it to be recognized at all.  I know I have worked with mothers in the
past whose problems were attributed to a pathological relationship to the
baby, and the relationship was merely a consequence of the baby's physical
inability to lie relaxed in mother's arms at the breast.  How sad is that?

Jane Kershaw and Kathy Eng both mentioned some of the same features that are
listed as possible causes of KISS.  From the Norwegian website, I quote:
babies born by CS, forceps or vacuum extraction are at higher risk.  It's
safe to assume that how we are born, matters in the long run too.  In places
with very high intervention rates, more of these cases will be solely
attributable to the intervention.  But in communities with lower overall
rates of birth intervention, we should keep in mind that whatever
necessitated the intervention could also be a contributor to the problems
after birth.  A baby with an abnormal body flexion will not traverse the
birth canal as easily, and we simply don't know whether this plays a role.
While we work to improve the circumstances of birth for all babies, we
should also do whatever we can to help babies whether or not we know the
cause of their troubles.

Sometimes in interdisciplinary discussions I have gotten the impression that
it is more important to be able to lay blame somewhere, than to solve the
problem at hand.  The NICU might criticize intrapartum care for a baby's
condition at birth, and the birth attendants would argue for antenatal
causes, and the lactation brigade would like to emphasize separation of
mother and baby as a cause of the resulting breastfeeding problems, and when
they go home, the well child care system is peeved because the hospital
didn't do a good enough job while we are exasperated at their failure to
follow up.  Even if all of us are right, the mother and baby aren't any
better off until we help fix it.

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