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From:
"Christina M. Smillie, MD, FAAP, IBCLC" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Fri, 14 Mar 2003 10:32:00 -0500
Content-Type:
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Dear Meg,

I'm a pediatrician/IBCLC who has worked in my own
practice exclusively limited to the specialty of
breastfeeding medicine for the past seven years--
that is, I don't do general pediatrics, I only see
mothers and their babies for breastfeeding issues.
Last year we saw about 650 dyads.

I have a lot to say about your question, but nor
much time this morning, so this may look long, but
to me it is frustratingly brief:

Re: Self attachment:
 #1. Babies keep their ability to self-attach for
a very long time, probably at least a year. (In
older babies, there are a lot of behavioral things
that can keep you from seeing this, but I believe
it still is a primary instinct, tho' pretty easily
interfered as babies become older.)
#2. Self attachment does not necessarily mean
"crawling  up the breast" which is just what
neonates will do if we leave them on the belly
after delivery. Babies will look for and find the
breast to laatch on from a variety of positions,
but there are certain things that we have noticed
seem to promote certain of these behaviors--
having the baby comfortable and cozy, chest to
chest, letting the baby get to a position where he
puts cheek or chin on breast, etc,  Talking and
eye contact helps babies organize and stay calm.
Skin on skin helps younger babies, but can
disorganize older babies.
#3. This ability can be interfered with by
forcing, pushing, shoving, and otherwise creating
an aversive association. But even when this has
happened, if a mom has been trying to latch the
way most people teach latch these days, the
infant's instinct is so primary that even breast
aversion, frantic baby, etc., can be overcome once
you understand how this works.
#4. The ability to self attach is also interfered
with by trying to make the baby play "follow the
leader"-- putting them in a horizontal
breastfeeding position, tickling their lips,
teasing to get them to open their mouths etc. In
short, the way we were all taught to teach latch.
But the problems created by this approach are also
easily overcome. I can't get into all the
solutions here now. We call our approach "baby-led
latching" instead of the more commonly used
"mother-led" or nurse-led, or LC-led approach to
teaching babies to latch, which I believe is the
cause of so many of the problems we see-- breast
aversion, "suck dysfunction" (which I believe is
totally iatrogenic, and easily cured without all
the "suck training" stuff), sore nipples, nipple
infections, etc. Puppies, kittens and baby monkeys
do not need veterinarians to teach them to latch.
#5 Babies are competent. We cause trouble when we
assume they are not, and try to teach them what
they are already preprogrammed to do.

Re: "normal" nipple pain
#1. Nipple pain is not normal. Ever. Pain is
always the body's signal to fix something.
#2. If nipple pain were normal, cats, dogs and
other mammals would have died out as species a
long time ago.
#. 3 The pain is mostly caused by trying to
encourage an unphysiologic  "centered" "bull's
eye" latch rather than the more natural assymetric
latch, in which the baby's lower lip is further
from the nipple than the upper lip. For some
unknown reason this approach has been advocated by
otherwise good lactation specialists for the past
decade or so now.
# 4 It is also caused by the follow the leader
approach mentioned above which causes a tense
baby, tight lips, disorganized latch etc.
#5. Mostly it is caused by moms thinking they have
to put up with pain, and thus allowing the baby to
get milk in a painful way, which teaches the baby
that their latch works. It is the flow of milk
associated with a certain mouth position that
teaches the baby what to do. If the baby is never
allowed to nurse in a painful way, if the latch is
always fixed if it is painful, then the baby only
develops an association with milkflow when the
latch is comfortable, which of course promotes the
best milk flow anyway. And then the baby gets a
motor memory for how to hold the nipple in a
comfortable way.
#6. We have moms who come to our office, having
been told their baby's latch "looks good" even tho
mom is in pain! Their nipples are scabbed,
bleeding awful. We show her how she can allow her
baby to latch comfortably, and, if it's not quite
comfortable (if she says that "it's okaaaay, it's
not that bad" it definitely still needs to be
fixed to pain free), we help them with the
asymtric latch, and within a few seconds or
minutes usually, she says "oh my!, it doesn't hurt
at all!"-- and the mom will say this, baby
suckling, even tho the nipples are still scabbed
etc. We almost never use nipple shields, hydrogel
pads, or nipple shells in our practice. We just
help mom allow the baby to latch correctly.
#7. Injured nipples can leave cracks and raw
spots, and these have more trouble resisting
infection. If yeast and/or staph have moved in,
even the most perfect latch will hurt, and in that
case she will need antifungal/antibiotic treatment
(mupirocin is good for both), and usually a break
from nursing to allow the nipples to heal. Moms
frequently think they have to nurse thru the pain,
so the baby doesn't "forget" how to latch-- this
is like walking on a sprained ankle for fear you
will never walk again-- walking on that injury is
more likely to cause the result you fear. It needs
time to heal, and then you can walk. As I said,
babies keep the abilty to self attach for a long
time, it is an instinct that is primary, as long
as the baby is happy and comfortable, so we don't
run into problems with taking time out to let the
nipples heal.
# 8. While our practice is fairly unique in using
the neurobehavioral competence of the newborn to
advocate a universal "baby-led" approach to latch,
we are not alone in promoting the asymetric latch.
This is not our personal discovery. It has been
advocated by many people, including Barbara
Wilson-Clay, Anne Barnes, Chloe Fisher, Jack
Newman, etc, and was recently discussed in
LaLecheLeague's Leaven. I haven't looked to see if
it has finally been put into the new
LLLBreastfeeding Answer book.

Your proposal--
I think baby led latching can definitely help
babies achieve a more comfortable latch for moms,
and thus better milk transfer, and I think your
proposal to look at this is a great idea. However,
just having the babies "crawl up the breast" every
feeding in the first week is not what I would have
in mind. Moms can and do have a role in latch.
Widstrom, Harris, and Righarde and Alade have all
demonstrated that babies can do this independently
of any help. This was important in turning people
around to recognize infant competence, and to
recognize that we don't have to force a baby to
latch, any more than we force them to learn to
talk or walk. But having moms sit by and do
nothing is actually very unphysiologic, against
mom's intincts. So we have moms help, but their
role is to play follower, in the follow-the-leader
game, where baby is the leader. Then, when mom
assists, in response to baby's behavior, it is all
a lot easier. However, with or without babyled
latching, anything that will promote an asymetric
latch will result in painfree nursing. Babyled
latching will just make it a whole lot easier. And
of course once they are latching easily, which
could be after the first nursing or three, you
don't have to keep up with all the various things
to make the baby start from scratch to find it,
crawling or searching or whatever, you just put
the baby anywhere near the nipple, let the face
touch the breast, and the baby does the rest.

I'm attaching our latch handout for for moms for
your information.
I also described how we do this for Klaus, Kennel
and Klaus's 2002 version of The Doula Book, which
goes a little more into what the doula or LC can
do to facilitate baby-led latching.

Although we often start young babies in a vertical
position on the chest, and our handout is written
describing that, the exact position is not
important, what is important is that baby and mom
are comfortable, relaxed, no agenda. Suzanne
Colson, CNM in the UK takes a similar approach to
ours, but without necessarily the vertical
position, and doesn't even use skin against skin.
She has moms find the place where she and baby fit
together "like two pieces of a puzzle,"
comfortable and cozy, and from there, the baby is
so relaxed and at home, the baby then can look for
the breast comfortably.

However, what we tell moms is just the tip of the
iceberg on this, the result of a lot of
observation, experience, and reading into the the
neurobehavioral and neuroendocrine basis for this,
which is totally fascinating.
I'll be giving a platform on this in Sydney at
ILCA in August.

Tina Smillie


> Date:    Thu, 13 Mar 2003 18:22:48 +0400
> From:    Pascoes in Dubai
> Subject: self-attaching
> MIME-Version: 1.0
> Content-Type: text/plain; charset=Windows-1252
> Content-Transfer-Encoding: 7BIT
>
> It would be interesting to see if the "normal" early nipple pain would still
> occur in a sample of babies given the opportunity to self-attach immediately
> after delivery?
>
> Also, this reflex to climb up the abdomen and self attach-is this a short
> lived post delivery reflex or can babies continue to do this for several
> days/indefinitely after the birth?
>
> If so, it would be interesting to study a sample of babies who self-attach
> every feed for the first week and examine for signs of nipple pain.
>
> Meg Kingsley IBCLC
> Dubai UAE
> Community worker-not much experience with neonates
>

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