Positioning: It’s All About the (Baby’s) Chin.

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Babies and breasts come in different shapes and sizes. This may be a very obvious statement but it bears consideration when we bring babies and breasts together. Suzanne Colson, Nancy Mohrbacher, and Christina Smillie teach us to lie back to achieve good positioning. This often works very well but not for everyone. If a parent lies back and the nipple points downward, the baby cannot get in a position where the chin contacts the breast under the nipple.

In the past, breastfeeding helpers taught the tickle (the lips with the nipple) wait for a wide open mouth, and RAM (rapid arm movement) method. Some providers suggest aiming the nipple toward the palate or brushing the upper lip with the breast and waiting for a wide open mouth. But what comes next? Often the baby’s head is pushed onto the breast and the baby can’t breathe and becomes frustrated. Or the baby is brought to the breast but closes their mouth on the way causing a shallow latch. Why is it so hard?

Again, breasts and babies come in different shapes. Some babies have very receding chins. Some breasts are very round and some are flatter or softer or smaller or larger or…

The best positioning for a particular parent and baby is to be sure that the baby’s chin contacts the breast before latching. Chin contact below the nipple allows a baby to achieve a deeper latch. There are many techniques that can help achieve this positioning (try Googling “laid-back breastfeeding” or “flipple” or “deep latch technique”) but the technique needs to match the shape of the baby and the breast so they come together in harmony.

I absolutely love the following photo for showing how to position your baby.

http://www.cwgenna.com/quickhelp.html (click on “Latching Your Baby 101”)

Whatever your shape or your baby’s shape, if you can achieve chin contact before latching, you may have a more comfortable latch. If not, you might just need more help from an International Board Certified Lactation Consultant.

Choosing a Breastfeeding Helper

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Parents who are struggling with breastfeeding need high-quality, timely support in order to ensure they meet their breastfeeding goals. Because optimal breastfeeding is critical for the health of Baby and Parent, it is important that they receive the best help available.

There are many knowledgeable volunteer breastfeeding supporters that can help parents to breastfeed. Often this peer-to-peer help is all that is needed to resolve a breastfeeding difficulty. For more complicated problems such as low milk-supply, painful breastfeeding, babies who have difficulty latching, and slow weight-gain, it is important to get timely professional help in order to get back on track quickly.

I frequently see parents who have tried many other professional breastfeeding helpers and did not receive the help they needed. Time, energy, and resources may have been wasted. Delays in following the best interventions often result in parents not meeting their breastfeeding goals and babies missing out on optimal breastfeeding. High quality professional breastfeeding support may seem expensive but it saves time, effort, and financial resources in the the long run. Additionally, lactation help from an IBCLC is usually reimbursable by insurance.

Parents are often confused about the many different kinds of professional breastfeeding support providers available in the community. It is critical that parents have access to information regarding these differences so that they can make informed decisions about whom to hire for help. The following links explain the different types of breastfeeding supporters and the training required for each. Be aware that the term “Lactation Consultant” can be used by anyone, no matter what training or experience they have with breastfeeding.

http://uslca.org/wp-content/uploads/2015/05/Whos-Who-Short1.pdf

http://massbreastfeeding.org/wp-content/uploads/2013/06/Landscape-of-Breastfeeding-Support-03-31-14.pdf

The following article explains why I chose to become an International Board Certified Lactation Consultant.

http://feedthebabyllc.com/why-i-became-an-international-board-certified-lactation-consultant/

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This site  is dedicated to helping parents find answers to their breastfeeding concerns and to provide a platform for posts regarding current breastfeeding topics. It has recently been optimized to be smartphone friendly. Breastfeeding information is easily accessible by clicking on the Menu link or Search box located at the top of the site.

None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice. If you are not able to solve your breastfeeding difficulties, please contact a Board Certified Lactation Consultant (IBCLC) or breastfeeding peer helper for more assistance.

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Other Breastfeeding Support

The contents of this site are the property of Laura Spitzfaden. Please do not reproduce anything without permission. You are welcome to link to my site if you wish to share any of the material you find here.

Contact me: laura@feedthebabyllc.com

Milk Expression

If you are expressing milk after you have established a full milk supply, a personal pump such as a Hygeia Enjoi, an Ameda Purely Yours or a Medela Pump in Style will likely be adequate for your needs.  If you are establishing a milk supply for a baby who is not directly breastfeeding, a multi-user pump will likely be necessary.  This type of pump is also referred to as a, “hospital grade pump.”

Be sure that you check and change membranes and tubing as needed and have properly fitting flanges.  Your nipples should fit well into the flanges with just a little space between your nipple and the flange.  Your nipples should not rub in the flanges.  Your nipples should also not bobble about in the flange.   This would indicate that the flanges are too large.  You may want to experiment with flange sizes to find which remove the most milk.  Some moms have better success with alternative type flanges such as Pump in Pals.

Before begining to pump try these techniques

-Massage your breasts in concentric circles as when doing a breast self exam.

-Draw the backs of your fingers or a comb across your breasts from the chest wall to the nipple all around your breast.

-Lean forward and shake your breasts.

Use reverse pressure softening (developed by K. Jean Cotterman RNC-E, IBCLC) until you see drops of milk, then apply the pump.

Use hands-on double pumping. Whenever milk flow slows, take the pump off and repeat everthing including the reverse pressure softening and re-apply the pump. Try to do this cycle three times.

Hands on pumping:

http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

Reverse pressure softening (developed by K. Jean Cotterman RNC-E, IBCLC):

http://www.youtube.com/user/IBCToronto?feature=mhee

If you only have single pumping capacity, just switch back and forth a few times using all the techniques in this article.  If you do not have a pump, use these techniques and then hand express.

http://www.bfmedneo.com/BreastMassageVideo.aspx (from Breastfeeding Medicine of Northeast Ohio)

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

http://ammehjelpen.no/handmelking?id=907  (video created by the Norwegian mother to mother breastfeeding support organization, Ammehjelpen–scroll down for English video)

Maintaining a Robust Milk Supply When Parent and Baby Must Be Separated

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I was inspired to write this post due to some recent helping situations.  I decided to compile all this information in one place.  I may add to it later.

In order to have an excellent milk supply, it is important to remove milk from the breasts at least 8-10 times a day. (http://feedthebabyllc.com/care-plan-for-milk-supply/)  When parent and baby are together, it is beneficial to keep baby skin-to-skin and allow free access to the breast.  A baby is better at maintaining a milk supply than a pump and the extra nursing stimulates breasts to make more milk.

When a breastfeeding parent is separated from baby, it is important to express milk as frequently as possible, at least every 3 hours from the beginning of one expression to the beginning of the next.  A double electric pump with properly fitting flanges works the best.  Be sure to check the membranes frequently and change them at least every 3 months.  A pump that is older than 1 year may not be as efficient.  See (http://newborns.stanford.edu/Breastfeeding/MaxProduction.html) for learning a technique that increases the amount of milk that can be expressed by 48%!

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Why I Became an International Board Certified Lactation Consultant

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In Honor of IBCLC day, March 6th 2013, I decided to explore the reasons why I chose to become an IBCLC, though there are easier and less costly pathways to providing professional breastfeeding support.

I had already been an active La Leche League volunteer leader for nearly 12 years when I decided that I wanted to extend my services to include professional breastfeeding support.  I knew that I had acquired a lot of the experience and knowledge needed through my volunteer work.  I had dedicated thousands of hours to learning about and supporting breastfeeding.  I had helped several hundred parents overcome breastfeeding difficulties and realize their breastfeeding goals.  I did not believe, however, that this was adequate training to provide professional breastfeeding services. Continue reading

How Tongue-Tie and Lip-Tie Affect Breastfeeding

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Tongue and lip-tie are common causes of nipple pain, uneven breast drainage, slow weight gain and low milk supply. Many physicians do not properly assess for tongue or lip-tie or recognize their impact on the breastfeeding relationship, leaving babies vulnerable to early weaning.

Image credit: Qole Pejorian on Flickr

This photograph  shows a very obvious tongue-tie and visible frenulum (the bit of tissue holding down the tongue) but not all restrictions are this obvious. Some restrictive frenulums attach further back on the tongue. Some are even buried under the floor of the mouth, causing the tongue to appear, “short.” The only visible indication may be that the floor of the mouth rises when baby lifts his tongue or the tongue stays flat or doesn’t rise to the palate when baby cries. Sometimes the sides of the tongue will rise but the center of the tongue will stay on the floor of the mouth. Even if a baby can reach his or her tongue past the gums or lips, there may still be a tight frenulum restricting baby’s ability to breastfeed effectively.

Ultrasound studies have shown that the tongue movements used by tongue-tied babies are qualitatively different from those used by by babies who are not tongue-tied. These movements are not as effective at removing milk from the breast and can cause significant pain and nipple damage.  In these studies, tongue-tied babies also did not draw the nipple as deeply into the mouth as babies who were not tongue-tied.

Some babies with tongue and/or lip-tie may manage to nurse well enough to gain weight adequately in the early weeks, but they may not be able to maintain a full milk supply as they grow.  Their restrictions will likely continue to affect the ease of breastfeeding.  Feeds may be long and frequent–10-12 times a day or more.  Often these babies do not nurse for comfort and may have difficulty managing solids when they are older.

Tongue and lip-ties affect more than breastfeeding.  Even if a baby can breastfeed well and without causing pain, restrictive frenulums can affect jaw and dental development, breathing, chewing, swallowing and digestion.  Tongue and/or lip ties are also associated with reflux, which can cause significant pain for baby and may result in the need for medication.

Any of the following symptoms in parent or baby may indicate that tongue-tie is affecting breastfeeding.

Signs in parent:
•nipple pain and/or erosions
•nipple looks pinched, creased, bruised, or abraded after feeds
•white stripe at the end of the nipple
•painful breasts/vasospasm
•low milk supply
•plugged ducts
•mastitis
•recurring thrush
•frustration, disappointment, and discouragement with breastfeeding
•weaning before mom is ready

Signs in baby:
•poor latch and suck
•unusually strong suck due to baby using excess vacuum to remove milk
•clicking sound while nursing (poor suction)
•ineffective milk transfer
•infrequent swallowing after initial let-down
•inadequate weight gain or weight loss
•irritability or colic
•gas and reflux
•fussiness and frequent arching away from the breast
•fatigue within one to two minutes of beginning to nurse
•difficulty establishing suction to maintain a deep grasp on the breast
•breast tissue sliding in and out of baby’s mouth while feeding
•gradual sliding off the breast
•chewing or biting on the nipple
•falling asleep at the breast without taking in a full feed
•coughing, choking, gulping, or squeaking when feeding
•spilling milk during feeds
•jaw quivering after or between feeds

Assessing baby for tongue-tie: (baby may not have every sign)
•Does baby’s tongue rise less than half-way to the palate when crying?
•Do the sides of the tongue lift but not the center?
•Can you see a dip in the tongue in the center of the mouth?
•Does tongue have a heart shaped tip?
•Does baby have a high, narrow or bubble palate?
•Can you see or feel a tight frenulum?

To feel for a restrictive frenulum, you can use the “Murphy Maneuver,” developed by San-Diego pediatrician Dr. James Murphy. Put your little finger at the base of baby’s tongue and draw across the floor of the mouth. If you feel a resistance in the center of baby’s mouth, that is the frenulum. If you cannot get past this frenulum without going around it, then it may be restrictive enough to affect baby’s ability to breastfeed.

The following link shows a method for visualizing a restrictive frenulum that is difficult to see.

Lip-ties often accompany tongue-ties. If you lift your baby’s upper lip and see a frenulum that is tight and if the gums blanch (turn white) when the lip is lifted, your baby may have a lip-tie. The following two articles may help with assessing for lip-ties.

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

What Can You Do?

Cranio Sacral Therapy is a helpful intervention for babies with restrictive frenulums.  CST is a light touch therapy that releases tight muscles and can improve baby’s ability to latch and breastfeed, but CST may need to be repeated frequently order to maintain its effectiveness. There are exercises that might help a baby to compensate for the restrictions and careful attention to latch and positioning, may also help the baby to breastfeed more effectively.  None of these interventions enable the tongue-tied baby to have full mobility of the tongue and they are most effective when used along with release of restrictive frenulums, in order to normalize function.  This procedure is performed with surgical scissors or laser and is called a frenotomy.

Many babies with restrictive frenulums cannot nurse effectively unless both tongue and lip-ties are revised by frenotomy.  With an experienced provider, revision is quick and discomfort is minimal.  The discomfort from a frenotomy varies from unnoticeable (some infants sleep through the procedure) to about the same amount of pain as a from a vaccination.  The baby can nurse immediately afterward which also relieves pain.

If breastfeeding hurts the parent or if baby struggles to get enough milk, then the breastfeeding relationship is at risk.  The risks of not breastfeeding outweigh the temporary discomfort of revision.  If you are considering a tongue and/or lip-tie revision, it is important to find a provider who is very experienced in revising restrictive frenulums in infants and who is very familiar with how these restrictive frenulums affect breastfeeding. Experienced providers will know how to revise completely and without the need for general anesthesia.

The following is a link to a video of laser tongue-tie revision in a 14 year old. The doctor has made this available for anyone to view. The mom wanted to have this procedure done because her daughter had jaw tension, clenching and tooth grinding. She also breastfed poorly as an infant.

For more information, visit the following links:

lactationkotlowTTnursingbookaugfc2011-1

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

http://kiddsteeth.com/articles.html

www.lunalactation.com/KnoxTT.pdf

American Academy of Pediatrics–Tongue-Tie

http://www.brianpalmerdds.com/

http://www.ncbi.nlm.nih.gov/pubmed/12415069

http://www.llli.org/llleaderweb/lv/lvaprmay02p27.html

http://lowmilksupply.org/tonguetie.shtml

http://breastfeeding.blog.motherwear.com/2011/01/guest-post-shannon-on-posterior-tongue-tie.html

kiddsteeth.com/articles/aerophagia_2011.pdf

http://www.tonguetie.net/

© 2012 Laura Spitzfaden, IBCLC (www.feedthebabyllc.com) laura@feedthebabyllc.com

Nipple Latch Trick

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I think this is a very helpful technique for moms who are having difficulty achieving a comfortable latch due to mom’s or baby’s anatomy.

The following is posted with permission from http://www.drmomma.org/

Breastfeeding Latch Trick

By Danelle Frisbie © 2010

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