Science & Sensibility

As the mother of two children, both who breastfed well into toddlerhood, and as a childbirth professional, I have spent a lot of time over the years 1) learning how to breastfeed or breastfeeding my children and 2) facilitating “how to breastfeed” conversations with pregnant women and their partners in my Lamaze classes, working as a birth doula with new mothers immediately after birth and in the first postpartum days at home with their newborn as well as regularly training new birth doulas and childbirth educators on how to prepare and work with their clients and students in the early days of the breastfeeding relationship.

I frequently find that new mothers often consider breastfeeding the next potential challenge after they have birthed, and getting it “right” includes avoiding pain, developing a good milk supply and making sure that their baby is getting all the nutrition they need in the vulnerable first days when things are so new and unfamiliar.  Breastfeeding challenges can increase the rockiness of an already emotionally and physically fragile time for the mother-baby dyad.

I have watched teaching methods, techniques and vocabulary change as more is learned about the newborn, their instinctive behaviors and the innate wisdom of the mothers of these new little ones.  Most of us have seen the widely viewed “Breast Crawl” video put out by UNICEF, WHO and WABA, and ooh-ed and ah-ed at the wisdom of the just born baby who self-latches when placed on its mother’s chest.   Suzanne Colson, Rebecca Glover, Christina Smillie and others have shared resources and information that has helped mothers and the professionals that support them get breastfeeding off to the best start possible, by introducing concepts such as baby led and laid back breastfeeding.

It was with great interest that I read Facilitating Autonomous Infant Hand Use During Breastfeeding and learned the important role the newborn’s hands play in helping to shape the breast, areola and nipple to facilitate breastfeeding.  I have always encouraged mothers to undress their newborn to allow for skin to skin when nursing, and sighed when I saw trained professionals encourage mothers to nurse a swaddled newborn.  But, I have to admit, I was guilty of encouraging mothers to “tuck” their baby’s hands out of the way when getting the baby to latch on, concerned that the baby’s hands would prevent a good latch as the baby seemed to want to suck on both the breast and their hand at the same time.

 In the past, the baby’s hand movements while at the breast where considered “uncoordinated,” “purposeless” and “random,” and were thought to interfere with the coordination of the breastfeeding process.  Current research shows that not to be the case at all.

Catherine Watson Genna, BS, IBCLC, RLC and Diklah Barak, BOT, the authors of Facilitating Autonomous Infant Hand Use During Breastfeeding share that babies that hug the breast with their hands are helping to stabilize their neck and shoulder girdle, by pulling together the shoulder blades. Hand movements, by the infant on the breast, increase maternal oxytocin.  It also causes the nipple tissue to become erect, which facilitates latch.  Babies are best able to use their hands “against gravity”, lifting them up, when their hands are in their field of vision.  The hands are used along with the lips and tongue to draw the nipple into the mouth, a behavior that disappears around 3-4 months of age.

The authors observed that infants use their hands to push and pull the breast to shape the breast and provide easier access to the nipple.  Newborns and young infants also use their hands to push the breast away, possibly to get a better visual sense of the location of the nipple.  Genna and Barak also state that an infant may feel the nipple with their hand, and use the hand as a guide to bring their mouth to the nipple.

 Wonderful black and white pictures accompany this article, and useful video clips are included for great visuals of the behaviors described by the authors.  The authors provide information on how to facilitate infant hand use during the breastfeeding session, including step-by-step instructions that can be shared with expectant and new mothers when you are teaching.

 Teaching new mothers that their newborn’s hands are a tool that the baby uses to find and latch on to the nipple, rather than something to be restrained and held out of the way, can help new mothers to appreciate the innate abilities of their newborn to self-latch and breastfeed successfully.  The materials in this article can be incorporated in the curriculum you cover when you discuss breastfeeding, and increase confidence and success for the new mother and encourage the breastfeeding relationship to have the best start possible.

 Please take a few minutes to follow the link and read the article, view the pictures and videos and let me know how you envision using this information in future classes?  Have you changed how you teach breastfeeding as new concepts and information have become available?  Share your tips and success stories with us, so that we all can become more skilled at providing new parents with effective teaching practices that support the breastfeeding relationship.  I look forward to hearing from you.

 Sources

Genna, C.W. & Barak, D.  Facilitating autonomous infant hand use during breastfeeding.  Clin Lact 2010; 1(1):15-20.

http://www.biologicalnurturing.com/

http://breastcrawl.org/index.shtml

http://www.breastfeedingresources.com/

http://www.rebeccaglover.com.au/

Sharon Muza Babies, Breastfeeding, Continuing Education, Doula Care, Evidence Based Medicine, Healthy Birth Practices, Infant Attachment, New Research, Newborns, Parenting an Infant, Practice Guidelines, Research Barak, breastfeeding, breastfeeding class topics, childbirth education teaching strategies, Colson, first weeks of breastfeeding, Genna, glover, how to breastfeeding, IBCLC, Lamaze Classes, newborns, postpartum, Smillie, teaching community breastfeeding classes, WHO breastfeeding recommendations

Where We’re At

Country				Initiation %			Exclusivity % at 6 months
Canada				90[1]			14[2]
Australia				92			14[3]
New Zealand				88[4]			26[5]
United States				75			13[6]
Austria				96			46
Germany, Switzerland:				94			11
United Kingdom overall				69			21[7]
Lithuania				98			14
Norway				99[8]			17*[9]
Ireland				47[10]			10*[11]
										*denotes any breastfeeding

There is much to celebrate in the breastfeeding world in regard to the world-wide increase in initiation rates (let’s ignore Ireland’s abysmal 47%).  Alas, such numbers plummet as we speak about duration rates.  Canada’s disappointing record of 17% of babies exclusive breastfeeding at 6 months[12] is matched in many European countries, and USA and others are lower still.  This is both strange and concerning in light of the World Health Organization’s call for exclusivity to around 6 months.  Do we not have enough marketing out there to demonstrate the importance of breastfeeding and the risks of not breastfeeding?  Is it that mothers are not trying hard enough to make it work?

In fact, we have done a great job with our marketing—the initiation rates prove that.  And many countries around the world have made great advances in ensuring babies have the right to breastfeed anywhere.  Like childbirth, the reclaiming of breastfeeding as a woman’s right has been a slow one but it has made concrete and substantial progress.  There is still a significantly long road ahead, to be sure, and we will get there—of that I am confident. 

The Issue of Support
This brings us to my second point, so let’s get the record straight: mothers are trying hard enough—some (like patients in the clinic where I work) are visiting up to 9 practitioners just to get the breastfeeding help they need.  The challenge is, though we encourage mothers to breastfeed, we don’t always make it easy for them to do so:  Birthing has become medicated all too frequently and studies are starting to reveal the adverse effects of this highly medicalized birthing model on the process of breastfeeding.[13],[14]  Despite improving federal policies, on a micro level we still tend to make our public environments non-breastfeeding friendly by admonishing mothers when they breastfeed in places like airplanes, museums, swimming pools and restaurants, and we provide them with very little support on the how-to part of this natural-process-but-learned behaviour. 

It is on this last point that I will focus these next few blog posts:  the support, or lack of good support we give mothers who choose to breastfeed.  This “support” comes in many forms, too many to delve into in this article and many that will eventually work themselves out as the marketing of breastfeeding continues to snowball and win over the nay-sayers and the practitioners who claim: “hey, I wasn’t breastfed and look at me, I’m just fine” (see James Akre’s The Problem with Breastfeeding[15]—it’s an easy read which elegantly addresses this point).  The kind of support I am most concerned about is that which is given in the guise of expert advice or care and yet is anything but.  This support usually comes from nurses and lactation consultants and often from midwives and doctors.  It comes from a lack of solid education in breastfeeding and lactation medicine.   That so many practitioners put so little importance on breastfeeding is a significant part of the issue, to be sure (though obviously this cannot be said of all midwives, doctors, and lactation consultants).  And even more, though they might believe in the importance of breastfeeding, many practitioners don’t have faith in breastfeeding as a way to sustain life and help perpetuate the species. The fact that we are almost 7 billion strong demonstrates breastfeeding must be somewhat responsible in perpetuating our species–remember, commercially–prepared artificial baby milks have only been around for a relatively short while.  In fact, up until very recently, few babies ever received any breastmilk substitutes, therefore it is safe to say that statistically speaking, almost every human being that has ever walked this earth was breastfed. 

So back to the issue of support.  Let me extend kudos to the practitioners who do make it their responsibility to stay updated with their skills and who are never afraid to say, “I don’t know how to fix this, let’s refer you to someone who may.”  The problem, however, lies in the numerous practitioners lacking proper training and education—or those underutilizing the training they do have—and instead rely upon tools and gadgets to augment their breastfeeding support. Unfortunately, nothing can replace good hands-off/hands-on training and mothers far and wide are suffering from practitioners’ ill-equipped attempts to mimic this type of support.   Over the next few months I will share with you my thoughts around how and where we fail when it comes to getting mothers and babies off to the best start.

Support Pitfall #1 ~ Lack of Skin to Skin Contact:  Early Separation/ Rooming in/Swaddling:
Rooming-in has become the norm in Canada for the most part, (thanks largely to The Baby Friendly Hospital Initiative—BFI[16], [17]) though all too often babies are removed from their mothers at night “to give their mothers some rest.” In fact, an alarming but well-intentioned, non-evidenced based new programme is now in place in Toronto, Canada that separates mothers and babies for 5 nights where there is a concern or suspected risk of postpartum depression. All this in the face of tremendous research with overwhelming and compelling evidence that goes against such practices[18],[19],[20],[21],[22],[23]. 

In fact, immediately after birth, babies do best when placed skin-to-skin (SSC—skin-to-skin care/contact[24]) with their mothers for many hours throughout the day not just during feedings but in between feedings as well[25].   Yet in most hospitals in the US, babies are kept either separated from their mothers or are kept swaddled in blankets.  In Canada, though most hospitals have made great strides toward SSC, many nurses still teach mothers how to wrap and swaddle babies in 2 or even 3 blankets to ensure baby stays warm instead of spending time teaching about the benefits of SSC (even though the evidence on SSC clearly shows that babies stay warmer when SSC with their mothers[26]).  With breastfeeding, we want to ensure baby and mother achieve the best latch possible (more on that in the next blog).  Imagine how challenging it is to latch a crying bundle with all those blankets in the way! When babies are kept SSC their SCRIP scores (stability of the cardiorespiratory system in premature infants³⁶)are stabilized.  Likewise, most mothers do better when their babies are with them; they witness less crying in their babies and breastfeeding gets off to the best start[27],[28],[29],[30] , [31],[32],[33].  As importantly, when baby is SSC with mother, the baby will behave in a way which is neurologically appropriate for a newborn—waking when appropriate and cueing when hungry[34].  The baby who is wrapped or swaddled tends not to cue early, and, it is suggested, is more likely to sleep through his/her hunger, “content to starve,” as the old paediatric adage goes.  Or, they sleep so long and then when woken, are so desperately hungry they cry inconsolably and often refuse to eat.  Conversely, SSC ensures timely waking and feeding. There are many recommendations for baby-led feeding and certainly SSC makes it increasingly possible. 

Paediatrician and public health specialist, Dr. Nils Bergman speaks about placing baby in the correct habitat[35] so that s/he can behave in a way which is neurologically appropriate[36].  Dr. Bergman suggests that when babies are wrapped or swaddled their behaviour changes and becomes conservationist (of their energy—they shut down, and seem to sleep but really are doing nothing of the sort) or becomes desperate (they utter distress cries)[37].  Furthermore, when a baby is placed skin to skin with his mother he will find the way to the breast on his own and begin the “breastfeeding process” (exchange of necessary sensory information[38]) well before actual sucking begins.  This journey and subsequent sucking at the breast is critically important for baby’s neurological organization and survival.

A baby will behave like a baby when in the habitat of her parent’s body, especially her mother’s.  Wrapping or swaddling babies is an unfounded practice that needs to go and this applies to babies whose mothers do intend to breastfeed and even more so for those who don’t.  If we want babies and babies’ brains[39] to have a healthy start it is crucial we help them get to the starting line.  And as for establishing breastfeeding?  Skin to skin!  Provide the vehicle, and they will know the way.  

---

---

[1]Breastfeeding Initiation in Canada: Key statistics and graphics 2007-2008 www.hc-sc.gc.ca

[2]Chalmers B et al. Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey of women. Birth 2009, June;36(2)122-132

[3] Australian National Breastfeeding Strategy. 2009, Commonwealth of Australia on behalf of the Australian Health Ministers Conference (2009)

[4] Breastfeeding and Weaning Practices in New Zealand: Breastfeeding and Prenatal Nutrition Issues.  Nutrition Research Newsletter. Aug 2002

[5] New Zealand Ministry of Health (2007) www.moh.govt.nx/moh.nst/index.mh/heha-nations-breastfeeding-campaign

[6]Centres for Disease Control and Prevention. www.cdc.gov/breastfeeding/data/NIS_data/index.htm

[7]Yngve & Sjostrom. Breastfeeding in countries of the EU and EFTA: Current and proposed recommendations, rationale, prevalence, duration and trends. Public Health Nutrition 4(2B)631-645

[8]Cattaneo et al. Protection, promotion and support of breastfeeding in Europe: Current situation. Public Health Nutrition 2005 8:39-46

[9] www.breastfeeding.ie/policy-strategy (2008)

[10]Tarrant & Kearney. Session 1:Public health nutrition. Breast-feeding practices in Ireland. Proc Nutr Soc 2008 Nov;67(4) 371-80

[11] www.breastfeeding.ie/policy-strategy (2008)

[12] It is important to note that many countries are still suggesting solid foods be introduced at 4 or 4-6 months and so this column might be somewhat skewed.  Often the number will refer to any breastfeeding.  Stats on true exclusivity are difficult to obtain.  The stats do show, however, that even at 3 months, there is not much difference between 3 and 6 months when referring to exclusivity.  

[13]Kroeger M & Smith LJ Impact of Birthing Practices on Breastfeeding: Restoring the Mother-Baby Continuum Boston, MA: Jones & Bartlett Publishers, 2004

[14]Ransjo-Arvidson, AB Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K. Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature, and crying.  Birth.  2001; 28 (1): 5-12

[15]Akre, James, The Problem With Breastfeeding:  a Personal Reflection,  Hale Publishing, 2006

[16] The Baby Friendly Initiative’s Ten Steps help to ensure rooming in is secure.  However, so few North American hospitals have earned this accreditation.

[17] Pincombe J, Baghurst P, Antoniou G, Peat B, Henderson A, Reddin E. Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia Midwifery. 2006

[18]Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia Pac J Public Health. 1991;5(3): 217-20.

[19]Song JE. A comparative study on the level of postpartum women’s fatigue between rooming-in and non rooming-in groups. Korean J Women Health Nurs. 2001;7:241–255.

[20]Kim ES, Park YS. The effect of rooming-in on maternal attitude and self confidence for infant care among primiparas. Korean J Women Health Nurs. 2001;7:256–270.

[21]Song JE, Lee MK, Chang SB. Differences of maternal fetal attachment between the rooming-in and non-rooming in groups of postpartum women. J Korean Acad Nurs. 2002;32:529–538.

[22]Kjellmer I, Windberg J. The neurobiology of infant-parent interaction in the newborn: an introduction. Acta Paediatr Suppl 1994; 397:1-2.

[23]Hofer MA. Early relationships as regulators of infant physiology and behaviour.  Acta Paediatr 1994; Suppl 397: 9-18.

[24]This kind of care is based on KMC (Kangaroo Mother Care) started in Bogotá, Columbia by Dr. Rey and Dr. Martinez, 1979

[25]Bystrova K, Matthiesen AS, Widstrom AM, Ransjo-Arvidson AB, Welles-Nystrom B, Vorontsov I, Uvnas-Moberg K.  The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling.  Early Human Develop. 2007; 83:29-39

[26]Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2003;(2):CD003519

[27] Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K. Elevation of oxytocin levels early post partum in women.  Acta Obstet Gynecol Scand. 1995; 74(7): 530-3.

[28] Boutet C, Vercueil L, Schelstraete C, Buffin A, Legros JJ. Oxytocin and maternal stress during the post-partum period.  Ann Endocrinal (Paris). 2006; 67(3): 214-23

[29]Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, Puyol P, Winberg J. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot.  Acta Paediatr. 1992; 81: 488-493.

[30]Michelsson K, Christensson K, Rothganger H, Winberg J. Crying in separated and non-separated newborns: sound spectrographic analysis.  Acta Pediatr 1996; 85(4): 471-5

[31] Rapley G. Keeping mothers and babies together–breastfeeding and bonding.  RCM  Midwives. 2002 Oct; 5(10): 332-4

[32] Vaidya K, Sharma A, Dhungel S. Effect of early mother-baby close contact over the duration of exclusive breastfeeding.  Nepal Med Coll J. 2005;7(2):138-40

[33] Rapley G. Keeping mothers and babies together–breastfeeding and bonding.  RCM  Midwives. 2002 Oct; 5(10): 332-4

[34]Hofer MA. Early relationships as regulators of infant physiology and behaviour.  Acta Paediatr 1994; Suppl 397: 9-18.

[35]Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram   newborns.  Acta Pediatr 2004; 93 (6): 779-85.

[36]Ferber SG, Makhoul IR. The effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioural Responses of the Term Newborn: A Randomized, Controlled      Trial.  Pediatrics 2007; 113: 858-865

[37]Bergman NJ, Jurisoo LA. The ‘kangaroo-method’ for treating low birth weight babies in a developing country.  Trop Doct 1994; 24(2): 57-60.

[38]McKenna JJ, Thoman EB, Anders TF, Sadeh A, Schechtman VL, Glotzbach SF.  Infant-parent co-sleeping in an evolutionary perspective: implications for understanding infant sleep development and the sudden infant death syndrome.  Sleep 1993; 16(3): 263-82.

[39]Schore AN. Effects of a secure attachment relationship on right brain development affect regulation, and infant mental health.  Infant Mental Health Journal 2001; 22(1-2): 7-66

Posted by:  Edith Kernerman, IBCLC, NBCI

Edith Kernerman Baby Friendly Initiative, Breastfeeding, Science & Sensibility breastfeeding statistics, breastfeeding support, breatfeeding gadgets, Edith Kernerman, Harvey Karp, how to breastfeeding, International Breastfeeding Centre, Jack Newman, James Akre, kangaroo care, latch-on, MD, Newman Breastfeeding Institue & Clinic, Nils Bergman, problems with breastfeeding, skin-to-skin contact, swaddling, The Problem with Breastfeeding