The World of Latch-On: One Leader’s Journey
Diane Wiessinger, MS, IBCLC
Ithaca NY USA
From: LEAVEN, Vol. 40 No. 1, February-March 2004, pp. 3-6.
Learning to breastfeed a baby can take time for some mothers. Learning how to help others breastfeed can be an extremely long and winding journey. My own journey into the "World of Latch-On" began in earnest with my second baby. I held him facing me, as LLL Leaders Chele Marmet, IBCLC, and Kittie Frantz, RN showed us in the videos and articles of the 1980s. Sure enough, I didn't experience the pain I had had in the early weeks with my first, who fed "sunny-side up" with his head turned. But in his own early days, my second baby would begin many breastfeeding sessions by shaking his head from side to side, as if to say, "Where is it?" "It's right here in front of your mouth," I'd tell him, just as frustrated as he was, wondering how he could miss it. We learned together, over the next couple of weeks, although I couldn't describe what it was we had learned.
Indeed, the first time I tried to help a mother with a baby who was not latching on well, I could see that it wouldn't work the way she was doing it. I found myself making repeated scooping motions with my lower jaw while I watched, but I couldn't explain to her what it was that I felt needed to happen. I finally offered to put my arms around her from behind and hold breast and baby as if they were my own. With experienced hands holding him, he latched right on, and the mother and I pieced together what I had done that was different. But I still had no clear language for what my body and eyes understood.
I did know the baby needed to end up with a wide open mouth. Two line drawings in Maureen Minchin's book, Breastfeeding Matters, showed the difference between a prissy-mouthed "bottle-suck" and the wide, wide mouth of a well-attached breastfeeding baby so clearly that I carried the pictures around when I talked with mothers, to remind us both of our goal. But how, exactly, did we get there?
Some years later, I was with my second child in a fast food restaurant. All around me were people eating fat hamburgers. "That's it!" I thought. "Babies eat the way grownups do. Their upper jaw doesn't move at all, so they focus on getting their lower jaw on the food." All those adults in the restaurant were keeping their thumbs way back on the underside of the sandwich. They didn't bother with the placement of their index fingers, sometimes even keeping those fingers very close to their lips in order to tuck a bit more hamburger bun in at the end. "It's only the lower jaw that matters!" Adults don't hold the hamburger with the top of the bun facing them; that would give them nowhere to land their lower jaw. They don't hold it with the hamburger's edge running floor to ceiling; that would be a sandwich turned in the wrong direction. And they don't center the hamburger in front of their mouth and whump! stuff it in. That's not the way to get the biggest bite.
An adult eating a hamburger gets her thumbs out of the way on the bottom of the sandwich. She lands her lower jaw well back on the sandwich, then rocks it up into her mouth so that her upper jaw lands on it as well. A quick tuck with her index fingers, and her mouth is full.
What if someone held the hamburger for her? The helper would hold it with the edge of the hamburger running left to right, just like the adult's lips. For the biggest bite, the eater would approach the hamburger from slightly below, with her nose starting at about the level of the hamburger. Her head would tilt slightly back so that her chin lifted toward the bottom of the hamburger. (Give a quick, hard "sniff," and you'll feel your head jerk into that "slightly back" position, like your parents reading through the bottom half of their bifocals.) She would land her lower jaw first, then land her less important upper jaw.
How does this translate to babies? Well, for one thing, when a mother squeezes her breast using the "C" hold (see illustration 1), the result resembles a hamburger held in the direction an upright adult would use. But most breastfeeding instructions talked about holding the baby sideways across the mother's torso. Adults hold a hamburger in a "C" when they eat sitting up, but picture how you would hold it if you ate it lying on your side! It would make no sense at all to continue to hold your sandwich parallel to the bed. A sideways baby needs a sideways sandwich a "U" hold (see illustration 2), not a "C" hold. I began paying attention to how the baby's mouth was positioned, and encouraged mothers to shape their breast to match the baby's mouth, with their lower-jaw finger way out of the way, and with their upper-jaw finger running parallel to baby's upper lip.
It was around the time of my fast food revelation that I became aware of Bestfeeding: Getting Breastfeeding Right For You, which was first published in 1990. Here was a whole book that talked repeatedly about the details of good positioning. Chloe Fisher, the British midwife who co-authored the book, positions a baby so that his lower lip is farther back on the breast than his upper lip. Because this means that his head is in "sniff position," his nose touches the breast only lightly, if at all. His chin is thrust forward, rather than receding even more by tucking toward his chest. And more of the areola shows above his top lip than below his lower lip. He is off-center on the nipple, in an asymmetrical latch-on, with his lower jaw, his working jaw well back on the breast (see illustration 3).
Bestfeeding shows babies whose heads aren't cradled in the crook of the arm the way I had begun with my first child. For most mother-baby pairs, the baby's head rested on the mother's forearm, if she used a cradle hold, or her hand held the baby's shoulders and neck, if she used the opposite arm to hold the baby. "Don't push on the baby's head," said Kathleen Auerbach, a lactation consultant and former LLL Leader who edited the Journal of Human Lactation and BREASTFEEDING ABSTRACTS for many years. She demonstrated at a conference, pushing on the head of an experienced nine-month-old while his mother nursed him. The baby pulled off, crying. "If an expert like this baby doesn't like it, imagine what it's like for a baby who's just learning."
In imitation of an experiment done with real babies and real breasts, I put lipstick on my lips and then sucked on a water-filled balloon. When I centered the "nipple&" in my mouth, I left a lovely, near-circular print that was centered on the "nipple." Then, I approached the water balloon "breast" as if it were a big hamburger, starting with my head tipped slightly back ("sniff position") with my nose near the "nipple," landing my lower jaw first. I left an enormous print, with my lower lip so far back from the "nipple" that my tongue would have no trouble milking the breast instead of rubbing on the "nipple." When I gave a water balloon to a fellow Leader to experiment with, her eyes flew wide with her second, asymmetrical approach. "Wow!" she said. The difference in how the balloon filled our mouths said volumes about how different it must be for the baby. (Use a helium quality balloon if you try this, fill it so that it feels like a breast, leaving a small nub for the "nipple." Wash it first to remove any latex powder.)
Kay Hoover, a lactation consultant and La Leche League Leader, used a protractor to examine pictures of babies who were well or painfully latched on (Hoover 1996). A baby who was "cliff-hanging" on his mother's nipple had an angle at the corner of his mouth of about 90 degrees (see illustration 4). Babies who were more deeply attached to the breast had an angle at the corner of the mouth of between 130 and 150 degrees (see illustration 5). (The well-attached baby in Breastfeeding Matters, by golly, had an angle of 140 degrees; his prissy partner was 90 degrees.) But I began to realize I couldn't see the mouth at all on most well-attached babies, at least not at the beginning of a feed if they were young and hungry. As they drew the breast in well, as the breast softened, and as they relaxed into the feed, that lovely wide mouth corner might become visible. But on a newly attached newborn, all I saw was cheek against breast, with the chin buried and the nose touching lightly or not at all.
Still, I always told mothers to tickle the baby's lips with their nipple, although I was rather vague about it. Tickle the upper lip? Lower lip? Both lips? Stroke from nose down to lips? I wasn't sure. But lips and nipples were clearly involved, according to everything I had read. Then came a day when a mother I was helping just wasn't helped. We did finally find the cause of her pain, unrelated to positioning, but in the meantime I offered to do the latch-on for her, at her own breast, to see if I did anything different from what she was doing. As soon as I did, she told me, "What you say is not what you do. You've been talking about tickling my baby's lips with my nipple. But you didn't have my nipple anywhere near her mouth!"
Moment of shock! I hadn't really known how to phrase the tickling part because somehow I'd rarely found tickling to be necessary. I began reviewing my technique. I generally kept the nipple tilted away from the baby's face, pointing up at his nose, nowhere near his mouth. When the baby had to reach for the nipple, lower lip landing first, then his mouth just naturally opened. Sometimes I brushed a resistant mouth with the part of the breast nearest the baby's lower jaw, but not with the nipple. Indeed, I used that part of the breast for leverage, buying a moment of extra time by using it to hold the mouth ajar as the nipple slipped in. I do something similar when I put a book back in a tight bookshelf, wedging one corner in to hold the space while I slip the rest of the book into place. We use this prying motion in all kinds of situations, and I realized I used it much of the time during latch-on as well.
Some 15 years after the fact, I understood why my newborn Eric didn't always recognize what I was offering when I brushed my nipple across his lips. He expected to put his head back and reach for it. Indeed, each of my older babies enjoyed "nosing onto the breast," nuzzling the nipple before latching onto it. They never, ever came to it from above if they could help it. Their definite choice, at any age, was to "come from below."
If you have one of those cloth breasts, try latching on by starting with it below your chin. Now try with the nipple resting somewhere near your upper lip. Quite a difference! I began showing mothers the pictures of latch-on from Jack Newman's The Ultimate Breastfeeding Book of Answers because of the way the baby's heads are tilted back slightly and the amazing amount of space his latch-on creates between nose and breast when the babies start with their nose near the nipple.
There I stayed, until I discovered a wonderful, validating video called Mother and Baby: Getting It Right, made by a Tasmanian lactation consultant named Sue Cox. Sue, whose video is sold through the Australian Breastfeeding Association, used approaches and words that I'd been circling around for years, only she seemed to do it better.
"Think of your breast as a clock," she says on the video, "with 12 at the top, 6 at the bottom." When a baby is held snugly on his side, the mother logically makes a sideways sandwich for him by having her thumb and index finger at 3 o'clock and 9 o'clock, lower-jaw finger far away from the nipple. But Sue doesn't worry about how close the upper-jaw-finger is. In fact, she deliberately puts it near the base of the nipple, running parallel to the baby's lips. When the mother presses with that thumb or finger, she makes the nipple tilt away from the baby's mouth without moving the whole breast. Now she can present a "lovely hunk of breast" to the baby's forward-thrusting lower jaw, teasing with it until his mouth opens wide, when she brings him quickly onto the breast. The baby can latch onto both nipple and finger; it doesn't matter, for the mother can easily slip the finger away as the baby's upper lip lands on it, and even flip the lip out nicely as she does so.
Rebecca Glover, another Australian, has a graphic demonstration for why a nipple brushed across the front of a baby's mouth isn't optimally effective: Look down, and open your mouth as wide as you can. You can't open it very wide. Furthermore, your tongue pulls back and up. Now tilt your head back, and open your mouth as wide as you can. Ahhh! An entire cavern opens up and your tongue lies down on the bottom of your mouth, just where it should be for nursing. Anytime a baby has to tuck his chin to reach the nipple, he reduces his mouth size and puts his tongue in his own way. So my poor Eric shook his head in frustration not only because he didn't expect my nipple right in front of his lips, but because he couldn't open his mouth and manipulate his tongue as well when I presented my breast that way. Catherine Watson Genna, a lactation consultant and LLL Leader near New York City, USA, now tells mothers to start with the nipple near the baby's philtrum, that cute little vertical hollow below the nose and above the center of the upper lip.
But now I was entering new territory indeed. Sue Cox, Rebecca Glover, and others are finding still more pieces of the latch-on puzzle. One of them is so simple that we've overlooked it for years. What do you do when a baby cries? You pick him up, hold him against your shoulder, and pat and talk to him. He calms for a variety of reasons, one of which is "positional stability": you have given him a totally secure position.
When a baby's whole front is securely supported, he is no longer a twitching bundle of reflexes but an organized, capable little being. Lay him on his stomach, and gravity provides that firm support. Even at one day of age, he can lift his head from that stable position. Put him in Kangaroo Care (skin-to-skin), and again, gravity supports him by keeping his front pressed firmly against you. It isn't just the magic of those post-birth minutes that prompts a baby to make his own way to the breast, it's the security of positional stability that allows him to focus. Hold him against your shoulder, and the pressure of your arm does the same thing. Put him in a "colic hold," and your forearm presses along his front and stabilizes him. "Close the gap," suggests Catherine Watson Genna when she sees a baby, not quite latching-on, begin to draw his knees up and thus pull away from the breast. Once he feels his mother’s body along his whole torso and lower face, he is likely to calm down and regain his interest.
So I had learned another reason that babies don't eat as well lying on their backs: they just don't feel as stable in that position. Pasted securely against their mother's torso, a hand and forearm holding them close, babies feel organized enough to take on the task of looking for lunch.
Christina Smillie is a physician and IBCLC in Connecticut, USA, whose whole practice is devoted to breastfeeding. She observed that the hungry baby who is held skin-to-skin against his mother's shoulder will move quite deliberately toward his mother's breast. Even babies who have been unwilling to latch on know how to make the trip and may complete the trip by latching on better than they ever have before. Sure enough, I suggested that the mother of a reluctant feeder hold her baby upright, skin to skin. The mother began to stroke and murmur, then exclaimed, "Oops!" as her daughter slumped abruptly toward her breast.
Is this a cure-all? No, although it may encourage the baby to be a willing participant for a time. Is it the final piece of the puzzle? Goodness, no! Christina compares the process of learning to breastfeed to learning to ride a bicycle. Both are "right brain" activities that do best with a sort of whole-body learning, rather than with the list of do's and don'ts that the left brain and breastfeeding pamphlets prefer. There's clearly more to come.
There is more and more information available about the cues, reflexes, and mechanics of breastfeeding. Does everyone need to know all this in order to breastfeed a baby? Of course not. "Correct positioning" means nothing more than that mother and baby are comfortable and milk is transferring easily. It's only when a mother and baby are having trouble that knowing a little theory and a few analogies becomes helpful. For my part, I've traveled from believing in a list, to knowing it has everything to do with the orientation of head and mouth, to realizing that the baby's whole body matters, to seeing it as more of a mother-baby conversation in which my role is to try to act as translator when needed. I'm scrambling to reinvent myself and I'm waiting eagerly for the next chapter. Sure, I know how to nurse a baby. But I'm only just beginning to understand how to help someone else.
Diane Wiessinger has been a Leader since 1985, an IBCLC since 1990, and a lactation consultant in private practice since 1992. She and her husband, John, live in Ithaca, New York, USA and have two grown sons. It took her over four years to become a Leader, but she says she'll always be glad she did it! Special thanks to Norma Ritter, Contributing Editor, who initially developed this article for the Leaven column, "Keeping Up-to-Date."
Central New York Breastfeeding Coalition conference, 1995.
Breastfeeding Your Baby: Positioning, Chele Marmet, 15 min., Medela, 1986, video cassette.
Delivery Self-Attachment, Lennart Righard, 6 min., Geddes Productions, 1995, video cassette.
Follow Me Mum: The Key to Successful Breastfeeding, Rebecca Glover, 20 min., Tapestry Films, 2000, video cassette.
Frantz, K. Managing nipple problems. La Leche League International Reprint #11. 1982.
Genna, Catherine Watson, 2003. Personal communication.
Hoover, K. Visual assessment of the baby’s wide open mouth. J Hum Lact 1996; 12(1): 9.
Minchin, M. Breastfeeding Matters. St. Kilda, Australia: Alma Publications, 1998.
Mother & Baby...Getting It Right, Sue Cox, 20 min., Australian Breastfeeding Association, 1996 video cassette.
Newman, J. & Pitman, T. The Ultimate Breastfeeding Book of Answers. Roseville, CA: Prima Publishing, 2000.
Renfrew, M. et al. Bestfeeding: Getting Breastfeeding Right for You. Berkeley, CA: Celestial Arts, 2000.
Smillie, Christina, 2003. Personal communication.
Wiessinger, D. A breastfeeding teaching tool using a sandwich analogy for latch-on. J Hum Lact 1998; 14(1): 51-56.
Editor's Note: During the editorial process for this article, editorial staff members used a realistically sized doll, an experienced LLL Leader as a simulated breastfeeding mother, and a lively discussion to bring the text to life. We highly recommend using some sort of "visual aid" while reading this article. The ideal "visual aid," of course, would be a willing newborn baby and his mother. Articles such as this one help keep us all talking and thinking about what makes breastfeeding work for mothers and babies, and about clear ways to describe breastfeeding techniques to mothers whose babies struggle with latching on.