Everything Old Is New Again?
Diane Wiessinger, MS, IBCLC, LLL Leader
dwiessin@baka.com www.normalfed.com
So much has happened lately regarding “The Latch” that I hesitate to put anything on paper. Here’spart of the swirling controversy. Make of it what you will! First of all what’s not controversial: This can’t be rocket science. After all, a frog may lay hundreds of eggs at a sitting, only two of which need to replace her and her mate in her lifetime. The survival rate for any one egg is pretty low. A dog has a litter of under a dozen, with a few litters in her lifetime, so their survival rate needs to be higher. A human can produce one offspring a year, top speed. It would make no sense at all for birth accidents to mother or baby to be common, or for babies to die of starvation in the first week or two because they couldn’t figure out how to latch on. No, this is a very sturdy system.
But.
Babies are built to withstand likely risks and go on to do fine. They’re built to deal with difficult births, cold, temporary separation, early hunger and thirst, and pathogens. These are all everyday hazards, and it would be a poor system indeed that produced young at such a slow, physically expensive rate anddidn’t protect them well during the pregnancy-to-breast transition. What babies are not necessarily built to deal with because they would never occur naturally are drugs and such surgical interventions as premature cord cutting and cesareans.
Interestingly, there have been huge efforts recently and in years past to protect newborns from difficult births, cold, the briefest of separations, early hunger and thirst, and pathogens. But we’ve had a pretty liberal hand with the drugs and surgical interventions. Might there be some connection with our breastfeeding problems? The drugs, especially, can surely pack a wallop for which babies are not at all prepared. Perhaps their mothers aren’t prepared for them, either.
The World Health Organization, UNICEF, and the World Alliance for Breastfeeding Action (WABA) have a video on-line now encouraging the “breast crawl” as a partial solution to early breastfeeding problems. The idea has its roots in the work of Lennart Righard and Margaret Alade, whose 1995 video shows newborns crawling to the breast all by themselves on a supine (face-up) mother who offers no help beyond keeping the baby from falling to the floor.
The WABA video is enthusiastic about babies’ instinctive abilities, and urges all maternity facilities to implement the “breast crawl”. But I think it overlooks some significant problems: No mother in her right mind would lie flat on her back to examine her newborn. She would sit up at least partway, or would roll onto her side. Imagine lying flat on your back and having someone put a marvelous, complex present on top of you. Would you stay in that position to look at it? No mother in her right mind would fail to interact with her newborn. It surely takes careful instruction, even physical restraint at times, to keep her from talking to, shifting, admiring, grooming, and encouraging her baby.
All this means that the mother is still being left out of the infant feeding equation. She is still being given instructions, rules, prohibitions. She is important not for her connection with the baby but as a nutrition source. When a mother lies on her back, her breast tissue sags toward her chest wall, away from the baby’s mouth. The prone (face-down) babies in what I’ve come to think of as the “Dead Mother Videos” grab a mouthful of nipple, yes, but I have yet to see a video that shows a really deep, solid latch. As a nurse at one hospital said, despairing over a midwife who promotes the Dead Mother Approach, “She doesn’t see those nipples the next day.”
Other mammal mothers help their babies. They don’t give much help – the dog rolls on her side instead of standing up; the horse stands up instead of rolling onto her side; both give the baby a vague nudge in the right direction if he strays – but they do help. Our problem has been that we’ve overassisted in the recent past, and now we’re having trouble backing off. Christina Smillie’s “Baby-led breastfeeding”(1) means exactly that: baby-led, but not mother-dead. She encourages mothers to simply “help the baby do what he’s trying to do.” But today’s mothers have learned their “how to” lessons very well, and many are almost literally paralyzed when they’re urged to follow the baby’s lead.
So where does that leave us? Well, my latest – and belated – revelation is what happened in the days before we knew anything. I’ve now polled a number of us gray-hairs, and we all seem to say the same things: “I don’t know; we just did it.” “I didn’t know anything at all. Fortunately, my baby did.” “I had the Womanly Art of Breastfeeding and Karen Pryor’s book, ‘Breastfeeding Your Baby,’ and wejust sort of worked it out.” And so on. Over and over again, “I don’t know; we just did it.” But what, exactly, did we do? If you read the WAB from 1963 – the thin blue volume that many of us old-timers used – here’s everything there was on positioning the baby:
“Whichever position you find most comfortable for you and the baby is the best for you. During the early weeks, you may find it more relaxing and convenient to lie down while you nurse the baby. Certainly this is the thing to do for those middle-of-the-night suppers, so that you can doze back to sleep while he is nursing. Later on, you may prefer to sit in a chair or in a corner of the sofa for most of his feedings during the day. “In the beginning, when you are lying down, and you are going to nurse your baby on the right side, lie down on that side, put your right arm up over the baby’s head or under it, whichever is more comfortable for you. With the left arm, bring the baby toward you till his cheek is touching your breast [italics original], with the nipple next to his mouth. He will turn his head toward it, for this is the way he is built, and open his mouth. When he does, pull him in a bit closer, just enough so he can get the nipple into his mouth and suck. For nursing on the left side, reverse all this. If you pull his legs close to you, it angles his body enough to keep his nose free. This keeps him warm and cozy besides.”
There is information embedded there that we’ve overlooked for a quarter century. First, notice that here’s nothing at all about “positioning the baby.” I think that “position” started to be used as a verb when we adults started taking full control of The Latch. Until then, we found “a comfortable position” for ourselves, and held our babies comfortably. And notice that the only thing in italics is the encouragement to let the baby’s cheek touch the breast.
My first baby was born in 1979. Most of us oldsters remember touch-the-cheek-with-the-nipple as the only instruction we received. Our babies were separated from us most of the time in the hospital, and many or most of them received bottles in the hospital, but my sense is that non-latching babies were truly uncommon. Many of us had sore nipples to overcome, though (mine lasted six weeks), and many of us failed because of terrible management advice. But when I nursed my firstborn in public, women would come up to me to tell me that they missed those days, or that they had wanted to breastfeed but hadn’t had enough milk. No one ever said to me, “I wanted to breastfeed, but my baby never latched on.” That part was confidently assumed. By all of us.
Then came the early to mid 1980s. In an effort to end those early sore nipples, breastfeeding helpers began to dissect “The Latch”. My six weeks of soreness were no doubt caused because my baby nursed with his head turned. I remember holding him sunny-side up at first, but a later picture shows me holding him facing me. Maybe that’s when I stopped being sore. My second was born in 1982, and I used the new positioning technique: hold the baby tummy to tummy and tickle his lips. Sure enough, I was only mildly sore for only part of a day. But while I remember no latching problems with my first baby, I remember my second baby shaking his head in confusion. “It’s right here in front of you,” I’d say to him out loud, and indeed his confusion didn’t cause us much problem. Still, I wonder, looking back, if he was on the leading edge of the non-latching generation.
We thought we were being logical. The baby turned his head in response to that cheek touch, and that meant he would be tugging on the nipple while he nursed. So let’s have him face the breast – not that sunny-side-up bottle-feeding position we used before. Ah, but if he faced the breast he’d have his head smushed into it until he latched, so let’s back him away from the breast a bit. I think what we did was remove almost all his feeding cues. Newborns don’t latch based on vision, they do it by feel. Left with only an unpredictable dabbing of his lips to the nipple, the newborn of the 1980s had little sense of what was being asked of him. We worked harder and harder to define one or two signals for him – we added the cross-cradle hold, we dabbed upper lip, lower lip, both lips, nose to chin, corner to corner, seeking the magic button that would make him open wide. We used a Rapid Arm Movement. We made sure his lower body was pasted to us. We used pillows and more pillows. But we steered completely clear of that basic rooting reflex, as if, powerful though it was, it was some accident of nature to be avoided. And some babies never attached. We blamed the kind of pillow, the post-birth separations, the birth medications, the bottles (but remember, the separations and bottles had been there before). And we came up with new and more meticulous approaches to The Latch, which was now a noun instead of an action that babies undertook, still without allowing the rooting reflex to be a part of it.
Co-bathing seemed to work for many, and so did skin-to-skin. Nurses reported leaving mothers in skin contact with their babies, and coming back to find them nursing. Was it the water in the bathtub? Was it the skin contact in the bed? Or was it something even simpler?
Suzanne Colson, in England, began suggesting what she calls Biological Nurturing (2). It’s simple. The mother leans back comfortably, every part of her head and body well-supported and relaxed. The baby lies prone on top of her, but remember, she isn’t completely flat. She’s somewhat upright, so her baby is too. Her position “opens her torso”, so that her lap isn’t an obstacle and the baby can lie in any of a near-infinite number of positions. Her breasts don’t sag completely into her body; the bit of sagging that they do tends to float her nipples to the top. And most important, gravity becomes her ally. The baby’s entire body is supported, mostly by the mother’s body but sometimes partly by the cushioning or bedding that surrounds her. The well-supported baby (no fool he) lies with his head turned, precisely so that his face isn’t smushed into his mother. That gives him cheek contact with her skin, and that prompts him to lift his head and root… and lo and behold, there’s the nipple, either right by his mouth or within head-bobbing distance. If he can’t seem to find it, his mother (no fool she) instinctively repositions him and he searches again. This isn’t a one-man show. She might hold her breast or not, move him again or not – whatever feels right to her at the moment. She may start to play idly with her baby’s feet – a maneuver that tends to open his mouth – and watch him woodpecker his way to her nipple. If she sits straight up to hold him, those same head bobs cause his head to fall away from her body, and she may take them as a sign of rejection. In a position of Biological Nurturing, she knows them for what they are – part of a competent search for Lunch. As mother and baby relax into the nursing, Suzanne says the mother’s oxytocin levels rise so high that she often develops an oxytocin flush and a little half-smile of contentment and relaxation.
I think we threw out a hugely important aid to latch when we tried to by-pass the rooting-toward-thecheek. Picture the baby who roots sideways. His mouth gapes W-I-D-E – the very mouth position we tried so hard to achieve by tickling his lips. But when you touch a baby’s lips, he’s more likely to respond with a forward-reaching OOOH mouth than the wider AAAH mouth. In a position of biological nurturing, a baby has all sorts of tactile cues that are denied him if we hold him close to us but keep his head kept away until the moment of latch. He needs those cues! Suzanne says she sees babies latch in drowsy sleep, because the moves are reflexive. Indeed, he may nurse even better that way, if there have been problems. Does this mean babies may latch even after a heavily drugged delivery? I don’t know yet. This is all really, really new.
I do know that her ideas feel right to me and to many others who are just hearing about them. She leaves everything to the mother – what she and her baby wear or don’t wear, what angle she finds comfortable, how she lays her baby on her, whether or not she holds or moves her breast, how she interacts with her baby, whether and when she shifts his position or hers. And come to think of it, all those decisions were left to me with my 1979 firstborn, too. I was in a hospital bed, which means I was leaning back somewhat, not bolt upright as we have advocated for so many years. I didn’t have my baby turned to face me, but I did have assistance from gravity that I lacked when I sat in a chair.
We oldsters may have known more than we knew:
Being comfortable is an important place to start. While breastfeeding is baby-led, it isn’t mother-dead. Babies have a powerful urge to root to the side that we’ve been ignoring. Gravity can work against us, or it can be our ally. Detailed instructions can’t possibly be as necessary as we’ve made them, or no mammal would be able to feed her babies.
And maybe:
Mothers and babies aren’t meant to begin this relationship under the influence of drugs. Mothers and babies aren’t meant to begin this relationship under the influence of rules. Some of the new ideas are going to change still further in the very near future. A year ago, I knew almost nothing that I’ve written about here. But use these thoughts as a starting point – especially those of you whose firstborns arrived before about 1982 – and think about how you got started. If you don’t remember… well, maybe that tells you something important too!
Diane Wiessinger, MS, IBCLC, LLL Leader
Hortense Breast Feeding Paul by Paul Cézanne (1872)
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