Positions for breastfeeding 101
You’ll hear two different messages about positioning and attachment that seem to contradict each other. On the one hand, baby is filled with natural reflexes and you are too and you are both created for this breastfeeding business by million of years of evolution. When baby comes out, they just instinctively know what to do and you do too – if you can just tap into those instincts. If you just lie back, a newborn baby will scoot themselves into position and away they go (cue videos of the breast crawl on YouTube).
Yet there’s another message coming through. Breastfeeding seems like an exact science. Mothers have to think about angles of mouth and hard palates and soft palates and size of gapes and catching gapes at the right moment and holding baby in a particular way. It’s like learning to drive except the gear stick is wriggly and cries a lot. It’s left brain and right brain – not just a case of letting Mother Nature and her cosmic power flow over you.
These two messages seem completely at odds with each other. What’s true?
Well, like most things. It’s all a bit true. Some babies and mums do just seem to ‘get it’. It’s never sore. It’s easy. It works.
However some mums need to take a bit more control over positioning. Perhaps some of baby’s instincts haven’t quite come to the surface because birth was complicated. Perhaps first breastfeeding experiences didn’t go well and it took a few days to get up and running. Perhaps you don’t start out quite right (maybe that breastfeeding pillow wasn’t such a great idea?) and now you need to concentrate a bit more to make things comfortable. Perhaps you just need to take charge a bit more and it’s not quite clear why. You may not be able to predict beforehand exactly how your breastfeeding experience is going to go. You may have to just wait and see what happens.
Whether you are in the nature-led or mother-led group when it comes to positioning and attachment, there are certain positions that seem to be used by most people. It’s a good idea to get pictures in your head now and embarrass your partner by practising with a doll. Although be warned a doll doesn’t have that flexible neck and that heavy head and that gorgeous biscuit baby smell.
The most important thing to remember is that one position isn’t automatically better than all the others. You might work with a breastfeeding supporter who has a favourite and encourages you to try one position and then the next person to walk in the door could have another suggestion. As long as the key features are there, there are lots of options. You need that big wide mouth, the tongue extending over the lower gum ridge and chin touching the breast. Their bottom lip will be flanged down (though you don’t want to fiddle around too much to check or you’ll mess things up). Their cheeks will be touching the breast and you may not be able to see their lips at all. You need baby’s body nice and close to yours without their neck or body being twisted. Remember the ear/ shoulder/ hip all in a line. You try and swallow something with your neck turned to one side! You need to be comfortable: your hands, arms and back. It's worth mentioning now that the upper lip doesn't also need to be flanged out like a fish lip. It often rests in quite a neutral position. Ideally it's relaxed but a very out -turned top lip can be an indication of a shallow latch.
The Reclined position
When you lie back, with the baby on their tummy on top of you, it does often seem to tap into some of their natural instinct and perhaps some of yours too. Sometimes when a baby has been really struggling to latch or even refusing entirely, lying right back and using the ‘biological nurturing’ position can make all the difference. We can give our arms a rest. We don’t have to worry about how to hold their head: whether we’re holding it too firmly, how that might feel for them after a difficult birth, are we squashing their ears? Have a look at www.biologicalnurturing.com. Babies will often self-attach and mum might just raise an arm to keep a baby in place and prevent them toppling off if they lean. If you’ve had a c-section it might be more uncomfortable if baby’s feet are placing against your scar and it’s going to depend a bit on your body shape and length as to whether this is a position for you. First you’ll need to lift baby onto your body (or get someone else to) and place their nose roughly around the nipple area and see what happens. Have their arms placed up either side of their head to help them stabilise themselves rather than down by their hips. It might look as if they are in a nearly crawling position. They may bob around and lift their head up and then plonk it back down again. You may not be able to see very much in terms of latching. It might a feel like you are a bit out of control. It can still be a great position and sometimes it’s worth lying back (literally) and seeing what your baby can do on their own. It may take a while before the baby settles down to feed so this isn't a position to rush. Have a go at the very earliest sign of hunger cues. It's best to try after a good stretch of skin-to-skin time. Results are unlikely to be positive if we scoop a baby out of a Moses basket, peel off their clothes and plonk them on when they are already pretty hungry.
Rugby-Hold
The rugby hold or football hold (when North Americans are writing about it) can be a good choice particularly when babies are little. Depending on your body shape and the shape of your breast, baby may be lying on their back or on their side or on a diagonal at your side. Importantly, baby shouldn’t have to twist their neck to reach the breast. Remember the ear/ shoulder/ hip in a line thing? If your breasts are larger, it’s more likely baby will be on their back. Remember to start with nose-to-nipple. If you start with mouth to nipple, the baby won’t do that lovely head tilt that brings the chin to the breast. The important thing with this position is that you want the head tilt so that the chin isn’t tucking into baby’s chest. The baby’s head should be stretched away from their chest. You try and drink a glass of water and swallow with your head tilted down! You’ll be supporting baby’s head by holding them around the base of their neck. Often your fingers will end up round their ears. The palm of your hand will be around the top of their back. You’re supporting their neck and the base of their head but you’re not putting pressure on their head. It’s a supportive but gentle hold. If they want to tip back, they can. If you put pressure anywhere, it’ll be on the top of their back to keep their chin tucked in close to the breast. Your arm should be supported probably by a cushion. It’s not easy to do this position with baby dangling in mid-air. This position is often good if baby has a tongue restriction or if baby hasn’t been doing really wide gapes in a cradle or cross-cradle hold.
Cross-Cradle
With this position, you start with baby’s weight on your arm. You want to be able to move their body across you and if you’re just holding their head, it may feel like you’re yanking them uncomfortably. The whole baby moves when we do ‘baby to breast’. You support their head by holding them round the ears, neck and top of their back. Imagine Elvis at the end of his career is Las Vegas. Your hand is the big Elvis collar. You want to check there isn’t clothing bunched up between you. A bra rolled down with a breast pad squashed inside it could push baby’s chest far away enough from your body that it affects the way baby will attach. Baby’s hands also can’t be between you. The bottom arm can be hugging your body and round towards your armpit or right down their side by their hip. Lots of new mums says that the baby’s hands are ‘getting in the way’ and it can seem to be very frustrating. Remember that baby uses its hands to help it find the breast and centre itself. If you can get baby’s chin and face to the breast quickly, you’ll find that very often the arms will instantly calm. Dab the baby’s nose against the nipple and wait for the gape.
Take a moment. It’s OK for this bit to take a couple of minutes at least. They will hopefully gape and tilt their head as they reach up for the nipple. When you feel you’ve got that gape, you’re going to move baby’s body quickly and plonk them on. Their bottom lip will be as far away from the nipple as possible. Just check your arm is well-supported. You’re not going to be able to hold the weight of a baby’s head throughout a feed on just a few fingers. It’s often a good idea to bring your other arm round and support baby’s head on that forearm. So perhaps start in a cross-cradle hold and then move into a cradle hold. You might even be then able to move your cross-cradle arm out slowly and leave baby in a cradle position. That gives you a spare hand for essentials like drinking, eating and reading. Or you might have cushions supporting your cross-cradle arm and taking baby’s weight. Another option is that you lean back so that baby’s weight is going through your torso. What’s going to be hard is an increasingly heavy baby balancing on your arms and hands as you sit bolt upright. By the way, you don’t need to sit upright for the milk to flow. The milk will flow even if you are leaning right back. It’s your milk ejection reflex, the baby creating negative space in their mouth and the baby’s tongue that moves the milk around. Gravity doesn’t have a lot to do with it.
One thing worth remembering, some women have naturally shorter forearms. You may not be able to have baby resting on your arm and be able to support the base of their head. Your arm may literally not be long enough. So if this position seems to be a struggle, you’re not going mad. You just needed a few more centimetres of arm. You may do better with a bit of cradle hold and using both arms for support, or the rugby hold.
Cradle hold
This is often the picture we imagine when we visualise breastfeeding for the first time. There aren’t many images of the Mother Mary and baby Jesus doing the rugby hold or laid-back breastfeeding. Baby’s head is resting somewhere around the crook of your elbow. Their body is close to yours and their hands aren’t squished between you. No clothing bunched between you. You dab baby’s nose around the nipple and when they gape, you bring them even closer to your body. You want their chin massaging the breast. Their head is ideally slightly tilted which gives them even more chance that the chin and tongue have good breast contact. When you bring them nice and close with that gape, focus on two things. First, you want their bottom lip to come as far away from the nipple as possible. It’s OK if the top lip is much closer. If you see any areola (and there’s going to be a lot of variation with this as areolas come in lots of different sizes), you can see some areola above the top lip but none below the chin. And secondly, try and picture the nipple heading up towards the roof of their mouth. You’re aiming for a point on the roof of their mouth rather than heading down towards the back of their throat. Once baby is on, check that you are well-supported. If you had to lean forward and move the breast around, something is probably going to adjust during the feed in a way we don’t want it to. Baby will have moved to you. Baby to breast is the phrase we say. We want you to finish a feed as comfortably as when you started. You shouldn’t have back ache or feel relief that your arm no longer has to do any work. If you finish a feed rubbing your sore arm or hand and thinking, ‘glad that’s over it’, something needs to change. You may have been slightly slipping during a feed without even realising it if something was uncomfortable. We only have to move a few millimetres for problems to start. The baby’s nose may sometimes be touching your breast. This is particularly likely if you have larger softer breasts. It’s not panic stations if a baby’s nose does make contact as babies will prioritise breathing and come off and adjust if they need to. You can tuck their bottom in a bit more and see if that tilts them so that their nose is a little more free. Ideally you’ll have got them on anyway with that head tilt that drives their chin in without burying the nose into the breast. What we want to avoid is pressing a finger into the breast to keep breast tissue away from the nose. That’s not a great plan for various reasons. Firstly, it means you are potentially affecting the flow of milk by pressing on a milk duct –some are quite close to the surface of the skin. It can also increase your chance of getting milk ducts and possibly mastitis. It’s also taking the emphasis away from that good quality head tilt
Lying down
Being able to breastfeed while lying down is one of the essential breastfeeding mummy skills. It’s right up there with being able to eat one-handed and opening a clasp on a nursing bra without losing your marbles.You might think you can get up all through the night and breastfeed in a chair but after a few weeks of that, it starts to become less fun. When you breastfeed lying down you can rest and you may even be able to sleep. 70-80% of breastfeeding families have the baby sleeping in their bed with them at some point. It’s a good idea to read more about bed-sharing and some of the risk factors so you can understand how to do it as safely as possible. I recommend visiting isis online. This is the Infant Sleep Information Service and if being called ‘ISIS’ helps sleep-deprived new parents to remember its name, that’s no bad thing. This is an excellent resource filled with useful accessible evidence-based information. It’s the place to visit if you want information about safe sleep for your baby.
When you breastfeed lying down, the principles of good attachment are the same. We still want that nice wide gape. We still want baby’s body close to mum’s body. What often works well is to have both mum and baby on their side. Take a moment to look at the bedding around you. Ideally your duvet is tucked under you or well away so it can’t flop on to baby. You may be determined that you won’t fall asleep while you are feeding but it’s sensible to think through what might happen if you did. Make sure baby is far away from your pillow. Perhaps put your pillow on a diagonal away from him. What is on other other side of baby? Babies can move surprisingly far even when they are very small. They can get trapped between walls and beds. Partners that aren’t breastfeeding don’t benefit from hormones that keep you more tuned into baby so ideally baby isn’t in the middle between you. One option is to have a side-car cot next to your bed and that’s behind baby when she feeds. After the feed, you may be able to slide her back into her space but if not, at least if she did move, she’s only got her cot space behind her. Some mums are so worried about falling asleep with baby in the bed that they get up and move to a sofa. It is far more dangerous to fall asleep on a chair or sofa than it is in a bed.When it’s time for latching, have your baby’s nose level with your nipple. Nose to nipple is particularly important in this position. We really want baby to be reaching up and tilting their head back to get to the breast. This will give their tongue optimum space on the breast, really get the chin pressing in nicely and help their nose to be as clear as possible (though some mums with larger softer breasts may still find baby’s nose touches). When the baby tilts and you get that gape, you press in on the top of their back and bring them as close as possible. You’ll probably need to keep that hand there so their chin and body stays close. The other hand may be propping up your head so you can see what's going on and once the feed has started, you can lit back down on the pillow. If you do fall asleep, your hand may start to relax and the baby may end up rolling onto their back to sleep once the feed has finished. When it’s time for the other breast, switch yourself round so your head is at the other end of the bed – go ‘top to tail’. Your breasts will be again on the outside and baby will be in the safer outside position in the bed (assuming there’s a partner on the other side).
Pick the position that seems to work best for your baby, your breasts, your chair, your life. If you can have a couple up your sleeve that's useful because it means the breast will get drained in different ways and it gives you options depending on where you are. Most mums do appreciate the opportunity to lie down so being able to breastfeed in bed is certainly worth practising. Don't let anyone tell you that one position is necessarily 'best'. Quite often people are loyal to the position that works best for them but there any many different options —including several not described here. If you are comfortable and baby can get the milk out effectively and you can reach the remote control— those are the things that really matter.
Thanks to Estelle Morris for the illustrations | www.estellemorris.co.uk