Attachment mantra

Check the positioning and attachment.

It is possible to repeat a statement so often that it loses it meaning. What do we really mean when WHO and many others down through the health care system say – ‘check the positioning and attachment is correct’.?

There are many references to correct positioning and attachment in the breastfeeding literature.

Clinical guidelines (KEMH 2006) indicate that correct positioning and attachment are vital to the success of breastfeeding.

Positioning relates to posture – primarily that of the infant and secondarily that of the mother. Both should be comfortable.

Attachment relates to the interface between the infant mouth and the breast (but also the bottle). It is not necessarily obvious from the outside. As yet, health professionals do not have x-ray vision. Subjective data from the mother concerning the ‘feel’ of the feed is a vital part of ‘checking that attachment is correct’. Many mothers continue to have feeding difficulty regardless of the fact that, ‘the midwife watched every feed I did in hospital, and she said it was alright’.

The aim is to have the baby in a position which facilitates efficient, effective feeding ie removal of milk from the breast. The bottle fed infant should be encouraged to suck as efficiently on the bottle as is necessary on the breast.

The infant is born with reflexes which in most cases form the basis of efficient feeding. Practice makes perfect and within a few feeds, correct stimulation of the neural pathways will lead to suck efficiency (coordination). If this does not occur suck re-training can be used to coach the infant.

Suck efficiency means that the infant is an efficient ‘suckling machine’; able to create a vacuum within the mouth, so that milk flows from an area of high pressure to an area of low pressure. To achieve this, the lips and tongue must form an airtight seal around the breast. The baby must breathe in through the nose, suck and swallow in a rhythmical fashion. If the tongue is in the correct position, over the lower gum, and cupping the nipple/breast the milk is stripped from the breast with each cycle.

If attachment is not correct (efficient) then signs of ‘failure’ will develop: sore nipples, blocked ducts, slow or no weight gain, short periods between feeds, unsettled infant, anxious mother.

What can we do to when we suspect that attachment is not correct?

  • Ask the mother if she has ‘sore nipples.
  • Observe the nipples for compression or skin damage.
  • Observe the infant sucking cycle for co-ordination of suck-swallow-breathe.
  • Monitor weight, length and head circumference.
  • Conduct an intra oral suck assessment (with expressed milk)

How can we assist the infant to correct attachment?

  • Teach parents to use suck re-training for short periods prior to feeds (5-6 sucks, then on to breast).
  • Use small tube (IGT No 5) and some expressed milk.
  • Ensure that the lips form an airtight seal, use firm chin pressure.
  • If the lips ‘curl’ to enable breathing, use cheek pressure to promote efficiency.
  • Check for tension in the temporo-mandibular joint (infant clamps down on the areola/nipple).
  • Use massage and facial stimulation to promote good muscles tone in the face.
  • Use prone/side lying and pull to sit exercises to promote central core stability.
  • Express prior to feed if breasts are very full.
  • If milk ejection reflex is very fast/strong, remove infant from breast, place finger/heel of hand against nipple to stop flow for about 30 seconds, then return to feeding as normal.

How does the mother ‘know’ if attachment is correct?

  1. Feeding will not hurt her.
  2. There will not be any leakage of milk from the mouth during the nutritive phase of sucking.
  3. Baby will give the impression of ‘a machine’ in rhythmical motion.
  4. The muscles at the corner of the mouth usually ‘pull in’ as the tone improves, but there is no dimpling in the centre of the cheeks.
  5. The infant will get 80% of the feed within 8-10 minutes.
  6. The infant will be sated following the feed.
  7. The infant will sleep for a ‘reasonable’ period (> 2 hours).
  8. Weight gain will be normal.
  9. Growth and development will be normal.

It is important to recognise that a health professional without the luxury of an ultrasound view will not be able to see good attachment, but can assess attachment with the subjective analysis of the mother. Too often women, who seek help from community nurses about breastfeeding difficulty, report that ‘the midwife watched every feed I did in hospital and she said it was OK’. Yet this mother is presenting with one or several of the signs of poor attachment (see above). If the mother reports pain – first assess attachment, then look for other causes e.g. thrush infection, dermatitis. The pain is a way of the ‘communication’ that the infant has with the mother via the medium of the pain and pressure receptors in the nipple. In the past, before health professionals, lactation consultants, and voluntary counsellors were deemed experts in breastfeeding, women were ‘advised’ by varying levels of pain when the feed was ‘incorrect’ and by the cessation of pain, when the issue was resolved. Once mothers have experienced a ‘good feed’, then they are able to assess the quality of the feed. Some feeds are really good, some are OK and sometimes we (mothers) don’t know why we bothered with feeding this time, at all. When attachment is correct the mother is not asking anyone to ‘watch the feed and see if I am doing it right’. This is the request of a mother, whose baby is experiencing some degree of difficulty.

In the community, general parameters can be used to measure succes:

  • the mother should be comfortable,
  • the infant should be comfortable.

If this is not the case, we can use our professional knowledge and skill to identify where the problem lies and implement corrective strategies. Some parents are interested in scientific detail eg the specific muscles involved, but some are not eg just want the baby to feed and sleep. Individualising the process for particular parents is a primary skill for community nurses and lactation consultants.

The mother can learn the principles of positioning but the baby must address the details of attachment. Parents can be effective coaches in developing more efficient attachment if it proves to be defective. We should abandon the mantra of – ‘check positioning and attachment’ and regard them as separate issues. We need to assess it, not just say it. Once the mother understands positioning we do not need to keep checking it. Efficient attachment is the next area of specialisation which will assist mothers to maintain lactation and achieve the goals set in the Australian Dietary Guidelines.

Once the gap in the assessment tools has been addressed, and intra oral assessment becomes a routine examination for feeding difficulty in any baby, our efforts to support parents in their feeding goals will be more realistic, objective and accurate. We need to correct the gap in assessment which was created in the 1970s and completely overlooked since. When a grandmother confides in me that she ‘wasn’t able to breastfeed’ and that her mother had the same problem, I reassure her that, now we know ‘it wasn’t you, it was the baby who couldn’t feed efficiently, but the health system was more interested in weight gain’. I trust that my granddaughter will now have the same poor advice when she has children. The advice that was given to my mother, to me and to my daughter is now outdated and simply waits for the research to back it up. Currently, planning the project in 2010…………..

Cheers, Ailsa