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Aetiology of sore nipples
MidwiJ)~y (1986) 2, I72-176 © Longman Group UK Ltd 1986
Aetiology of sore nipples Michael W. Woolridge
Based u p o n a description of the mechanics o f milk r e m o v a l contained in a foregoing article, suggestions are m a d e as to the potential physical sources of nipple t r a u m a which can result in sore nipples. T h e i m p o r t a n c e o f correct fixing and positioning o f the b a b y on the breast is considered as a p r i m e requisite for reducing t r a u m a , a n d hence the incidence of sore nipples, thus practical r e c o m m e n d a t i o n s are given for achieving optimal a t t a c h m e n t o f the b a b y at the breast. Special emphasis is placed on ensuring physical opposition o f the baby's lower j a w and tongue .to the u n d e r s i d e of the areola so t h a t the b a b y can effectively strip milk from the lacteal sinuses lying b e h i n d the nipple. It is h o p e d t h a t these guidelines will help midwives in c o m m u n i c a t i n g to mothers the essential skills r e q u i r e d to achieve satisfactory breastfeeding.
INTRODUCTION This discussion will be largely theoretical, based upon interpretation of the description of normal feeding contained in the foregoing article. It will be confined to potential physical sources of nipple pain rather than to organic sources which might include topical infections (e.g. thrush), and sensitivity to applications or irritants. The work of Gunther (1945) remains one of the few studies which has tackled the practical issue of the causes and prevention of sore nipples, and it remains essential reading for people concerned with this issue. An individual's perception and response to pain varies markedly: some mothers will persist with breast-feeding despite severe pain, whereas others will discontinue if they experience even moderate discomfort, especially if this was not Michael W. Woolridge BSc, DPhil, Research Fellow in Child Health, Department of Child Health, University of Bristol, Royal Hospital for Sick Children, St Michael's Hill, Bristol BS2 8BJ.
Manuscript accepted 18 July 1986
172
anticipated. Nipple pain remains the commonest cause of complaint with breast feeding and is the second most frequently stated reason for discontinuing (Sloper, Elsden & Baum, 1977; Martin & Monk, 1983). Yet it is a biological truism that pain is an evolutionary protection mechanism, the function of which is to indicate to the individual experiencing pain that the present situation should be rectified, thereby alleviating the source. Perhaps the reticence with which this is acknowledged with breast feeding is in some part due to a lack of awareness of the possible changes which might bring relief. Potentially, one of the most harmful aspects of nipple pain is that a mother will come to anticipate the aversive effects of putting her baby to the breast and become increasingly reticent about doing so. This will run counter to the natural conditioning of the milk ejection reflex (m.e.r.), and if the inhibitory effect of stress on oxytocin release indeed applies to human breast feeding (Newton & Newton, 1948), then nipple pain will have a potent effect in preventing effective milk transfer from the alveoli to the sinuses of the nipple. The alleviation of nipple pain is therefore
MIDWIFERY
an essential objective for ensuring trouble-free breast-feeding. Two main sources of nipple pain can be suggested on the basis of incorrect or unphysiological mechanisms of attachment and milk transfer:-1. Frictional trauma. 2. Suction lesions. These may not be independent and correcting the source of one may automatically benefit the other.
Frictional trauma I f inadequate amounts of breast tissue are presented to the baby for 'stripping' (e.g. by the mother's fingers impinging on the areola when the breast is offered) then insufficient tissue will be formed into a teat (Woolridge, 1986). Such a teat does not extend well into the mouth but is repeatedly drawn in and out of the mouth, between the tongue and gums, by the cyclical application of suction, and frictional damage to the nipple m a y be incurred by this process. I f an adequate teat fills the baby's mouth then in the normal course of events it is milk within the sinuses which should be transported across the mouth border, rather than the tissue of the nipple itself. The shape of the relaxed nipple and its protractility will play an important role in this. Clearly mothers with inverted or retracted nipples will have difficulty in intially forming an adequate teat from their breast tissue. Valuable benefits are claimed from antenatal nipple preparation and the use of'Woolwich' shells. However, the benefit of such preparation is difficult to verify. Marked changes occur in the nipple in the later stages of pregnancy (Hytten & Baird, 1958), and the baby's sucking immediately post-partum would appear to be a powerful effective agent in bringing about an improvement, making it difficult to assess the value of antenatal preparation. Babies with relatively small mouths (e.g. premature infants) or those with even slightly recessive chins may also have difficulty taking in adequate breast tissue. Contrary to these suggestions, one of the few correlations which Gunther noted was that sore nipples are more prevalent with larger
173
babies, i.e. babies for whom one would not assume smallness o f ' g a p e ' to be a contributory factor.
Suction lesions The assumption that larger babies can exert a more 'vigorous' sucking action may lead to the inference that nipple trauma is brought about by excessive negative pressure, although there is no evidence to suggest that this is so. Similarly, it is argued that large babies have a 'healthier' appetite, and this may manifest itself in the tendency to persist in sucking at the breast beyond the point at which available milk is depleted. During 'nutritive' sucking (see Woolridge, 1986), milk issuing from the nipple diminishes the pressure being exerted in the baby's mouth. However, very little milk transfer is necessary to cause a shift away from a purely 'non-nutritive' pattern sucking. If little milk issues from the nipple, or the baby's appetite has not been assuaged after milk flow has ceased, then unrelieved suction will be applied to the nipple surface and this may lead to suction trauma. In attempting to correct this, efforts would need to be made to increase the rate of milk release from the breast. Two possible ways of achieving this might be (i) the administration of a Syntocinon nasal spray, mimicking the effect of oxytocin and increasing the strength of the mother's let-down reflex; or (ii) improving the baby's positioning or degree of attachment on the breast so that he has a greater amount of tissue in his mouth from which to strip milk more effectively. O f these suggestions I would discourage intervention with drugs since positional changes may not only correct the situation but may also enhance the mother's natural oxytocic activity. By encouraging the baby to take more breast tissue into his mouth milk should be removed more efficiently and consequently a natural relief of the applied intra-oral pressure should be experienced. M a n y mothers experience transient discomfort at the start of a feed. This can be explained in terms of the pressure exerted by the baby not
174
MIDWIFERY
being relieved by milk issuing from the nipple until the mother's m.e.r, has been initiated. O f far greater concern is pain which increases in severity as the feed progresses. An explanation, consistent with this observation, is that during the feed milk flow subsides but the suction exerted by the baby does not abate. The characteristic crescent-shaped petechial lesion, described by Gunther (1945) may arise as a result of the combination of these problems. When inadequate amounts of breast tissue are drawn into the baby's mouth two problems become compounded: firstly, milk is not stripped efficiently from the teat, so that during suckling there is little relief from the suction exerted by the baby; secondly, because so little tissue is in the baby's mouth the pressure exerted acts upon a restricted surface area. Added to this, is the fact that it is difficult to form and maintain a teat from a small amount of breast tissue; moreover, the teat has a natural elasticity which tends to make it withdraw from the baby's mouth. The baby may attempt to counter this tendency by sustaining negative pressure during periods of rest. This is a phenomenon on which Gunther concentrated her attention, and was able to document (ibid). At this point, I would like to pass on a statement in relation to the origins and correction of nipple pain which appeals to me as being a piece of inarguable logic.* A question which is asked repeatedly when recommending that babies should be allowed unlimited sucking time i s 'Doesn't it lead to a high incidence of sore nipples?'. The reply to this question is illustrated by two logical statements.~ Clearly, if there is nipple trauma then the amount of pain that is experienced will be directly related to the length of feeds; the longer the feed the worse the pain. However, the remedy is not to limit the length of feeds but to remove the cause of the nipple trauma. If the trauma is caused by physical problems of attachment, then getting the baby correctly positioned on the breast, with respect to
both the amount and location of breast tissue in the mouth should rectify the cause of the trauma and allow normal feeding to recommence. Special circumstances apply, however, once the nipple has been severely traumatised or damaged. Although correcting the cause of the problem may bring some relief, additional procedures may be required to effect a cure. One approach to such a problem which has proved successful is contained in a companion article (manuscript in preparation). As to the beneficial effects of antenatal preparation, or topical applications (e.g. nipple cream, ointment, spray), Inch (in preparation) in reviewing 10 studies of potential treatments aimed to alleviate nipple pain and soreness, concluded that no treatment or application had been shown to be of discernible benefit in protecting nipples from damage caused by trauma. The inference is striking: in the absence of any protective therapy, the only policy should be to attempt to remove the source of the trauma. Resting the nipples allows recuperation, but this may not be to the long-term benefit of lactation, and, by not tackling the source of the trauma, there is every chance that the problem will recur when normal feeding resumes. I would contend that the best way to achieve trauma-free feeding is to promote the optimal attachment of the baby on the breast. I f this can be achieved, resting the nipple is unnecessary.
PRACTICAL SUGGESTIONS The theoretical solution to these problems would appear to be to offer an adequate amount of the breast tissue (lying behind the nipple), together with the nipple, into the baby's gaping mouth. A suitable 'teat' can be formed by thinning the breast between the thumb and fingers in the same plane as the baby's mouth when closed, taking care not to let the fingers impinge on the areola so preventing tissue from being drawn into the
* For this I am indebted to Chloe Fisher.
UNLIMITED SUCKING TIME + NO NIPPLE TRAUMA = NO PAIN, NO DAMAGE A N Y L E N G T H OF S U C K I N G + N I P P L E T R A U M A = N I P P L E P A I N , N I P P L E D A M A G E
MIDWIFERY
mouth. The 'scissor' technique for holding the nipple between the first and second fingers is undesirable in my view; I would encourage holding the breast between the opposed thumb and remaining fingers. This is best done using the hand on the same side as the breast being used, allowing the fingers to lie naturally on the underside of the breast where they can provide sustained support after attachment. It is implicit in the description of feeding given previously that the initial placement of the baby's lower lip and gum against the breast, at a point well below the nipple, is critical if the tongue and lower jaw are to carry out their job of'milking' the sinuses lying behind the nipple. Once the baby is attached, the grip on the breast can be released so as to avoid constricting the ducts or sinuses and inhibiting milk flow. Sustained support of the breast from below with the hand would appear beneficial to counter sagging of the breast tissue under gravity. Without this support the sinuses and connective tissue lying behind the nipple tend to be drawn back from the nipple; while applying support from below causes the internal fabric of the breast, including the sinuses, to be pushed forward into the 'teat'. This may have the added benefit that the baby does not feel that the breast is continually being lost from his grasp, removing any need to counter such a tendency on his part with sustained suction during rests. Circumstances mitigating against satisfactory attachment are often worst at the start of the feed, e.g. when the breast is fullest and most tense with milk, making it inflexible. There may be every advantage in allowing the baby to feed for a while to remove the initial flush of milk, then reattaching the baby on the same breast to improve his/her positioning, or 'angle of attack', once the shape and pliability of the breast has changed.
CLUES FOR PRACTICAL MANAG EM ENT Many midwives have an intuitively based skill, founded upon experience, as to what is the 'ideal' position for the baby on the breast. Where a mother is unable to achieve this, it is not always
175
possible to verbalise the crucial difference between this 'ideal' and what is being practised. One abiding difference, which deserves to be emphasised, is that for the mother breast feeding is predominantly a manual skill, not a visual one; for the midwife the reverse is the case. Even when a midwife has the necessary manual skill she has a different view of the baby at the breast to the mother. The mother's position relative to her breasts is fixed, such that she has a frozen view of them from above. The critical area for attachment, that is the region below the nipple, apposed to the baby's lower jaw and tongue, is the one of which the mother has the poorest view. Accepting the description of the mechanisms of milk transfer, there can be little dispute that it is the breast tissue opposed to the baby's lower jaw which is the critical region in the transfer of milk. It is to the underside of the nipple that the peristaltic force is applied by the tongue. The hard palate plays a relatively passive role in the process providing the necessary resistance to the tongue's action. To recommend that mothers 'get as much of the areola into the baby's mouth as possible' is insufficiently specific; mothers may feel they have complied with this advice simply when the areola region above the baby's mouth is no longer visible. Since the point of contact between the lower jaw and the breast below the nipple is most important it seems logical that this is where first contact should be made when the baby is put to the breast. For most mothers the position of their baby when feeding dictates that this point of contact is not visible to them and can only be located by touch. This is the main reason why I emphasise the manual aspects of breast feeding skill over the visual ones. To enable first contact to be made between the tissue below the nipple and the lower border of the baby's mouth, the breast can be tilted up slightly as the baby's head is brought towards the breast. Then as the correct relationship between these two has been established the breast can almost be 'folded down' into the baby's mouth. To achieve the correct relationship it is essential to ensure that the baby is held in the correct posture relative to the mother's body. This aspect has been eloquently argued by Gunther (1970).
176
MIDWIFERY
Flexion of the baby's neck can make it difficult to achieve an ideal relationship between the relevant anatomies of the mouth and breast, in addition to creating other postural problems which may impair swallowing ability. In contrast, slight extension of the neck aids correct fixing at the breast, as well as ensuring that the baby's nostrils are not occluded by being pushed into the breast. Extension of the neck is best achieved, and adverse flexion avoided, by supporting the baby across the shoulders, rather than by holding the baby's head directly. The necessary manual skill for breast feeding can only be developed by the mother with practice, and it is just as much a question of developing the right timing as it is of learning the correct position. As with all manual skills some people take longer to acquire them than others, and some will always appear ungainly no matter how hard they try, and the skill may be unattainable. Teaching such skills necessitates an understanding of the mechanisms involved in milk transfer, the ability to verbalise the important features of the process; and the patience to observe the mother's own faltering attempts.
Acknowledgement M a n y of the views expressed in this article, particularly those relating to practical aspects of management, were derived through close observation of a skilled practitioner fixing babies correctly on the breast, for which I owe an enormous debt to Chloe Fisher. The author also wishes to express his thanks to Lewis Woolf Griptight Ltd, who generously made funds available during their centenary year for the preparation of this manuscript.
References Gunther M 1945 Sore nipples, causes and prevention. Lancet ii: 590-593. Gunther M 1970 Infant feeding. Methuen, London Hytten FE, Baird D 1958 The development of the nipple in pregnancy. Lancet ii: 1175-7. Inch S t985 T h e basis for advice in relation to the problem of sore nipples. Presentation to the Royal Society of Medicine, December 2nd 1985. Martin J, M o n k J 1983 Infant feeding practice in 1980. OPCS Survey, H M S O London. Newton M, Newton NR 1948 The let-down reflex in h u m a n lactation. Journal of Pediatrics 33: 698. Sloper KS, Elsden E, B a u m J D 1977 Increasing breast feeding in a community. Archives of Disease in Childhood 52: 700-702. Woolridge M 1986 The 'anatomy' of infant sucking. Midwifery 2(4): 164-171
Aetiology of sore nipples Michael W. Woolridge
Based u p o n a description of the mechanics o f milk r e m o v a l contained in a foregoing article, suggestions are m a d e as to the potential physical sources of nipple t r a u m a which can result in sore nipples. T h e i m p o r t a n c e o f correct fixing and positioning o f the b a b y on the breast is considered as a p r i m e requisite for reducing t r a u m a , a n d hence the incidence of sore nipples, thus practical r e c o m m e n d a t i o n s are given for achieving optimal a t t a c h m e n t o f the b a b y at the breast. Special emphasis is placed on ensuring physical opposition o f the baby's lower j a w and tongue .to the u n d e r s i d e of the areola so t h a t the b a b y can effectively strip milk from the lacteal sinuses lying b e h i n d the nipple. It is h o p e d t h a t these guidelines will help midwives in c o m m u n i c a t i n g to mothers the essential skills r e q u i r e d to achieve satisfactory breastfeeding.
INTRODUCTION This discussion will be largely theoretical, based upon interpretation of the description of normal feeding contained in the foregoing article. It will be confined to potential physical sources of nipple pain rather than to organic sources which might include topical infections (e.g. thrush), and sensitivity to applications or irritants. The work of Gunther (1945) remains one of the few studies which has tackled the practical issue of the causes and prevention of sore nipples, and it remains essential reading for people concerned with this issue. An individual's perception and response to pain varies markedly: some mothers will persist with breast-feeding despite severe pain, whereas others will discontinue if they experience even moderate discomfort, especially if this was not Michael W. Woolridge BSc, DPhil, Research Fellow in Child Health, Department of Child Health, University of Bristol, Royal Hospital for Sick Children, St Michael's Hill, Bristol BS2 8BJ.
Manuscript accepted 18 July 1986
172
anticipated. Nipple pain remains the commonest cause of complaint with breast feeding and is the second most frequently stated reason for discontinuing (Sloper, Elsden & Baum, 1977; Martin & Monk, 1983). Yet it is a biological truism that pain is an evolutionary protection mechanism, the function of which is to indicate to the individual experiencing pain that the present situation should be rectified, thereby alleviating the source. Perhaps the reticence with which this is acknowledged with breast feeding is in some part due to a lack of awareness of the possible changes which might bring relief. Potentially, one of the most harmful aspects of nipple pain is that a mother will come to anticipate the aversive effects of putting her baby to the breast and become increasingly reticent about doing so. This will run counter to the natural conditioning of the milk ejection reflex (m.e.r.), and if the inhibitory effect of stress on oxytocin release indeed applies to human breast feeding (Newton & Newton, 1948), then nipple pain will have a potent effect in preventing effective milk transfer from the alveoli to the sinuses of the nipple. The alleviation of nipple pain is therefore
MIDWIFERY
an essential objective for ensuring trouble-free breast-feeding. Two main sources of nipple pain can be suggested on the basis of incorrect or unphysiological mechanisms of attachment and milk transfer:-1. Frictional trauma. 2. Suction lesions. These may not be independent and correcting the source of one may automatically benefit the other.
Frictional trauma I f inadequate amounts of breast tissue are presented to the baby for 'stripping' (e.g. by the mother's fingers impinging on the areola when the breast is offered) then insufficient tissue will be formed into a teat (Woolridge, 1986). Such a teat does not extend well into the mouth but is repeatedly drawn in and out of the mouth, between the tongue and gums, by the cyclical application of suction, and frictional damage to the nipple m a y be incurred by this process. I f an adequate teat fills the baby's mouth then in the normal course of events it is milk within the sinuses which should be transported across the mouth border, rather than the tissue of the nipple itself. The shape of the relaxed nipple and its protractility will play an important role in this. Clearly mothers with inverted or retracted nipples will have difficulty in intially forming an adequate teat from their breast tissue. Valuable benefits are claimed from antenatal nipple preparation and the use of'Woolwich' shells. However, the benefit of such preparation is difficult to verify. Marked changes occur in the nipple in the later stages of pregnancy (Hytten & Baird, 1958), and the baby's sucking immediately post-partum would appear to be a powerful effective agent in bringing about an improvement, making it difficult to assess the value of antenatal preparation. Babies with relatively small mouths (e.g. premature infants) or those with even slightly recessive chins may also have difficulty taking in adequate breast tissue. Contrary to these suggestions, one of the few correlations which Gunther noted was that sore nipples are more prevalent with larger
173
babies, i.e. babies for whom one would not assume smallness o f ' g a p e ' to be a contributory factor.
Suction lesions The assumption that larger babies can exert a more 'vigorous' sucking action may lead to the inference that nipple trauma is brought about by excessive negative pressure, although there is no evidence to suggest that this is so. Similarly, it is argued that large babies have a 'healthier' appetite, and this may manifest itself in the tendency to persist in sucking at the breast beyond the point at which available milk is depleted. During 'nutritive' sucking (see Woolridge, 1986), milk issuing from the nipple diminishes the pressure being exerted in the baby's mouth. However, very little milk transfer is necessary to cause a shift away from a purely 'non-nutritive' pattern sucking. If little milk issues from the nipple, or the baby's appetite has not been assuaged after milk flow has ceased, then unrelieved suction will be applied to the nipple surface and this may lead to suction trauma. In attempting to correct this, efforts would need to be made to increase the rate of milk release from the breast. Two possible ways of achieving this might be (i) the administration of a Syntocinon nasal spray, mimicking the effect of oxytocin and increasing the strength of the mother's let-down reflex; or (ii) improving the baby's positioning or degree of attachment on the breast so that he has a greater amount of tissue in his mouth from which to strip milk more effectively. O f these suggestions I would discourage intervention with drugs since positional changes may not only correct the situation but may also enhance the mother's natural oxytocic activity. By encouraging the baby to take more breast tissue into his mouth milk should be removed more efficiently and consequently a natural relief of the applied intra-oral pressure should be experienced. M a n y mothers experience transient discomfort at the start of a feed. This can be explained in terms of the pressure exerted by the baby not
174
MIDWIFERY
being relieved by milk issuing from the nipple until the mother's m.e.r, has been initiated. O f far greater concern is pain which increases in severity as the feed progresses. An explanation, consistent with this observation, is that during the feed milk flow subsides but the suction exerted by the baby does not abate. The characteristic crescent-shaped petechial lesion, described by Gunther (1945) may arise as a result of the combination of these problems. When inadequate amounts of breast tissue are drawn into the baby's mouth two problems become compounded: firstly, milk is not stripped efficiently from the teat, so that during suckling there is little relief from the suction exerted by the baby; secondly, because so little tissue is in the baby's mouth the pressure exerted acts upon a restricted surface area. Added to this, is the fact that it is difficult to form and maintain a teat from a small amount of breast tissue; moreover, the teat has a natural elasticity which tends to make it withdraw from the baby's mouth. The baby may attempt to counter this tendency by sustaining negative pressure during periods of rest. This is a phenomenon on which Gunther concentrated her attention, and was able to document (ibid). At this point, I would like to pass on a statement in relation to the origins and correction of nipple pain which appeals to me as being a piece of inarguable logic.* A question which is asked repeatedly when recommending that babies should be allowed unlimited sucking time i s 'Doesn't it lead to a high incidence of sore nipples?'. The reply to this question is illustrated by two logical statements.~ Clearly, if there is nipple trauma then the amount of pain that is experienced will be directly related to the length of feeds; the longer the feed the worse the pain. However, the remedy is not to limit the length of feeds but to remove the cause of the nipple trauma. If the trauma is caused by physical problems of attachment, then getting the baby correctly positioned on the breast, with respect to
both the amount and location of breast tissue in the mouth should rectify the cause of the trauma and allow normal feeding to recommence. Special circumstances apply, however, once the nipple has been severely traumatised or damaged. Although correcting the cause of the problem may bring some relief, additional procedures may be required to effect a cure. One approach to such a problem which has proved successful is contained in a companion article (manuscript in preparation). As to the beneficial effects of antenatal preparation, or topical applications (e.g. nipple cream, ointment, spray), Inch (in preparation) in reviewing 10 studies of potential treatments aimed to alleviate nipple pain and soreness, concluded that no treatment or application had been shown to be of discernible benefit in protecting nipples from damage caused by trauma. The inference is striking: in the absence of any protective therapy, the only policy should be to attempt to remove the source of the trauma. Resting the nipples allows recuperation, but this may not be to the long-term benefit of lactation, and, by not tackling the source of the trauma, there is every chance that the problem will recur when normal feeding resumes. I would contend that the best way to achieve trauma-free feeding is to promote the optimal attachment of the baby on the breast. I f this can be achieved, resting the nipple is unnecessary.
PRACTICAL SUGGESTIONS The theoretical solution to these problems would appear to be to offer an adequate amount of the breast tissue (lying behind the nipple), together with the nipple, into the baby's gaping mouth. A suitable 'teat' can be formed by thinning the breast between the thumb and fingers in the same plane as the baby's mouth when closed, taking care not to let the fingers impinge on the areola so preventing tissue from being drawn into the
* For this I am indebted to Chloe Fisher.
UNLIMITED SUCKING TIME + NO NIPPLE TRAUMA = NO PAIN, NO DAMAGE A N Y L E N G T H OF S U C K I N G + N I P P L E T R A U M A = N I P P L E P A I N , N I P P L E D A M A G E
MIDWIFERY
mouth. The 'scissor' technique for holding the nipple between the first and second fingers is undesirable in my view; I would encourage holding the breast between the opposed thumb and remaining fingers. This is best done using the hand on the same side as the breast being used, allowing the fingers to lie naturally on the underside of the breast where they can provide sustained support after attachment. It is implicit in the description of feeding given previously that the initial placement of the baby's lower lip and gum against the breast, at a point well below the nipple, is critical if the tongue and lower jaw are to carry out their job of'milking' the sinuses lying behind the nipple. Once the baby is attached, the grip on the breast can be released so as to avoid constricting the ducts or sinuses and inhibiting milk flow. Sustained support of the breast from below with the hand would appear beneficial to counter sagging of the breast tissue under gravity. Without this support the sinuses and connective tissue lying behind the nipple tend to be drawn back from the nipple; while applying support from below causes the internal fabric of the breast, including the sinuses, to be pushed forward into the 'teat'. This may have the added benefit that the baby does not feel that the breast is continually being lost from his grasp, removing any need to counter such a tendency on his part with sustained suction during rests. Circumstances mitigating against satisfactory attachment are often worst at the start of the feed, e.g. when the breast is fullest and most tense with milk, making it inflexible. There may be every advantage in allowing the baby to feed for a while to remove the initial flush of milk, then reattaching the baby on the same breast to improve his/her positioning, or 'angle of attack', once the shape and pliability of the breast has changed.
CLUES FOR PRACTICAL MANAG EM ENT Many midwives have an intuitively based skill, founded upon experience, as to what is the 'ideal' position for the baby on the breast. Where a mother is unable to achieve this, it is not always
175
possible to verbalise the crucial difference between this 'ideal' and what is being practised. One abiding difference, which deserves to be emphasised, is that for the mother breast feeding is predominantly a manual skill, not a visual one; for the midwife the reverse is the case. Even when a midwife has the necessary manual skill she has a different view of the baby at the breast to the mother. The mother's position relative to her breasts is fixed, such that she has a frozen view of them from above. The critical area for attachment, that is the region below the nipple, apposed to the baby's lower jaw and tongue, is the one of which the mother has the poorest view. Accepting the description of the mechanisms of milk transfer, there can be little dispute that it is the breast tissue opposed to the baby's lower jaw which is the critical region in the transfer of milk. It is to the underside of the nipple that the peristaltic force is applied by the tongue. The hard palate plays a relatively passive role in the process providing the necessary resistance to the tongue's action. To recommend that mothers 'get as much of the areola into the baby's mouth as possible' is insufficiently specific; mothers may feel they have complied with this advice simply when the areola region above the baby's mouth is no longer visible. Since the point of contact between the lower jaw and the breast below the nipple is most important it seems logical that this is where first contact should be made when the baby is put to the breast. For most mothers the position of their baby when feeding dictates that this point of contact is not visible to them and can only be located by touch. This is the main reason why I emphasise the manual aspects of breast feeding skill over the visual ones. To enable first contact to be made between the tissue below the nipple and the lower border of the baby's mouth, the breast can be tilted up slightly as the baby's head is brought towards the breast. Then as the correct relationship between these two has been established the breast can almost be 'folded down' into the baby's mouth. To achieve the correct relationship it is essential to ensure that the baby is held in the correct posture relative to the mother's body. This aspect has been eloquently argued by Gunther (1970).
176
MIDWIFERY
Flexion of the baby's neck can make it difficult to achieve an ideal relationship between the relevant anatomies of the mouth and breast, in addition to creating other postural problems which may impair swallowing ability. In contrast, slight extension of the neck aids correct fixing at the breast, as well as ensuring that the baby's nostrils are not occluded by being pushed into the breast. Extension of the neck is best achieved, and adverse flexion avoided, by supporting the baby across the shoulders, rather than by holding the baby's head directly. The necessary manual skill for breast feeding can only be developed by the mother with practice, and it is just as much a question of developing the right timing as it is of learning the correct position. As with all manual skills some people take longer to acquire them than others, and some will always appear ungainly no matter how hard they try, and the skill may be unattainable. Teaching such skills necessitates an understanding of the mechanisms involved in milk transfer, the ability to verbalise the important features of the process; and the patience to observe the mother's own faltering attempts.
Acknowledgement M a n y of the views expressed in this article, particularly those relating to practical aspects of management, were derived through close observation of a skilled practitioner fixing babies correctly on the breast, for which I owe an enormous debt to Chloe Fisher. The author also wishes to express his thanks to Lewis Woolf Griptight Ltd, who generously made funds available during their centenary year for the preparation of this manuscript.
References Gunther M 1945 Sore nipples, causes and prevention. Lancet ii: 590-593. Gunther M 1970 Infant feeding. Methuen, London Hytten FE, Baird D 1958 The development of the nipple in pregnancy. Lancet ii: 1175-7. Inch S t985 T h e basis for advice in relation to the problem of sore nipples. Presentation to the Royal Society of Medicine, December 2nd 1985. Martin J, M o n k J 1983 Infant feeding practice in 1980. OPCS Survey, H M S O London. Newton M, Newton NR 1948 The let-down reflex in h u m a n lactation. Journal of Pediatrics 33: 698. Sloper KS, Elsden E, B a u m J D 1977 Increasing breast feeding in a community. Archives of Disease in Childhood 52: 700-702. Woolridge M 1986 The 'anatomy' of infant sucking. Midwifery 2(4): 164-171