Laid-back Breastfeeding

Laid-back breastfeeding, also called Biological Nurturing, is a method of baby led breastfeeding that starts with the mother first being in a comfortable reclined position. The keys to this position are:

-tummy to tummy on top of mummy

-baby is given time to seek the breast

-baby is free to explore the mother’s body with hands and head

-the nipple is still (mom is not holding the breast as a bottle)

Here’s a video of how this position is achieved on our YouTube channel: https://www.youtube.com/watch?v=PKoEnqrSkvs

Laid-back nursing is ideal for babies who have latch on difficulties from a high palate,  bubble palate, tongue tie, lip tie, recessed chin, or birth trauma. Most healthy full term babies can achieve this position from birth.

Laid-back breastfeeding increases skin-to-skin which helps babies coordinate better for feeding and improves mom’s milk production. This position also adds gentle pressure to the abdomen to help babies release gas more easily.

Laid-back breastfeeding is the original tummy time, leading to the other label “biological nurturing.” Babies nursed frequently in this position may avoid flat spots on the head and enjoy on or above target physical development because they are engaging in developmental appropriate baby “exercise.”

Tummy down feeding stimulates baby’s inborn feeding reflexes. This position helps the jaw rock forward, the neck and head lift, and the arms work the full range of motion. You may find your baby making motions very similar to swimming in this position. These movements will later translate into skills for rolling, sitting up, pulling to standing, and crawling.

 

10 Questions with a Pediatric ENT

1) How can an ENT be part of a breastfed baby’s healthcare team?

Successful and efficient breastfeeding requires the tongue and lips to have adequate mobility (structure) to stably maintain an airtight seal between the tongue, lips, palate and nipple during the process of extracting milk, as well as proper strength, coordination, and movement (function) of these tissues. This is why optimal treatment of breastfeeding problems may require a team effort between the pediatric ENT to address the structural concerns, and a lactation consultant and/or occupational therapist to address the functional concerns.

2) Is tongue tie a fad diagnosis? Why has there been such an increase in tongue tie revision in the last decade?

Tongue ties have always been around, but the increase in emphasis on benefits of breastfeeding, and less willingness to accept the advice just to bottle feed if breastfeeding is difficult, have led to an increased exploration and awareness of tongue tie as a treatable structural concern that may improve the comfort and efficiency of feeding.

3) What is the reason for controversy about tongue tie? Why do so many healthcare providers disagree on this diagnosis?

There is a spectrum of ways in which the tongue can attach to the floor of mouth, and some tongue ties, particularly those that are anterior, are more obvious than others. The presence of a tongue tie that is less obvious is diagnosed by the feeding pattern more than the exam. Those who do not have a good understanding of the ways in which the relationship between the tongue, lip, jaw, palate and nipple can affect breast feeding, may not be willing or able to recognize a functionally significant tongue tie if it is not readily visible. The tongue-tie feeding pattern is a consequence of inability to maintain an airtight seal due to an imperfect relationship between these structures, which leads to a cascade of potential issues including shallow latch, frequent separation/repositioning, nipple pain/cracking/blistering, plugged ducts or mastitis, clicking/air swallowing which makes the baby gassy and fussy after feeds, biting or chomping behaviors (as the baby works as hard as they can to maintain the latch given the structural limitations), leading to fatiguing during feeds before obtaining adequate milk intake, resulting in frequent, inefficient cluster feeds. If these symptoms are present, it should prompt evaluation for an oral tie.

4) Do all tied babies need a frenotomy? Are there evidence-based non-surgical options to resolve this issue?

How likely the frenotomy is to be helpful for breastfeeding problems depends on how much tethering tissue can be released, relative to how restricted the movement is. If the baby has feeding issues suggestive of tongue/lip restriction, then a frenotomy is likely to be helpful. Beyond breastfeeding, the frenotomy is particularly recommended for babies with anterior tongue ties, which are more likely to affect speech articulation.

Non-surgical treatment cannot address the structural restriction of the tongue and lip. Although some babies may gain more strength and coordination, and be able to compensate better, the structural relationships do not change. Toddlers will often fall and lacerate the labial frenulum, but it’s not exactly a workable treatment plan.

5) What is the role of the palate in diagnosing tongue tie?

The tongue must have enough mobility to rise up and pin the nipple against the palate to maintain an airtight seal. If there is a high arch to the palate, then the tongue has to elevate further in order to achieve enough surface contact to achieve this seal. So it is often more the relationship between the tongue and palate, rather than the tongue itself in isolation, that determines whether the baby will have a tongue-tie feeding pattern.

6) Plenty of moms are posting photos on Internet forums asking if their babies have a tie. Can you make a diagnosis from a photo? Is there a difference between form and function when diagnosing ties?

Anterior tongue ties, where there is an obvious tethering band restricting movement of the tongue tip, can be diagnosed from a photo or examination alone, although the history is still helpful in determining how much it is affecting feeding. Less obvious tongue ties are diagnosed much more by the feeding pattern than the exam. There is not always a good correlation between form and function, because there are so many other factors beyond the visible structure of the tongue and lip which may affect the latch. My approach is that the feeding pattern (function) tells you that a tie is present, while the exam (structure) tells you how much of a target you have to improve the situation.

7) What are the long term consequences of untreated oral ties? Is there a way to predict if a tie will be problematic down the road?

Untreated oral ties can contribute to feeding problems with handling certain textures of solid foods, dental hygiene problems including cavities (imagine not being able to use your tongue tip to dislodge crumbs caught between the gum and cheek), and speech difficulties (try to talk while holding your tongue tip against the inner surface of your lower teeth, and you will hear the effects on articulation).

Again, since form and function do not always correlate, it is difficult to predict for sure how much these effects will occur if the tie is untreated. As a rule, the closer the tie is to the tip of the tongue, the more likely it is to affect speech. As the procedure is easier and better tolerated in younger infants, and it is better to prevent the speech problems than to treat later and need speech therapy to re-learn articulation, I am in favor of early treatment once a tie is identified.

8) Why do so many healthcare providers seem to miss this diagnosis? Many moms report being told the latch looks great even though they experience pain. What should they be looking for instead?

Again, this comes back to frequently poor correlation between the exam and the feeding pattern. Many providers are trained only to recognize the structurally obvious anterior ties, or may have even been taught that tongue ties do not affect breast feeding, because some babies with visible tongue ties are able to breast feed without difficulty. (This is like saying that smoking does not cause cancer, because some people smoke their entire lives and never get cancer). Recognition of the tongue tie feeding pattern (see #3) should help determine when a baby could benefit from tongue tie evaluation and/or treatment.

9) Other than oral ties, what other conditions do ENTs treat that may require special breastfeeding support?

Conditions that affect the tongue, jaw and palate, such as cleft lip and palate, Pierre Robin and other craniofacial syndromes, or tongue cysts, may make breast feeding difficult or impossible and require special support.
10) Laser vs scissor: any truth that one is better?

There are no head-to-head studies comparing them, although some providers are laser proponents because there may be less bleeding, which potentially allows the procedure to be done without a local anesthetic (numbing injection), or because it may allow for a more precise cut. On the other hand, laser is possibly more dangerous if the baby moves, certainly requires more setup time and precautions, and is a much more expensive piece of equipment. So I see no convincing evidence to prefer laser over scissors, especially for office-based procedures.
Bonus question 11! Share a memory or reason breastfeeding had a positive health impact for your family.

When my wife and I were in residency and she was on call, I would pick up my son from daycare and bring him to her to breastfeed, then pick up all the bottles she had pumped during the day so that I could feed him overnight. It was nice for them to have that bonding moment in the midst of her busy day, and put him in a better frame of mind to come home with me for the evening.

~~~~

From very early on, Dr. Erik Bauer has been fascinated with language and communication, which led him to an interest in hearing and speech, and from there to the versatile specialty of pediatric otolaryngology. Born and raised in Chicago, Dr. Erik Bauer graduated from Harvard University magna cum laude before enrolling at the University of Michigan Medical School. He went on to surgical internship and residency in Otolaryngology-Head and Neck Surgery at Washington University in St. Louis, Missouri, then stayed on for the Pediatric Otolaryngology fellowship at St. Louis Children’s Hospital. This fellowship prepared Dr. Bauer to recognize and treat a full range of pathologies including pediatric hearing loss, cochlear and BAHA implantation , chronic ear disease, congenital and acquired airway problems, foreign bodies, and sinus disease.

Dr. Bauer joined Pediatric Ear, Nose & Throat of Atlanta in September 2006. In practice, Dr. Bauer has developed a special interest in tongue and lip ties, especially as they affect infant breast feeding. He feels fortunate to have learned a lot about this previously under-recognized issue, and to have the opportunity to help many infants and moms navigate this challenging territory.  Allowing babies to feed more comfortably and effectively has turned out to be one of the most rewarding aspects of his practice.

Outside practice, Dr. Bauer does his best, along with his wife Mandy, a breast radiologist, to keep his two active boys entertained, between helping with science fair projects and social studies homework, shuttling to soccer and chess tournaments, and attempting to make sense of their video games. He also enjoys travel, dining, live music, and trying to teach himself languages with varying degrees of success.

Dr. Bauer is a diplomate of the American Board of Otolaryngology, having received his board certification in June 2006, and a fellow of the American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Pediatrics. He practices at our Main Office, Alpharetta, and Marietta locations.

www.childrensent.com

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What is a Normal Feeding Routine? How Does it Change with Age?

The one thing that is certain with babies is they change every day. Knowing what the range of normal is for infant feeding can help parents make better decisions about the family rhythm.

Exclusive Breastfeeding and Human Milk Feeding

0-6 weeks: This is the time when babies nurse constantly. Their tiny tummies want a constant and steady fuel supply, just like they were accustomed to in utero. The placenta nourished the baby so well, hunger is something completely new after being born. It’s easiest to feed babies before they show signs of agitation. Nursing in clusters is common. Nursing every 1-3 hours day and night is normal. Nursing sessions may last 5-35 minutes at a time. Babies frequently fall asleep at the breast and nurse in their sleep. Expect 10-15 nursing sessions per 24 hours. Babies should be fed on cue or on demand. No medical organization endorses scheduled feeds for breastfeeding infants.

6-12 weeks: This period is usually full of what most people call growth spurts. Babies this age are still nursing around the clock. Remember, human milk is digested in about 90 minutes. The tummy is still small, maybe as little as 2 or as many as 5 ounces. Some babies will have a “witching hour” in the early evening where they feed in a cluster of sessions. Babies who have been separated from mom during the day may be particularly interested in a marathon evening nursing session. Nursing and bottle feeding human milk should continue on cue or on demand.

3-6 months: The World Health Organization and the American Academy of Pediatrics recommend that babies continue to receive only human milk at this time. Babies in this age range have a variety of sleep patterns and growth patterns. Teething may begin during this stage which may disrupt feeding or increase night wakings. All of this is normal. The stomach size is 3-5 ounces. Babies in this age range may increase their nursing or cluster feed just as newborns do. On cue feeding should continue at this age.

Breastfeeding with Complimentary Solids

6-9 months: Most babies will have a first tooth appear at this point. Babies who have a tooth, can sit well unsupported, and have lost the tongue thrust reflex are ready to begin solids in compliment to human milk. Human milk is still recommended as a primary source of nutrition. Ideally, the baby is nursed first then solids are offered as “dessert.” You may have heard “food before 1 is just for fun.” Small amounts of complimentary solids are important for iron and other minerals as stores from birth are utilized by this age. Human milk should be offered on cue. Solid foods can be offered at scheduled meal times.

9-12 months: Most babies are interested in self-feeding. They have mastered the pincer grasp and can put bits of food into their own mouths. Human milk is still the bulk of their nutrition. Some babies may not have had a tooth erupt yet. Nursing through the night is very common.

Nursing a Toddler

12- 15 months: The American Academy of Pediatrics feels this is a safe time to replace human milk with other foods including the milks of other mammals. Many mothers continue to nurse their toddlers for nutrition. Toddlers at this age are busy and may have nutritional gaps because they are out exploring the world instead of eating. Their stomachs may only be a few ounces bigger than they were a year ago. Continuing to breastfeed at this age can help a growing toddler meet nutritional needs during a “picky” phase.

15-18 months: Children who are still nursing may continue to do so at night as well. Mothers commonly explore night weaning around this age. Other mothers are glad to nurse through the night to help with the pain and wakings associated with eruption of molars.

18-24 months: By this age, most children are well established on solids interested in eating with the family at more regular times. Self feeding has been mastered. Many children can drink out of a small cup unassisted. Toddlers who are nursing may nurse frequently or only once a day. The range of normal is very wide.

Full Term Nursing

2 years and beyond: The World Health Organization recommends that children breastfeed for a minimum of 2 years with nursing continuing if both mother and child so desire. Children often self-wean some time after the second birthday. Pregnancy or extended separation may motivate a child to wean faster from nursing.

Are My Breasts Empty?

Our lactation counselors are frequently told that the mother feels her breasts are empty or not full any more. This anxiety often causes mothers to end exclusive breastfeeding prematurely or begin supplementing with formula when it is not needed. One of the most common misconceptions about breastfeeding is that breasts, like tanks or bladders, fill and empty. Here are some facts about the way human lactation works to help nursing mothers understand what is going on in there.

Fact: Breasts contain glands, not bladders. Milk production is continuous.
Human milk is made by specialized cells called myoepithelial cells. Blood is supplied to these cells, and they turn blood into milk, drop by drop. The milk is continuously being produced by these cell as well as continuously reabsorbed into the blood stream. During periods of engorgement, the body tries to reabsorb the milk faster and slow down the production. When the baby is actively nursing or mom is actively pumping, the reabsorption is slower and production is faster. Breasts can never be empty until after the baby is fully weaned off breastfeeding.

Fact: Babies don’t take all of the available milk during nursing.
Using ultrasound, science has determined that babies take about 65% of the available milk in the breast during a feeding session. This is why pumping milk after feedings is recommended for mothers who are pumping and storing milk for future separations.

Fact: The more rapidly milk is removed from the breast, the more rapidly new milk is made.
When milk is being removed from the breast, the milk making hormone prolactin is highest. Frequency of nursing and pumping is key to making more milk. Women who “save up” or try to wait for the breast to feel full before nursing are actually lowering their prolactin levels. This is why supply and demand is the law for breastfeeding and making more milk. Moms who remove milk the most frequently will make the most breastmilk.

Fact: Even a hospital grade double electric breast pump cannot empty the breast.
Because milk making hormones peak during milk removal (nursing, pumping, or hand expression), the body will always rush to make more milk every time mom is pumping.

The Take Away

Continuous breastfeeding or breast milk removal is the key to high levels of milk production. If a mother is doubting her milk production capabilities, milk production is easily assessed by an LC at a home visit or office visit. LCs employ techniques like weighed feeds and latch assessments to determine how well the baby is “transferring” or getting enough milk. When in doubt, it is always better to nurse more and pump more. Supply and demand is the ruling principle of lactation. Feelings of fullness do not happen for all women who make a full milk supply. Feelings of fullness may come and go but do not indicate milk production levels or how well the baby is eating.

 

Breastfeeding and Maternal Diet

There are thousands of myths about what mothers should or shouldn’t eat when breastfeeding. The current recommendation is that the mother should eat a varied diet of healthy foods that are typical for her geographic region or culture and not limit or include any special foods without medical indication.

To understand why maternal diet should not be restricted, it’s best to examine how milk is made. Milk is made inside glands from the blood stream. Breast milk is NOT made from the mother’s stomach contents. The foods mom eats are broken down in the digestive system. Blood reaches the milk glands where it delivers carbohydrates, nutrients, white blood cells, enzymes, pro- and pre-biotics water, fat, and proteins into the gland.

The foods that mom eats have a long trip to the milk. Not every food is able to pass a whole protein or fat or carbohydrate out of the GI and into the blood stream. Most of the proteins moms eat are broken down substantially in the digestive system. Insoluble fiber is a component of mom’s diet that never leaves the GI and never reaches the milk.

When considering foods to include or avoid when breastfeeding, we must remember that the whole food does not enter the milk. Here is a list of common food myths for nursing mothers and the facts:

MYTH: Broccoli, cabbage, beans, and cucumber give the baby gas.
FACT: Vegetables cause gas because of insoluble fiber mixing with gut bacteria. Insoluble fiber does not leave the GI tract and cannot reach the milk.

MYTH: Spicy food will make the breastmilk spicy.
FACT: Human milk is very sweet. No evidence has been found of capsaicin in human milk. Many moms taste-test their own milk after eating well seasoned food.

MYTH: Strong flavors a like garlic or onions will give the baby colic.
FACT: In a garlic breastmilk study, the babies in the garlic group spent more time at the breast and took more milk. Garlic might be helpful for moms who need to nurse more.

MYTH: If the baby is fussy or has colic, cut dairy.
FACT: Cow milk protein allergy is only in 2-7% of the population. Fussiness is not a symptom for diagnosing cow milk protein allergy.

MYTH: If the baby is gassy or has colic, switch to lactose-free milk
FACT: Lactose is the primary carbohydrate in human milk. It does not come from lactose in mom’s diet. The breast glands make lactose. Lactose intolerance in a newborn is a serious metabolic issue that needs to be addressed by a medical doctor.

MYTH: Mom should avoid soda because it gives the baby gas.
FACT: Carbonated drinks don’t carbonate the blood. The bubbles can’t reach the milk.

MYTH: Peppermint (tea, candy, essential oil) will dry up your milk.
FACT: Some folklore and historic herbal texts list peppermint as a lactogenic herb. There is no science to support either claim. Peppermint is one of the herbal teas listed as compatible with breastfeeding by The Academy of Lactation Policy and Practice.

MYTH: You have to drink milk to make milk.
FACT: Plenty of dairy-free women make milk.

 

Have your own favorite dietary myth to add? Leave us a comment! Breastfeeding myths are a favorite topic at our regular free mother to mother support group.

 

How Do Moms Pump Enough to Return to Work?

Many moms want a safety net of pumped milk in the freezer for their return to work away from their babies. While it’s only necessary to have enough milk saved for the first two days back at work, many moms want to save several days or even weeks worth of feedings during their maternity leave.

Please read What to Expect When Pumping to trouble shoot and get the most out of your pumping experience. This article addresses how to juggle pumping during your maternity leave and during the working day.

When to start building a “stash”

Most women start with over production. The first 10 weeks of breastfeeding are the easiest for milk collection. This is also a critical time for conditioning the body to respond to a pump. Ideally, moms should nurse on cue and spend a great deal of time resting skin to skin with their babies for the first 2 weeks. Once baby has regained birth weight, around day 10-15, it’s time to try pumping.

Milk collection is easiest in the morning hours when the milk making hormones are highest. Beginning at this favorable time will help make pumping a more positive experience. After nursing the baby, pump either one or both sides for 20 minutes each. Even if the milk stops flowing, continue pumping for 20 minutes per side.

Weeks 2-4, pump one time per day in the morning after nursing. Expect to collect 1-2 ounces each day. Remember: 20 ounces is enough milk for about 16 hours of mother-baby separation.

If you wish to increase your daily milk collection, add a second daily pumping session weeks 4-6. Pumping only twice a day will help you collect several days worth of milk before returning to work.

If your baby cues to nurse after pumping, just nurse. The breasts are never truly empty until you wean. The more milk removed, the faster the glands work to produce more milk. No pump is as efficient as a baby who is properly latched. There is no need to feed the baby the pumped milk in place of nursing.

If your maternity leave is longer than 6 weeks, continuing pumping 1-2 times per day as is possible for the duration of your leave. This helps maintain a conditioned response for more efficient pumping in the future.

When to Pump at Work
No two work environments are the same. No two work days are the same. Not every work environment allows for predictable or scheduled pumping sessions. Things to consider:
– aim to pump every 1-3 hours. This is a range. Babies and breasts are flexible.
– don’t feel trapped on a schedule
– if you anticipate a long meeting or event you cannot break out of, consider pumping once an hour for 2-3 hours beforehand and/or afterward
– your body does not require you to pump on a set schedule just as your baby does not feed at set time
– a hands free pumping bra can help you pump during your drive to and from your work location
– hand expression may help moms who have a short break but can’t make it to the pumping room
– taking a lunch break to nurse your baby may be easier than pumping as frequently at work

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