If, like me, you’ve been teaching birth education for many years, it’s important to keep up on how advice changes or evolves as new information is learned. There have been huge shifts in lactation advice over the past 10 or so years, so I will summarize those here to the best of my understanding. I am not a lactation consultant and never have been, so IBCLC folks, please let me know if I’ve got anything wrong or am mis-interpreting the data.
I have created a PowerPoint curriculum for a breastfeeding class that you can download, which reflects this updated advice.
Antenatal Milk Expression
We once advised parents against a lot of nipple stimulation during pregnancy, concerned that it might start labor. That’s changed. It is now reasonable to recommend hand expressing colostrum started at week 36 of pregnancy unless care provider considers someone high risk for preterm labor. It can help milk volume increase sooner after birth. Those who might want to express: people with diabetes (any type), PCOS, high blood pressure, obesity, breast hypoplasia, history of low supply or previous breast surgeries. It may also be helpful if they are expecting multiples, or a baby with a cleft lip, palate, IUGR, Down Syndrome or other complications that might lead to them needing special care after birth and increase the chance that formula or supplemental feeding would be recommended. It can also be helpful for any expectant parent to help them feel more confident about breastfeeding.
I also do feel that overall, we are seeing more attention on hand expression than in the past. There are helpful videos showing how to do hand expression at: https://med.stanford.edu/newborns/professional-education/breastfeeding/hand-expressing-milk.html and https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/breastfeeding-resources/hand-expression-video/.
- Patient Education: University of Washington Medical Center Lactation Services, “Expressing Milk Before Giving Birth,” University of Washington Medical Center. (2019) https://healthonline.washington.edu/sites/default/files/record_pdfs/Expressing-Milk-Before-Giving-Birth.pdf
- Research showing no risk to antenatal milk expression: Della Forster, et al, “Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME])” Lancet, 389: 10085 (2017). https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31373-9/fulltext
Laid Back Position
When I first trained 20+ years ago, we were teaching cradle, cross-cradle, football and side-lying positions. About 10 years ago, I started hearing more about sitting up / straddle hold and more about the laid-back position. (Laid-back is a semi-reclined position, like resting on a deck chair by the pool.) Now, most research and practice seems to be leaning toward this (combined with infant-led latch) as the best option.
Colson describes the Biological Nurturing approach: “Mothers lean back and place the baby on top so that every part of the baby’s body is facing, touching, and closely applied to one of the mother’s curves… Nursing in a laid-back position… promotes neonatal locomotion by releasing up to 20 primitive neonatal reflexes which act as breastfeeding stimulants. BN is quick and easy to do; there is no lining up of body parts and no “correct” breastfeeding procedures…” Note: in this position, the parent does not support her breast, and gravity holds baby in place, so it can free up one or both hands.
You can find videos with more information about how to use the laid-back position and baby led latch at Laid-Back Breastfeeding: https://www.biologicalnurturing.com/sample-of-biological-nurturing/ and https://raisingchildren.net.au/newborns/breastfeeding-bottle-feeding/how-to-breastfeed/attachment-techniques
This approach significantly reduces cracked and sore nipples. (Milinco, Wang.)
- Suzanne Colson, “Biological Nurturing: the laid-back breastfeeding revolution,” Midwifery Today 101: 9-11. (2012) https://www.midwiferytoday.com/mt-articles/biological-nurturing/
- Zhi Wang, et al, “The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis,” BMC Pregnancy Childbirth, 21(1): 248. (2021) https://pubmed.ncbi.nlm.nih.gov/33761882/
- Mariarosa Milinco, “Effectiveness of biological nurturing on early breastfeeding problems,” International Breastfeeding Journal, 15:21. (2020) https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-020-00261-4
Baby-Led Latch / Symmetry?
There is also an increased emphasis on letting the baby take the lead in latching on. This increases duration of exclusive breastfeeding, decreases nipple pain. (Baby-Led Latch: Caixin Yin, et al. “Effect of Baby-Led Self-Attachment Breastfeeding Technique in the Postpartum on Breastfeeding Rates,” Breastfeeding Medicine, 16:9. (2021) https://pubmed.ncbi.nlm.nih.gov/33913745/). This video illustrates an infant led latch. https://www.breastfeeding.asn.au/resources/baby-led-attachment
There is a lot less talk about the old method (using U-holds and C-holds to shape the breast like a sandwich before latching, tickling baby’s lip till mouth is open wide, then rapid arm movement to get them to latch on). It’s more about just bringing baby’s nose near the nipple, touching the nose or upper lip with the nipple so the baby tilts up, opening mouth wide and taking a big mouthful of nipple.
Jack Newman describes the ideal latch as asymmetrical, where more areola is covered by the bottom lip than the top, and where the chin indents the breast, but the nose never quite touches the breast. (When Baby is Latching Well: Jack Newman and the International Breastfeeding Center. “Latching and Feeding Management”, 2021. https://ibconline.ca/information-sheets/latching-and-feeding/)
Conversely, Pamela Douglas has a very different view based on her reading of ultrasound images of latch. She prioritizes a symmetrical face-bury, where the nose is against the breast. She also says there should be no visible lips, because if you can see lips, there is drag on the nipple which causes pain. (This idea of neutral lips is different than the flanged / “fish lips” I was once taught.) She has a video at https://possumsonline.com/video/how-babies-breastfeed that highlights her concept of gestalt breastfeeding. (Pamela Douglas, “A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding,” BMC Pregnancy Childbirth, 22:94. (2022) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8808964/ see additional file 1 in that article for details on gestalt method.)
Of course, a good position and good latch continue to be key to reducing nipple soreness. Where I used to see recommendations that if the latch isn’t good, you should break suction and try again, more recommendations now say that most latch issues can be fixed by: tucking baby in closer to the parent so there’s no gap between them and making sure baby is aligned (ears, shoulders and hips in a line.) “Adjust the body, adjust the breast, adjust the baby” – microadjustments in each can fix the latch.
Some breastfeeding parents with persistent nipple pain during and between feeds also may have shiny pink nipples with white flakes of skin. In the past, this was often diagnosed as a yeast infection and treated with antifungal medications. But there’s no evidence that candida causes the nipple pain, and antifungal treatments are no more effective at treating it than doing nothing.
- Pamela Douglas, “Overdiagnosis and overtreatment of nipple and breast candidiasis,” Women’s Health, 17. (2021) https://pubmed.ncbi.nlm.nih.gov/34269140/.
- Esther Jimenez, et al “Mammary candidiasis: a medical condition without scientific evidence?” PLoS One, 12:7. (2017) https://pubmed.ncbi.nlm.nih.gov/28704470.
- Ryan Colton Betts, et al. “It’s Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain,” Breastfeeding Medicine, 16:4. (2021) https://pubmed.ncbi.nlm.nih.gov/33305975/
In the past, I have been told to recommend lanolin, hydrogel dressings and other moist wound healing approaches. Current research indicates that hydrogel, lanolin, antifungal creams, Vaseline, expressed breast milk and all-purpose nipple ointment are no more effective at reducing nipple pain than it is to do no treatment at all, and some may actually delay healing due to moisture related damage.
Most nipple pain reduces to mild levels by 7 to 10 days postpartum no matter what you do or don’t do.
- Nipple Pain section: Pamela Douglas, “Re-thinking lactation-related nipple pain and damage” Women’s Health, 18. (2022) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8966064/
- Nipple pain ointments: Cindy-Lee Dennis, et al, “Interventions for treating painful nipples amongst breastfeeding women”, Cochrane Database. (2014) https://pubmed.ncbi.nlm.nih.gov/25506813/
Anatomy / Engorgement / Mastitis
We have a new understanding of breast anatomy based on ultrasound imaging vs. cadaver study as past models were based on. A summary is here: “Anatomy of the Lactating Breast,” Medela. https://www.medela.com.au/breastfeeding-professionals/research/breast-anatomy. And the research: D. T. Ramsay et al., “Anatomy of the Lactating Human Breast Redefined with Ultrasound Imaging,” Journal of Anatomy 206, no. 6 (2005): 525–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1571528/
Here is an image from the Ramsay article with an artist’s impression of breast anatomy – note how this differs from older illustrations showing “bunches of grapes” in the alveoli and lactiferous reservoirs.
We have learned there are not sinuses / reservoirs that store milk in the breast. Only about 1 – 10 ml can be expressed before a let-down. So, getting a good latch so you get a good letdown is essential.
We used to teach about plugged ducts, saying that milk was clogging a duct, and we had all sorts of advice for placing baby’s mouth so it lined up with the lump, and massaging as the baby nursed, or using a vibrating device like an electric toothbrush to relieve that. Based on new learnings about breast anatomy, clogged ducts are not actually possible. “Ducts in the breast are innumerable and interlacing and it is not physiologically or anatomically possible for a single duct to become obstructed with a macroscopic milk ‘‘plug.’” (Mitchell, et al) And deep tissue massage to relieve a clogged duct can worsen edema, inflammation and pain.
Parents should be taught that slightly lumpy breasts are normal, and that localized inflammation is just that, and can be treated similar to how we treat engorgement.
For engorgement, ice and ibuprofen to reduce pain and inflammation are recommended. Cabbage leaves are no more effective than ice. Heat (e.g. warm compresses and showers) may provide comfort but can also worsen symptoms. If using hand expression or pumping to treat engorgement, express only enough milk for comfort and/or to help baby latch on. Over-pumping can worsen engorgement.
If the symptoms are pain, redness and a short-duration fever, that is considered inflammatory mastitis, and likely not an infection. It can resolve on its own with continued breastfeeding, rest and plenty of fluids.
If the fever, pain and inflammation continue for more than 24 hours, it could be bacterial mastitis, an infection. They should check with a lactation consultant or care provider – antibiotics may be recommended at that point.
To learn more about all the topics in this section, read: Katrina Mitchell, et al, “Academy of Breastfeeding Medicine Clinical Protocol #36, The Mastitis Spectrum,” Breastfeeding Medicine, 17:5. (2022) https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf
Paced Bottle Feeding
When giving a bottle to any baby, but especially one who is primarily breast-fed, we can use a method called Paced Bottle Feeding. Many parents hold the baby horizontal on their back and the bottle vertical, so the nipple is filled with milk. Baby takes in a lot of milk really fast this way, which might seem efficient, but can lead to over-feeding or increased spit up. It also teaches a baby to expect this fast flow and “flow preference” might be the true “nipple confusion” as baby gets used to fast flow. With paced bottle feeding, instead we hold the baby vertical and the bottle horizontal so they’re taking milk in more slowly. When they pause a bit in sucking (as they would at a breast), you can tilt the bottle completely horizontal to give a rest. When they resume sucking, you tilt it up just a bit so they get more milk. Check out these videos: https://www.youtube.com/watch?v=OGPm5SpLxXY and https://www.youtube.com/watch?v=TuZXD1hIW8Q.
If you have comments on anything you read here – about any surprises you see, or any misinterpretations you want to clarify, please comment below!