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5.1 Positioning Principles

It's fundamental!

The mother provides the position. The baby does the latching (attaching).

Mother and baby

Observation of experienced mothers will reveal that they adopt a myriad of positions for breastfeeding throughout the day, even walking. A breastfeed may last from a few minutes up to an hour. And the mother will repeat this many times a day for at least a year. Your guidance to her is simply to adopt a position that will facilitate the baby's feeding reflexes, will avoid muscle strain and in which she is comfortable.

Reclining positions are comfortable and facilitate rest while feeding. This is the best position for mothers during the learning period.

Biological nurturing position

Current studies have demonstrated that the position that maximizes the release of pre-feeding neonatal primitive reflexes is when the mother is laid back semi-reclining with the infant prone on her chest.
This position has become known as the biological nurturing position. 1

The biological nurturing position facilitates the baby's sensory input and maintains positional stability as a result of the prone body position of the baby acting as a gravity pull towards the mother. The infant is able to use his hands and feet to push off his mother's abdomen and thrust himself toward the breast. He will lift his head up into extension to allow his chin to push forward into the breast and prepare for latch.
Biological nurturing positioning

Biological nurturing positioning.
© D.Fisher, IBCLC

Biological nurturing position

Biological nurturing position.
© K.Small


Workbook Activity 5.2

Go to your workbook and complete Activity 5.2

What about other positions?

The principles remain the same for all positions. Ensure that the infant has:

  • Sensory input: Babies depend on smell and chest-to-chest contact to initiate their feeding behavior.

The unwashed breast has a unique and individual odor that stimulates prefeeding activity and delays crying in the baby. 2 Only if necessary a drop of milk may be expressed and wiped over the mother's nipple and areola to stimulate this reflex (the infant can smell his mother very easily so don't waste time doing this when the baby is frantically seeking to latch).

Skin-to-skin contact (ie baby and mother unrestricted by clothing from the waist up) is best in the early days or when experiencing any latching difficulties. When baby and mother are clothed (light clothing, no blankets or other restrictions) is also effective allowing the baby to orientate and focus. This position calms the baby and initiates his seeking behaviours.

  • Positional stability: Positional stability is necessary for the baby to control his body and head movements. There are three aspects to this stability...
A stable base : in human anatomy terms that base is provided for the head by the shoulder girdle.
Proximal stability : infant's head and neck in alignment and supported, and
Midline symmetry : ie. the muscles on either side of the spine are experiencing equal movement.

Full chest-to-chest contact, with arms and legs free to move, achieves this. Light pressure to hold baby close to mother's chest is needed. This is best achieved by gravity in the biological nurturing position, and by having the mother's hand on the infant's back in other positions.
Cross cradle hold

Cross cradle hold.
© D.Fisher, IBCLC

Underarm hold

Underarm hold.
© D.Fisher, IBCLC


Cradle hold

Cradle hold.
© D.Fisher, IBCLC

Side lying

Side lying.
© D.Fisher, IBCLC


Closely examine each of the photographs above noting:

  • Is there adequate sensory input? chest to chest and baby held firmly against mother's body?
  • Is base stabilised? check for support across back and between shoulder blades
  • Is there proximal stability? neck and head supported NB** NEVER hold the back of the baby's head at any time during positioning, latching and feeding
  • Is there midline symmetry? baby's head and neck aligned with his spine; one arm on either side of breast
  • Is chin firmly applied to breast, nose free to breathe?
  • Is mother relaxed and well supported?
  • Is mother's arm supporting baby held comfortably, with relaxed wrist and fingers?

The Principles of Positioning

Workbook Activity 5.3

Complete Activity 5.3 in your workbook.

Start at the beginning

Do you see some mothers who are struggling with breastfeeding - they feel awkward and unsure how to hold the baby; maybe the baby's responses seem confused?

Rather than rush in with an intervention, suggest that the mother lie back slightly and bring her baby onto her chest. Encourage her to talk to him to help calm them both. It won't be long before he "bobs" his head seeking her breast. She can assist to free his arms or support his head if he needs guidance.
No interference, maximum opportunity for baby and mother to perform at their best!

(This is best in skin-to-skin for a newborn, however, it can be very successful for the older baby who has becomes confused and is also effective when infant clothed, but not restricted by blankets.)

Positioning and latching - baby-led

View the video below. When you do note:
  • the position of mother and baby
  • the calming effect of this position on baby
  • the beginnings of mouthing and interest in the breast
  • the keen interest in the breast as soon as colostrum had been wiped onto the breast (note: this was probably not necessary to do - baby was already showing interest)
  • the head bobbing and seeking with the tongue
  • finally the baby latched and suckling.


© Denise Fisher

What should I remember?

  • The importance of the mother's position in providing the basis for the baby's position.
  • The BEST position for baby and mother when learning to breastfeed.
  • Techniques which provide a stable base, proximal stability and midline symmetry.
  • How to apply the same principles to all positions which the mother may use.

Self-test Quiz

Click and drag the missing words below into their correct place

The missing words are: alignment chin gravity odour pre-feeding prone raise reflexive shoulders skin-to-skin smell turned

To assist the mother and baby to achieve successful breastfeeding, you will need an understanding of all the factors which facilitate the best circumstances:

  • A newborn baby's feeding behaviour is instinctive and __________.
  • The baby's sense of __________ will direct him towards the __________ of his mother's breast.
  • When the mother is semi-reclined her baby will be __________ on the front of her body. This natural biological nurturing position releases many primitive neonatal reflexes which stimulate __________ behaviour.
  • Baby's position firmly against mother's chest is maintained primarily by __________, though the mother may support her baby's back and __________ to provide stability.
  • The infant's head and neck need to be in straight __________. The infant will not be able to latch effectively if his head is __________ to the side.
  • Once the correct position has been achieved, the infant will __________ his head and reach for the breast.
  • His __________ will touch the breast first and make an indent in the breast.
  • When an infant is having latching difficulties the first suggestion to make to the mother is to place her infant __________ on her chest.

Notes

  1. # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.
  2. # Doucet S et al. (2007) The "smellscape" of mother's breast: effects of odor masking and selective unmasking on neonatal arousal, oral, and visual responses.