Latch

Teach mom:

• to look for feeding cues to determine if infant is ready to eat
• to hold baby facing her breast, placing infant’s nose opposite her nipple extending baby’s neck slightly. 
• to touch her nipple to top of infant’s lip to elicit a wide-open mouth.

When the baby's mouth is open wide, the mother should aim her nipple toward the roof of the baby's mouth, bringing the baby swiftly to her breast with a firm but gentle movement.

With initial latch, the sucks will be fast, short bursts interrupted by pauses that trigger the mother's let-down reflex. As milk flow is established, the sucking rhythm changes and becomes slow, deep and continuous. Swallowing is usually heard.

The infant’s bilateral lips will be flanged out. Infant’s chin should be buried into the breast and the nose may be touching.

Teach mom to look for baby’s satiety cues to determine completion of feeding. Baby may come off the breast spontaneously or change suckling from slow deep sucks to quick light sucks. The mother may end the feeding by inserting a finger into the baby's mouth, separating the gum line and breaking the suction seal.

At the next feeding, the mother should start with the breast offered last at the previous feeding.

• Emptying of breast is noted; softer at end of feeding.
• Mom denies pain.
• Nipple is longer and fuller, non-distorted shape.
• Baby ends feeding with signs of satiety.
• Infant void and stool patterns are within normal expectations.
• Infant weight loss/gain is within normal expectations.

• Dimpled cheeks (a sign that baby is using positive pressure, not negative).
• Mouth with rapid movement, like a flutter continuously with no slow deep suckling.
• Lips are rolled in (can be one or both) with a shallow latch. (Babies with thin lips may appear to have a poor latch as their lips do not always look flanged. If there is good milk transfer and no signs of a poor latch use your best judgement). 
• Baby has a shallow latch.
• Baby unable to settle, may bob head.
• Clicking or noisy feedings at breast.
• Misshaped nipple upon infant release after feeding.
• Persistent nipple pain throughout feeding.

Concern over milk supply is a common reason for mothers to start supplementation and eventually quit breastfeeding. Most moms will make enough milk if they exclusively breastfeed. Help mothers meet their breastfeeding goals through encouragement, education and support. 

Reinforce the following concepts when supporting a mother who perceives low milk supply:

• Supply and demand theory.
• Signs that her baby is getting enough.
• Normal expectations for infant weight gain.
• Minimum number of expected breastfeeds in 24 hours and urine/stool patterns as indicated on the table below:

Clinical Guidelines

• Brodribb, W. (2018). ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018. Breastfeeding Medicine, 13(5), 307–314. 
• Kellams, A., Harrel, C., Omage, S., Gregory, C., & Rosen-Carole, C. (2017). ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeeding Medicine, 12, 188–198. 

References

1. Campbell, S. H., Lauwers, J., Mannel, R., & Spencer, B. (2019). Core curriculum for interdisciplinary lactation care. Jones & Bartlett Learning. 
2. Lawrence, R. A., & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Elsevier. 
3. Section on Breastfeeding (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841. 
4. Walker, M. (2017). Breastfeeding management for the clinician: Using the evidence. Jones & Bartlett Learning.