The Biggest Mistake People Make When Assessing Breastfeeding

Time and again in clinic, I hear of this classic and oh so common mistake. I’d say in fact at least 90% of families report it happened to them, have you guessed what it is?

Only watching the start or some of a breastfeed.

This gives a completely inaccurate picture of what’s going on.

Why?

1. A baby may appear to gape and latch OK, but it may not be sustained and they may persistently slip or pull back, resulting in a smaller mouth/shallower attachment.
2. The first “milk ejection reflex” (MER) or “letdown” is often triggered easily once baby has attached and suckled briefly. For a newborn this one MER may constitute a whole or a good chunk of a feed; however as baby grows, they will most often need to trigger more MERs.  For this the majority of babies need:

• A wide gape which helps close gaps at the corners of the mouth and creates a seal.  This also means the correct part of the breast is stimulated (nipple sucking doesn’t trigger the MER)
• To position the tongue forward over their gum margin, keeping it there throughout the feed (to maintain the seal)
• To move their tongue in the correct way

When we only watch the start of a feed – here is what we see:

Baby gapes, attaches and start a regular suck-swallow pattern. The busy observer notes that baby has latched and they’ve observed active drinking or transfer (baby sucking and swallowing).  Confident baby is drinking well, receiving lots of milk, they tick a box and away they go.

Sometimes this initial MER will even seem super fast to the baby in a shallower latch, leaving baby gulping rapidly and even coughing and spluttering:

Here’s why:

If baby has a deep effective attachment, milk hits the back of the tongue.  Baby elevates this section of the tongue, to tip the bolus into the pharynx for swallowing. As the tongue drops again, the mouth can refill and the pattern repeats.

If latch is shallower – baby has milk hitting the front of their mouth, which they then need to move backwards, before tipping for the swallow.  When it does tip, rather than the edges curling like a pipe, the tongue tied baby’s tongue can be more like a ramp – allowing the bolus to over-spill into the airways.  This additional process means baby can sometimes drink faster and faster in a bid to keep up, struggling to fit paced breathing into the equation – instead as the MER slows, they can end up panting as though they’ve been running.

Watch this same baby with a deep attachment:

Baby allows his mouth to fill fully before tipping it “down the hatch”.

Only watching a few moments of a feed is rather like watching the warm up act at a show, before writing a review of the headliner.

What breastfeeding supporters need to watch, is what happens after the first milk ejection finishes. How long this initial ejection lasts varies mother to mother, but we’ll naturally see baby start to slow down a little from the suck swallow or suck, suck swallow pattern we typically see when drinking well.

What should happen next is baby pauses, does some shallower, more rapid sucks which in turn helps to elicit the next MER. They then re-commence the regular suck swallow or suck, suck swallow drinking pattern seen at the start of a feed.

Except some don’t.

If baby isn’t managing one or more of the bullet list points above, in practice they can struggle to trigger more MERs.  For them once the first finishes, the breast reduces to a drip/drip release.

Baby will then typically either “breast hang a while” (suck, suck,suck suck, suck suck, swallow, pause, eyes drift, suck, suck, suck, pause, until the pauses become more frequent and longer), which can shift into the “baby powernap”  – or, they’ll fuss to let you know this is not working out how it should!  Baby may do a combination of these things depending on the day/hour/feed etc.

Of course a baby falling asleep at the breast when they’re full is completely normal – the scenario though we’re exploring here, is baby either breast hanging for long periods (making things unsustainable for many families), or power-napping before they’re full, sometimes rousing as soon as they realise (ie you try and move them away from a chest and their hunger cues begin again).

When observing a breastfeed to support someone else, or when watching your own baby feeding – checking in at regular intervals throughout the feed is key.

• Is baby sustaining a big wide mouth?
• Are they triggering more MERs and continuing to drink well?
• Are they drinking in an effective, organised way that isn’t going to result in tummy ache, trapped wind or “reflux” ?