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Optimal Milk Production Starts with an Optimal Latch

A condensed excerpt from "Making More Milk: A Nursing Mother's Guide to Milk Supply" by Diana West and Lisa Marasco (publication TBA)

If baby is not latched deeply, he cannot remove milk well from the breast, so it is very important for baby to latch as deeply as possible. Ideas about how to do this have been evolving in recent years.

At one time, it seemed that the "experts" believed that there was only one right way to to attach a baby to a breast.  We are now learning that there is no single correct way.  Every mother’s breast anatomy and every baby’s oral anatomy are different. Whatever helps baby to get on the breast deeply and comfortably and results in good milk transfer is the “right” position or technique for you.  What works for one baby may not work for another.  Breastfeeding can be like dancing:  While we all hear the same music, we each may dance to it a little differently depending upon our personal styles and our dance partners.

How Do You Know When the Latch is "Right"?

The most important factor of latch is low it feels: if you and your baby are comfortable, and it doesn't hurt at all, the latch is right, no matter how you did it or how it looks.

There are also other clues that a latch is right:

• You should feel a deep drawing sensation in your breasts.
• Baby should make a good seal on the breast and there should be minimal or no “clicking” or “popping” sounds, indicating suction breaks. 
• The nipple should come out of baby’s mouth as round as it went in, though perhaps somewhat elongated, with no flattening, crimping, creasing, blanching (whiteness), or bruising. 
• The corner of baby's mouth should not usually be visible because it is covered by the breast. If you can see it, it should be wide open, without any sharp angles.
• Baby should transfer enough milk to grow well. If he isn't, but latching isn't painful, then the problem is not likely to be the latch. There are many other things that can cause low milk production.
• Your breasts should feel softer at the end of the feed than at the beginning.

No one can ever tell you that a latch is right just by looking at it because they cannot tell what is going on inside your baby's mouth. If it hurts at all, even just a little bit, something is not right, no matter how good it looks on the outside, although the problem is not always the way he is latched.

Latching is for Newborns

Latching technique is only a concern for babies in the first six weeks or so. After that (sometimes long before) most babies are strong and physically coordinated enough to be able to latch deeply on their own.

What Do You Do When the Latch isn't "Right"?

The first thing to try is to see if a deeper latching technique makes a difference. There is a way of latching called the "Asymmetrical Latch Technique" that might be helpful if latching effectively has been a problem. There is absolutely no need to make a change if you're not having pain and baby is getting enough milk. But if it hurts or baby isn't gaining well, this technique is a tool you can try to see if it helps. This technique encourages the head to tilt back, so that the mouth opens more widely and the lower jaw can “lead,” grasping a larger amount of breast tissue than it would in traditional center (bull’s-eye) latch technique.

The Asymmetrical Latch Technique Step-by-Step

Bring baby's shoulders and chest tightly against you.  If your nipples point downward, baby is rotated slightly belly-up so that he is looking up at you.  Cup your hand around the base of baby’s head, supporting the weight of his head with two lower fingers and with thumb on top, just behind the baby’s ear.  With your hand in this position, the heel of your hand naturally rests between baby’s shoulder blades, so that his chest is in contact with your body.  Keep your wrist straight to allow baby’s head to tilt back. If you are holding him across your lap with the arm on the same side as the breast he is nursing from, rest his head on the muscle of your forearm, rather than at your elbow. Unless your nipple points straight down, don't try to lift your breast to baby.  Instead, position him just under your breast, wherever it may be.  Move baby so that his NOSE touches your NIPPLE and his chin is against your breast. If baby is lying across your lap, lift your other breast (the one nearest to baby’s hips, not the one you will be nursing from) over baby.  His body may angle downward. If he is large enough, his hip may rest on your thigh. Wait for baby to open his mouth widely.  If he doesn't do this in a minute or two, gently stroke his philtrum (the vertical crease between his nose and top lip) with your nipple, always bringing your nipple back up his nose. When baby opens his mouth widely, bring him toward you quickly and firmly (but gently) with the heel of your hand pressing against his shoulder blades so that his cheeks make contact with your breast. It is important to make sure that baby's bottom jaw makes contact with the breast low enough, which is usually about an inch and a half to two inches (40 - 50 mm) below the nipple (not the areola), so that it scoops up a large amount of breast before the top jaw closes down over the nipple.  If your baby overshoots the nipple and begins to tuck his chin to try and find it again, gently move him back slightly so that the nipple is at the level of his nose again.  Once latched, baby's nose should not be touching your breast, his chin and cheeks should be buried deeply into it, and you should not feel any pain at all. If your nipple hurts at all at any point, break the seal by gently inserting your finger between his jaws against his tongue and pull baby away from the breast.  Start over. Click here if you continue to feel nipple pain

Why the Asymmetrical Latch Technique Results in an Easier, Deeper Latch

There are four key elements to the asymmetrical latch technique:

• Allow baby to take the active role
• Ensure positional stability
• Shape and lift the breast only when necessary
• Initiate the feeding sequence by starting with baby's nose at your nipple

Asymmetrical Latch Technique Key Element #1: Allow Baby to Take the Active Role

Self-Latching Most calmed-but-hungry babies under three months old are able to self-attach to the breast.* This could be a valuable technique to try if you find that your baby begins rooting and bobbing to the side when he is skin-to-skin with you. Place baby skin-to-skin (no bra) in an upright position between your breasts with his head resting just below your chin, holding him with one hand on his bottom and the other hand on his back. After a few moments, he may begin to bob down to a breast. If you support his head and his body as he bobs or wriggles down, he may self-attach to the breast. It happens most easily when babys cheek or chin has frequent contact with the breast as he travels down. Beware: sometimes babies lunge towards the breast so quickly that mothers are caught off guard!  * Some babies with physiological or psychological problems may not be able to latch successfully once they get to the breast.

Babies are actually remarkably able to latch well all on their own, provided that we give them clues to help them understand what to do. Many times breastfeeding is difficult because we are overthinking it and making it more complicated than it needs to be.  We are also trying to control a situation that nature set up to be baby-driven.  Rather than having us work hard to improve our latching technique, most babies really just need us to get out of the way so they can do what they are biologically programmed to know how to do. 

Some babies do need more help, especially when they have had difficult births or have physical or psychological difficulties.  The best way for your baby to latch is going to be individually tailored to him and may involve a lot or very little help from you.   The starting place, though, is to assume that he has the ability to latch well all on his own and give him a chance to do it.

Asymmetrical Latch Technique Key Element #2: Ensure Positional Stability

Animal biologists have long known that baby mammals feed most readily when they are in a position that is secure (positional stability). Human babies are in positional stability when they are positioned so that their chests are held firmly up against their mothers with their backs and shoulders supported. This position calms and organizes them so that they are able to focus and begin the feeding cue sequence. This is especially helpful when babies fuss or flail their hands at the beginning of the feeding because fussing and flailing are often an expression of confusion about what they are supposed to do.

The feeding cue sequence starts when babies feel their chin against your breast and your nipple against their philtrum, which are the clues they need to trigger their nursing instincts. It also eliminates the gap between their mother and themselves that confuses them and makes them feel physically insecure (a feeling that is very upsetting for newborns).

Position Labels You may have noticed we are not using terms such as “cradle,” “cross-cradle,” “football,” or “clutch” hold on this site.  Those names imply a four-sizes-fit-all approach that may cause as many problems as they solve.  We hope that, by explaining what a hungry baby is trying to accomplish rather than telling you to use a specific pre-defined “hold,” we can encourage you simply to support your baby, both physically and emotionally, as he goes about a job that is much more his than yours.

Your baby will probably be able to latch most easily when he is:

• Skin-to-skin, wearing only a diaper and with your chest bare (you don’t need to take your top completely off to do this; just wear a top that opens down the front)
• In your arms
• Held firmly against you
• Supported with the heel of your hand against his shoulder blades and your thumb and forefinger behind his ears
• Angled down with his legs below the opposite breast, rather than perfectly horizontal (it is unnecessary for baby to be perfectly horizontal with his bottom tight up against you so long as he is positionally stable with his chest held firmly against you)
• Not lying on a pillow

If your breasts are large or long, you may find that baby's hip rests on your thigh, as you keep his front in full contact with your chest.  If your nipples point downward or your breasts are very large or long, your baby may be more “sunny-side up,” perhaps in your lap with your breast resting gently on his chest.  In this position, the weight of the breast itself can help the baby feel stable.

It is usually easiest for mothers to learn the asymmetric latch technique when holding baby with the arm on the opposite side of that she is nursing from.  However, if you need to use the arm that is on the same side you are nursing from, just be sure to place your baby’s head on the “meaty” part of your forearm, rather than in the crook of your elbow.  This will keep you from having to pull your breast to one side in order to line up your baby with your nipple.  It will also keep your baby from having to tuck his chin downward to reach your nipple, which would make latching more difficult.  

Try Standing Up Some mothers find it helpful to stand up while letting the baby make his way to the breast.  Standing, you’ll find you are concerned more about not dropping the baby than about placing your hands just so.  You’ll tend to hold him closely without following any preconceptions, and you may find that you have your most comfortable latches that way at first.

It is very important to place your hand so that your index finger and thumb are behind your baby’s ears and the heel of your hand is against his shoulder blades.  Don’t cup your hand on the back of baby’s head and try to move his head to the breast.  No one wants to have his head pushed toward his dinner plate; it drives away all thought of food.  Pushing on a baby’s head also tips his nose, rather than his chin, toward the breast, causing the baby’s chin to pull away from the breast and his tongue to retract.  Holding him so that his head is free to rock back allows him to move his head freely and extend it when he needs to. 

If the baby lies across your front, sliding his body so that his head is a little closer to the middle of your body will help position him so that his nose, rather than his mouth, is in front of your nipple.  If you are holding baby at your side, pull him more underneath the breast (his hips snuggled around your back) rather than starting him in front.  This will naturally result in his head tipping back to reach the breast. Your breast should not rest heavily on baby’s chest.  (If your breasts are exceptionally large and the weight would be too much on top of your baby, tuck him in tightly against the breast or angle his legs down so that his hip rests on your thigh, still keeping his front in full contact with your front.)   Whichever option you use, baby’s chin should end up touching the breast because that is his cue to open widely.

Experimentation will help you find the best position for your baby to approach each of your breasts. It is not about rules for “the right way,” it is about understanding what your baby needs in order to follow his instincts to latch well, and finding the best fit between you and your baby in order to optimize your baby’s ability to latch on to the breast comfortably and effectively.

Asymmetrical Latch Technique Key Element #3: Shape and Lift the Breast Only When Necessary

Your breast and nipple shape can influence the way you position your baby and the way your baby latches onto the breast.

• Interesting Fact The traditional “C hold” can cause the breast to flatten into a wedge that is horizontal instead of vertical or diagonal, 90-135 degrees off. This can be like putting a sandwich in front of someone, then turning it vertically and asking him to take a bite—almost impossible!

  Small, upright breasts may not be very elastic, which makes it challenging for baby to draw the breast deeply into his mouth.
• Large, soft breasts are often pillowy and lack definite form.
• If the skin is only loosely attached to the glandular tissue, it is possible for baby to draw in a lot of loose skin without getting enough glandular tissue.
• Flat nipples lack landmarks for babies to feel, sometimes causing confusion and not stimulating his sucking instinct.
• Breasts that are extremely firm due to postpartum edema may be difficult to latch onto. 
• A baby who has a very small mouth may find it difficult to grab enough breast tissue. 

Although shaping the breast is not necessary for most mothers, those who have these breasts or nipples or a baby with a very small mouth may find that shaping the breast with their hand can help create the landmark that baby’s instincts are seeking. Often it is only necessary to maintain the wedge until the baby empties the breast some and it becomes softer.

Shaping the Breast

Latching with Engorged Breasts In some cases, latching difficulty is due to temporary swelling of the breast tissue. Offering an oval-shaped wedge can help baby get his mouth around what otherwise may feel like a beach ball. It may be necessary to move some of the edema out of the tissue in order to make the wedge. Reverse Pressure Softening (RPS) as taught by Jean Cotterman, RN, IBCLC, may help to push out some of that fluid and soften the breast before trying any shaping.(1), (2), (3)

To shape your breast:

• Start with your fingers no closer than about 1.25-1.5 inch back from the tip of your nipple because this is how much space baby needs to get a deep latch.
• Compress your breast into a long wedge that lines up with baby’s mouth
• Place your thumb near baby’s lip, pointing up (think about making a "moustache" for baby)
• Place your index finger near the bottom of his chin, but at least far enough away from his chin so that it’s out of the way when he opens widely
• If he is horizontal against you, his mouth will be vertical, so your wedge will be vertical
• If he is tilted at a downward angle, his mouth will be diagonal so your wedge will be diagonal

It may be necessary to continue the wedge hold throughout the feeding for a while as the breast can “spring back” and pull away from baby when released. The experienced baby learns to keep it all together, but new babies sometimes need this help. If you make sure that you’re not holding too tightly or tensely, you should be able to maintain this hold comfortably throughout the feeding.  If you do release the wedge during an inexperienced baby’s feed, do so only after baby has begun long, slow, suck-swallows, and do it slowly so that your baby can adjust to the change in shape.

Lifting and Holding the Breast

Our breasts are attached to us.  They are already fully supported and never fall to the floor.  Lifting the breast to baby’s height became a common recommendation when it was thought that babies needed to be lifted into a horizontal position midway between a mother's lap and her face.  The most current thinking, though, is that there is no true reason for baby to be lifted higher than where your breasts naturally lie.  When there is no need to lift the breast, there is no need to hold it throughout the feeding (unless you also have to shape it for baby to latch). 

Instead, position your baby just under your breast where it naturally lies, with his nose at your nipple, wherever it may be.  At the most, position your fingers up against your ribcage or even on your breastbones so that your fingers are well away from baby’s mouth. 

Mothers who have very long breasts or nipples that point straight down are the exception.  If your breasts are so long that it's inconvenient to position your baby where your nipple normally is, you may decide to lift your breast somewhat.  If your nipple points straight down, you may need to lift the breast slightly so that you’ll be able to position your nipple pointing toward his nose.  Remember that if you do lift your breast you will probably have to hold it throughout the feed, to keep it from slipping from your baby's mouth.  For this reason, it's worth experimenting to see if there is some way to bring your baby to your nipple's natural level.  For instance, some lucky mothers are able to lay the baby face up on their laps and sit fully upright - no hands - to nurse.  A nursing bra with a detachable flap can also lift your breasts into a position to makes latching easier, without requiring you to hold your breasts during feedings.

Since you don't need to lift baby into an unnaturally high, horizontal position, there may not be a need for pillows in your lap, depending on what kind of furniture you are sitting on and how low your lap is in relationship to your breasts.

Asymmetrical Latch Technique Key Element #4: Initiate the Feeding Sequence by Starting with Baby's Nose at Your Nipple

Biologists have also learned that once they are positionally stable, baby mammals need an order of movements that instinctively signal that a feeding is happening (a feeding cue sequence). Human babies seem to feed more readily when they are brought to the breast with the nipple pointing toward their nose or the philtrum, the little indentation between the baby’s nose and mouth. This prompts the following feeding sequence:

• Tilting the head back
  
• Opening the mouth widely ("gaping")
  
• Lowering and extending the tongue
  
  
• Reaching up and forward toward the breast
  
• Bringing the chin into the breast first
  
• Closing the top jaw over the nipple
  
  
• Resulting in a deep, off-center latch with the nose not touching the breast and the chin buried deeply into it

To understand why these motions are helpful your baby get a deep latch, try the following demonstration:

• Drop your own chin down as far as it will go
• Open your mouth as widely as you can
• Can you feel how your tongue humps up in the back of your mouth?
• Try swallowing
• Is it difficult? 
• Now, tip your head back slightly and try opening widely
• Is this easier?
• Try swallowing again
• It’s much easier, isn’t it? 
• Notice how your tongue is able to extend and how widely you are able to open your mouth now

This is exactly how it works for your baby.  In order to feed effectively, he needs to be able to open widely, extend his tongue, and swallow easily.  Feeding with his head tilted back slightly will make feeding much easier and effective for your baby than feeding with his chin tucked.

What to Do if You Just Can’t Get a Comfortable Latch

Beware of latching and unlatching too many times. This can be frustrating for both you and baby, and can result in increased nipple soreness or nipple tissue damage.

If you just can't get a comfortable latch, you have a few options:  you can go ahead and let baby latch shallowly and cope with the pain.  While it may minimize baby’s frustration, it is likely to also reduce the amount of milk baby gets.  Another option is to stop trying to latch and feed baby away from the breast, making sure to pump with a high-quality pump to drain your breasts as thoroughly as possible (in the first few days, this may only be a few drops or tablespoons).  This will ensure that your milk production continues at the highest rate.  Either way, it will be important to get help quickly from a lactation consultant to find ways to get to baby latched more deeply or rule out a problem with tongue restriction or something else that may be going on.

Click here for more information on nipple pain