1. HISTORY OF ATTACHMENT HOW HAS THIS COME FULL CIRCLE? Kittie Frantz, RN, CPNP-PC Clinical Instructor in Pediatrics Keck School of Medicine at University of Southern California Los Angeles CA USA frantz@usc.edu 1

2. DISCLOSURE I am the owner of Geddes Productions,LLC film maker of breastfeeding educational DVDs & distance learning course called The Baby’s Perspective I was breastfed for 9 months I breastfed all three of my children 2

3. I have received copyright permission to show these photos/films/drawings only to the live conference audience. Handouts, photographing or recording may not duplicate these images. 3

4. ATTACHMENT from an anatomy & physiology perspective ©1980,1990 Kittie Frantz 4

5. WHAT DO WE KNOW? 5

6. Best if baby doesn’t take just the nipple © 1980, 1990 Kittie Frantz 6

7. Gum compression somewhere behind the nipple is best to protect the nipple © 1980, 1990 Kittie Frantz 7

8. Baby lengthens the nipple into his mouth to form a “teat” (Ardran & Kemp) © 1980, 1990 Kittie Frantz 8

9. Posterior tongue moves upward and back to milk the breast © 1980, 1990 Kittie Frantz Woolridge, M.W., Ultrasound video analysis for understanding infant breastfeeding. 18 th International Conference on Image Processing, Belgium 2011. 9

10. WHAT WE DON’T KNOW 10

11. Hartman group disputes the existence of sinus’ under the areola © 1980, 1990 Kittie Frantz © Medela Ag Geddes, D T (2009) Ultrasound Imaging of the lactating breast: Methodology and application, INTL BREASTFEEDING JOURNAL 4;4 11

12. Breast sinus or bolus? Hartman’s ultrasound research shows the lactiferous ducts widening under the areola Could this be milk rolling down the duct in a bolus? © 1980,1990 Kittie Frantz 12

13. Baby’s mouth placement Does it matter? Makes sense that the tongue moves under the areola to move the milk through the nipple ©1980, 1990 Kittie Frantz 13

14. What does holding the baby have to do with it? © 1980, 1990 Kittie Frantz 14

15. Old advice was to give no advice to moms while baby was laid on her back ©Ross 15

16. This position was hard to get baby close & he often took only the nipple ©Quimby 16

17. Moms were told to tickle his cheek so he would turn his head to the breast 17

18. This was hard on baby’s swallowing ©Quimby 18

19. In the 1970’s, Applebaum said to lay the baby on his side at a 45° angle © 1969 Richard Applebaum Abreast of the Times: Breastfeeding for the Modern Mother 19

20. We progressed to Tummy to Tummy © 1990 Spangler AMY SPANGLER’S BREASTFEEDING: A PARENT’S GUIDE. Marietta, GA, 20

21. Legalism began: It became an absolute that ears, shoulders, hips were all lined up with baby exactly on his side © 1979 Frantz 21

22. The Royal College of Midwives reviewed Mavis Gunther’s work from the 1940’s and said “slightly rolled back for eye contact while on his side” © Quimby 22

23. In the 1970’s, Elsa Wood of New Zealand said hold baby’s bottom flush to her body to clear the airway ©1980, 1990 Kittie Frantz 23

24. Jack Newman talks of holding behind the ears for cross cradle hold 24

25. So what can we conclude? We thought baby was comfortable on his side But not 100% on his side Baby’s pelvis snug against mom clears the airway for opposite hand and side holds 25

26. What can we conclude? Baby’s body in a 45° angle is kind to baby due to normal reflux © 1980 Frantz 26

27. Then along came the pillows? Make mom comfy? Raise baby up to the breast? © 1979 Frantz © Kay Hoover 27

28. Pillows laid baby flat and interfered with baby’s 45° angle Four Dee Pillow advertisement 28

29. SOME POPULAR PILLOWS Baby is pictured flat on his side 29

30. What if mom has a short torso? ©1974 Frantz 30

31. If she sits in a chair, elbow support is what she needs Loving Moms advertisement 31

32. Most women support baby’s weight on their thigh so baby is in a 45° angle ©Quimby 32

33. Very uncomfortable unless feet are flat on the floor or supported © Kay Hoover 33

34. Foot rest pitches her back so baby’s weight is off of her arm © Kay Hoover 34

35. HOLDING THE BREAST 35

36. Old advice was to just nuzzle baby close to your nipple and not even hold the breast © Quimby 36

37. Then we progressed to grasp nipple between thumb and finger and insert into baby’s mouth © 1979 Frantz 37

38. Then the “scissors hold” was changed to supporting the breast in the “C” hold 38

39. Then we began to hear about the wide open mouth so baby can attach to the areola and not to the nipple 39

40. LET’S STOP FOR A MINUTE… 40

41. How do we get baby’s mouth open? © 1979 Williams 41

42. Cadwell says to touch nose to nipple and baby will back off and open 42

43. Newman says to slide nipple back and forth on upper lip 43

44. Renfrew & Fisher say to brush both lips with the nipple © 1974 Frantz 44

45. Cox says to rub the lower areola on the lower lip 45

46. How can she see her lower areola?? © 1979 Frantz 46

47. BABY FRIENDLY SAYS…. NOSE TO NIPPLE OR NIPPLE TO LIPS 47

48. Frantz says to touch the nipple to lower lip/chin © 1980, 1990 Kittie Frantz 48

49. WHAT IS A WOMAN TO DO? 49

50. Infant reflexes say lower lip © 1985 Frantz © 1983 K Frantz 50

51. Righard shows baby crawling doing this © 1992 Righard 51

52. Smillie says babies plant their chin first on the breast © 2005 Frantz 52

53. Colson says babies prone use their reflexes better © Kay Hoover 53

54. GO PLAY WITH BABIES! 54

55. What starts baby to suckle and draw the nipple in? 55

56. Marmet says suckling starts when the nipple touches the “S” spot on the palate © 1980, 1990 Kittie Frantz 56

57. That led to instruction for moms to “insert” the nipple pointed upward to touch the roof of the mouth 57

58. Infant reflexes show that the inner lips touching the breast all at once causes the tongue to reach forward © 1980, 1990 Kittie Frantz 58

59. What has happened to the latch over the years? 59

60. READY, SET, LATCH… 60

61. The “target latch” used to be centering the baby’s mouth on the areola 61

62. The “up and over the top of the areola” latch began as women thought they should “cover the areola” © 1985 Frantz 62

63. Newman, Fisher, Frantz, Weissenger, realized that attaching to the lower areola was best © 1980, 1990 Kittie Frantz 63

64. It became known as the asymmetrical latch Safer for the nipple as tongue and gum are under it © 1980, 1990 Kittie Frantz 64

65. WHY? Better swallows Means better weight gain Less nipple trauma 65

66. When we watched babies, we saw them pitch their heads back slightly © 1980, 1990 Kittie Frantz 66

67. When baby is brought straight in and close, he naturally attached to the lower areola © 1980,1 990 Kittie Frantz 67

68. Babies prone used their head lifting reflex to do this © 2009 Frantz 68

69. Sounds simple but some new methods try and force the issue ©UNICEF 69

70. New in concept: The “Hamburger sandwich” deep latch method by Weissinger, Sullivan, Harvey, Glover 70

71. Glover says catch lower lip to pry mouth open Glover, JR. “Attachment – The Key to Successful Breastfeeding” teaching aid, 2013. www.rebeccaglover.com.auwww.rebeccaglover.com.au 71

72. Glover…Bring baby up to just cover the nipple Glover, JR. “Attachment – The Key to Successful Breastfeeding” teaching aid, 2013. www.rebeccaglover.com.au 72

73. Weissinger’s drawings of the same swiping down the mouth Weissinger, D.: A breastfeeding teaching tool using a sandwich analogy for latch-on. JOURNAL OF HUMAN LACTATION, 1998, 14(1): 51-56. www.wiessinger.baka.comwww.wiessinger.baka.com 73

74. Harvey says to swipe from the nose down to upper lip to lower lip to get lower lip out Sullivan, D.: The Art of Breastfeeding, FIT PREGNANCY, April/May 2001: 104-105. 74

75. I found moms tried hard to bring baby’s mouth up to “cover” the areola with these methods © 1980 Frantz © Bocar 75

76. Fisher, Renfrew say nipple by the upper lip, baby drops the jaw & bring in the shoulders ©1990 Renfrew, M.; Fisher, C.; Arms, S.: BESTFEEDING: GETTING BREASTFEEDING RIGHT FOR YOU. Celestial Arts, Berkeley 76

77. Bringing in the shoulders and not the head is the key 77

78. Having said all of that, what do we see experienced moms doing? 78

79. But don’t we see experienced moms leaning back for comfort? © 2005 Frantz 79

80. Doesn’t that put baby “tummy to mummy”? © 2005 Frantz 80

81. Isn’t that what a rocking chair did? ©2009 Frantz 81

82. PUTTING IT ALL TOGETHER 82

83. Hold baby so that he can see mom © 1980,1990 Kittie Frantz 83

84. Hand supports breast with fingers off of the areola © 1980 1990 Kittie Frantz 84

85. Baby touches lower lip and chin to the breast © 1980, 1990 Kittie Frantz 85

86. Baby’s tongue and jaw drop down & the baby’s head moves slightly back © 1980 1990 Kittie Frantz 86

87. Baby moves straight in and close (Mom’s forearm may help) © 1980 1990 Kittie Frantz 87

88. Remember to bring the whole baby inward © 1980 1990 Kittie Frantz 88

89. BABY-LED LATCH and then Tina Smillie changed it all !!! Gift from Patient 89

90. THREE WEEK OLD BABIES BABY SELF ATTACHES DVD © 2005 Kittie Frantz www.geddesproduction.com 90

91. And then……. Suzanne Colson looked at what women have been doing since time began ! Colson, S, et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding EARLY HUMAN DEVELOPMENT, 84(7) 91

92. Laid back breastfeeding Is prone better? BIOLOGICAL NURTURING®: LAID-BACK BREASTFEEDING FOR MOTHERS © 2009 Colson, Makelin, Frantz www.geddesproduction.com 92

93. Prone allows baby to anchor with his hands and lift his head BIOLOGICAL NURTURING®: LAID-BACK BREASTFEEDING FOR MOTHERS © 2009 Colson, Frantz, Makelin 93

94. Which mom looks more comfortable?? BIOLOGICAL NURTURING®: LAID-BACK BREASTFEEDING FOR MOTHERS © 2009 Colson, Frantz, Makelin 94

95. Is this the same thing but in prone position? © 1980 Frantz 95

96. Baby-led & Laid-back methods show baby automatically attaching to the lower areola © Bocar 96

97. Magic happens because her hands are free BIOLOGICAL NURTURING®: LAID-BACK BREASTFEEDING FOR MOTHERS © 2009 Colson, Frantz, Makelin www.geddesproduction.com 97

98. She can do this in the NICU © 2009 Frantz, 98

99. Which is more comfortable when she gets home? BIOLOGICAL NURTURING®: LAID-BACK BREASTFEEDING FOR MOTHERS © 2009 Colson, Frantz, Makelin www.geddesproduction.com 99

100. So…which method is best? What seems easier for your client to visualize? Do you know if what you teach really works for the moms? What kind of follow-up do you have to know this? 100

101. WATCH HER TECHNIQUE © 2009 Frantz 101

102. Watch her technique when you see her Analyze what you see What is right…..tell her What is wrong…ask her if she wants help Moms think there is only “one right way” They are confused when “right” becomes “wrong” 102

103. Dancing around the changes you want to make “I am sorry you are so sore.” Ask permission to change her technique: “Would you like to try something different and see how it feels?” 103

104. Old habits are hard to break She can’t see from this angle She will try to do it as she has it imprinted in her mind Try the self latch! If less pain….now you have her attention! © 1985 Frantz 104

105. Follow-up Self attachment is so easy and instills confidence Try prone laid-back position for comfort This could be a “method-free” experience! 105

106. It is working if… It does not hurt There is nutritive suckling Baby gains weight The baby drives the system! 106

107. We have come full circle letting the baby do it himself! It works Mom suddenly feels confident No “method” means she and the baby are dancing together Respectful of baby who doesn’t feel forced 107

108. CONFIDENCE ! BABY-LED BREASTFEEDING DVD © 2007/2010 Smillie, Makelin & Frantz www.geddesproduction.com 108

109. Our goal…happy mom and baby! © 2005 Frantz 109

110. Any questions? 110