pleasurable for the mother. She does not feel pain. Poor attachment Figure 7 shows what happens in the mouth when a baby is not well attached at the breast. The points to notice are: K only the nipple is in the baby’s mouth, not the underlying breast tissue or ducts; K the baby’s tongue is back inside his or her mouth, and cannot reach the ducts to press on them. Suckling with poor attachment may be uncomfortable or painful for the mother, and may damage the skin of the nipple and areola, causing sore nipples and fissures (or “cracks”). Poor attachment is the commonest and most important cause of sore nipples (see Session 7.6), and may result in inefficient removal of milk and apparent low supply. 2. The physiological basis of breastfeeding Figure 6 Good attachment – inside the infant’s mouth Good attachment Figure 6 shows how a baby takes the breast into his or her mouth to suckle effectively. This baby is well attached to the breast. The points to notice are: K much of the areola and the tissues underneath it, including the larger ducts, are in the baby’s mouth; K the breast is stretched out to form a long ‘teat’, but the nipple only forms about one third of the ‘teat’; K the baby’s tongue is forward over the lower gums, beneath the milk ducts (the baby’s tongue is in fact cupped around the sides of the ‘teat’, but a drawing cannot show this); Figure 7 Poor attachment – inside the infant’s mouth 14 Infant and Young Child Feeding – Model Chapter for textbooks Signs of good and poor attachment Figure 8 shows the four most important signs of good and poor attachment from the outside. These signs can be used to decide if a mother and baby need help. The four signs of good attachment are: K more of the areola is visible above the baby’s top lip than below the lower lip; K the baby’s mouth is wide open; K the baby’s lower lip is curled outwards; K the baby’s chin is touching or almost touching the breast. These signs show that the baby is close to the breast, and opening his or her mouth to take in plenty of breast. The areola sign shows that the baby is taking the breast and nipple from below, enabling the nipple to touch the baby’s palate, and his or her tongue to reach well underneath the breast tissue, and to press on the ducts. All four signs need to be present to show that a baby is well attached. In addition, suckling should be comfortable for the mother. The signs of poor attachment are: K more of the areola is visible below the baby’s bottom lip than above the top lip – or the amounts above and below are equal; K the baby’s mouth is not wide open; K the baby’s lower lip points forward or is turned inwards; K the baby’s chin is away from the breast. If any one of these signs is present, or if suckling is painful or uncomfortable, attachment needs to be improved. However, when a baby is very close to the breast, it can be difficult to see what is happening to the lower lip. Sometimes much of the areola is outside the baby’s mouth, but by itself this is not a reliable sign of poor attachment. Some women have very big areolas, which cannot all be taken into the baby’s mouth. If the amount of areola above and below the baby’s mouth is equal, or if there is more below the lower lip, these are more reliable signs of poor attachment than the total amount outside. 2.9 Effective suckling If a baby is well attached at the breast, then he or she can suckle effectively. Signs of effective suckling indicate that milk is flowing into the baby’s mouth. The baby takes slow, deep suckles followed by a visible or audible swallow about once per second. Sometimes the baby pauses for a few seconds, allowing the ducts to fill up with milk again. When the baby starts suckling again, he or she may suckle quickly a few times, stimulating milk flow, and then the slow deep suckles begin. The baby’s cheeks remain rounded during the feed. Towards the end of a feed, suckling usually slows down, with fewer deep suckles and longer pauses between them. This is the time when the volume of milk is less, but as it is fat-rich hindmilk, it is important for the feed to continue. When the baby is satisfied, he or she usually releases the breast spontaneously. The nipple may look stretched out for a second or two, but it quickly returns to its resting form. Signs of ineffective suckling A baby who is poorly attached is likely to suckle ineffectively. He or she may suckle quickly all the time, without swallowing, and the cheeks may be drawn in as he or she suckles showing that milk is not flowing well into the baby’s mouth. When the baby stops feeding, the nipple may stay stretched out, and look squashed from side to side, with a pressure line across the tip, showing that the nipple is being damaged by incorrect suction. Consequences of ineffective suckling When a baby suckles ineffectively, transfer of milk from mother to baby is inefficient. As a result: K the breast may become engorged, or may develop a blocked duct or mastitis because not enough milk is removed; K the baby’s intake of breast milk may be insufficient, resulting in poor weight gain; Breastfeeding pattern To ensure adequate milk production and flow for 6 months of exclusive breastfeeding, a baby needs to feed as often and for as long as he or she wants, both day and night (28). This is called demand feeding, unrestricted feeding, or baby-led feeding. Babies feed with different frequencies, and take different amounts of milk at each feed. The 24-hour intake of milk varies between mother-infant pairs from 440–1220 ml, averaging about 800 ml per day throughout the first 6 months (29). Infants who are feeding on demand according to their appetite obtain what they need for satisfactory growth. They do not empty the breast, but remove only 63–72% of available milk. More milk can always be removed, showing that the infant stops feeding because of satiety, not because the breast is empty. However, breasts seem to vary in their capacity for storing milk. Infants of women with low storage capacity may need to feed more often to remove the milk and ensure adequate daily intake and production (30). It is thus important not to restrict the duration or the frequency of feeds – provided the baby is well attached to the breast. Nipple damage is