Friday, October 30, 2009

Safe Positioning in Slings

Consumer Reports blog this week announces the heartrenching death of 6 day old Derrik Fowler in an Infantino Slingrider. He died of positional asphyxia- when a baby asphyxiates due to the airway being compressed by the weight of his own head.

This happens when babies are poorly positioned in all types of products: car seats, baby chairs & yes, baby carriers. When babies chins are touching their chests, their airway is compressed. They lack the muscular control to lift their heads to prevent asphyxiation, placing them in an extremely dangerous situation- one Derrik's parents must be devastated about.

I cannot imagine their feelings when they learn that his death was completely preventable. In 2006 & 2007, informal tests were done on the respiration rates & oxygen saturation rates of babies in Infantino Slingriders. They were performed by a former RN & babywearing educator. She sent her findings, along with supporting information, to Infantino & to the American Consumer Product Standards council. Further detail can be found at www.thebabywearer.com

While the Infantino sling is obviously a disaster waiting to strike again, poor positioning in any carrier places infants at risk. It is essential that babies faces are never covered by the fabric of a carrier & that their heads are angled back, keeping their chins well away from their chests. The photos on the Infantino product site are a good indicator of the unsafe positioning that must be avoided.

While some brands of carrier are designed in a way that does not allow the possibility of safe positioning, many excellent brands that do allow for it are used in a position that I no longer consider safe or biologically correct- the cradle hold.

There are a number of reasons I will no longer teach this position. In most photos of babies placed in the cradle position, the baby's chin is down at its chest. It is very difficult for most parents to safely position the baby while it is in the cradle hold.

Second, the cradle position does not place the baby in the position it expects to be in- vertically, between its mothers breasts. Dr Nils Bergman, a physician & researcher who has extensively studied the immensely beneficial practice of keeping babies in their habitat- vertically, between the mothers breasts, says: "The baby is in the right place and therefore has the right behaviour."

As a Lactation Educator (LE) & a Babywearing Educator, I often help parents resolve difficult breastfeeding problems by simply recommending Kangaroo care- ie, time spent skin to skin, vertically, between the mothers breasts.

When babies begin a nursing session in the vertical position (moving themselves over to actually nurse), they are best able to effectively coordinate their suck/swallow/breathe reflexes (for more information on these concepts, see the work of Dr Suzanne Coulson , Kittie Frantz, Dr Michel Odent as well as Dr Bergman)

If babies orient vertically, I believe placing them at an angle, or horizontally, can disorient them. In my experience, this can lead to, or exacerbate, breastfeeding difficulties.

The cradle position continues to be taught by manufacturers & educators, but I recommend you avoid using this positioning. It makes it difficult to position the baby safely & appears to contribute to breastfeeding problems.

Instead, newborn babies should be positioned tummy to chest, with their legs in a frog position, knees higher than bum. The carrier should support them well enough that they are not slumping down in it, potentially compromising their airway.

Babywearing is a wonderful tool that gives babies the minimum they expect- to be carried by their mother. It is also a learned skill that requires a bit of background knowledge to safely perform. Please always be certain that your baby is safely carried.


17 comments:

  1. Excellent post! I'm extremely interested in the link between carrying positioning and breastfeeding, as of course the cradle hold for nursing seems to be the dominant position taught by breastfeeding educators. How would you advocate re-educating breastfeeding educators, particularly about how to nurse a baby when mom is sitting down?

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  2. I don't understand how you describe the proper position. Could you incle a diagram or photo? Thank you so much if you can.

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  3. Lelah, I've added a pic- it shows correct positioning, with the baby's head tilted slightly back & legs positioned with the knees higher than the bum.

    Quirky, I am working on some material (a DVD coming out hopefully early in the new year) on this concept, which I call Normalised Breastfeeding. I will blog here about it soon as well.
    This is a very new concept, inspired by Kittie Frantz' & Dr Suznne Coulson's work (both have released DVDs to assist with putting their ideas into practice).
    It was pioneered & put to use in babies of all ages by myself & a couple of other breastfeeding educators in my city (Kirsten, our other editor, being one.)

    Basically, women should be taught to nurse in a reclined position, with their body mainly supporting the baby, as opposed to their arms.
    This becomes less of a concern as the baby ages & develops neurologically- the ability to effectively remove milk in any position improves with age (as anyone nursing a toddler can attest to!)

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  4. Arie, I'd love some more information on that kind of positioning. I've tried it and it just doesn't seem right. I have a large 3 month old and have tendinitis in my wrists from holding him to nurse so much. The only comfortable position is side laying and that's just not practical a lot of the time with two toddlers running around. I'm considering giving up BFing because it just hurts so bad.

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  5. Thank you for this post. I tried wearing my daughter in a sling and then Moby as a newborn and just couldn't get it right. I tried over and over again and both her and I hated it. All I tried was the cradle position because I thought that was the only correct way to carry an infant. That is what I had been exposed to. So I all but gave up on babywearing.

    Then around two months I discovered the position you illustrate and two and a half years later we are still happily wearing. That new position was a total game changer for me.

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  6. This position has become pretty much natural to me as well. I have never been able to sling my little ones horizontally. They have always been upright between my breasts. It is easy to secure my ring-style slings around their little behinds and above their shoulders and they just snuggle up right there on my chest. (check this link out for another example of a larger little one nursing in what I believe would be the position you are writing about...

    http://www.facebook.com/photo.php?pid=30502286&l=13204228fd&id=1011833083)

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  7. Hi Deborah- I would like to try to help you if I can- are you local to Edmonton? If not, I can do phone consultations as well.
    I wonder if your tendinitis was preexisting, or if it has been caused by the position you are nursing in?
    There should be absolutely no strain placed on your wrists while nursing. I wonder if you are sitting upright in a chair, or using a nursing pillow? A semi reclined position, with the weight of your baby resting on your abdomen, is a much more ergonomic way to nurse...

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  8. I'm very curious to see your additional work too, particularly because my own experience does NOT support the idea that cradle positioning is not good for breastfeeding. I have a short torso and long babies, and I simply could never get nursing with the baby in an upright position to work at ALL. It was horribly uncomfortable. But I find that the "cradle" position to which I naturally resorted, both in arms and when using a sling, is really a semi-reclining position, with the baby's body at a diagonal to mine, with head higher than hips. So in my teaching I focus on showing mothers who want to use a cradle position how to do it RIGHT; I believe it's not useful to tell them simply not to do it. (Of course, for someone who does not want to use a cradle position, I can also show them how to correctly support a newborn in an upright, tummy-to-tummy carry. For many parents this is a useful revelation!)

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  9. Hmm- I want to clarify a bit, because I think a couple of concepts are getting muddled here.
    There is very little research on any of these topics, so we have to go with what we know. It is very important to not let individual variations of experience override what we know about infant physiology. We know babies orient vertically. We know that we often see disorganised behaviours in breastfeeding babies. It follows that placing a baby in their orienting position allows them to move themselves into the nursing position best suited to them. This nearly always turns into the baby being at a diagonal across the mothers body, & requires that the mother is somewhat reclined. Normalised breastfeeding is not nursing the baby in an upright position, while in a carrier.
    The reason the cradle position appears to contribute to breastfeeding problems is that it requires the baby to spend time in a disorienting position- this can lead to disorganised behaviours that make latching & removing milk difficult or impossible.
    It does not make sense to me to demonstrate a carrying position that orients the baby in a position they were not designed to be in, regardless of whether they are horizontal in the sling, or semi-reclined. Neither is the position the baby expects to be in.

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  10. This is a great article, thank you.
    I was fortunate enough to attend a wonderful workshop run by Suzanne Colson 2 years ago on the subject of Biological Nurturing which promotes this upright position for nursing. It was truely fascinating. Worth reading this article and learning about natural neo-natal reflexes and how babies, like other newborn mammals, are born with the reflexes to move from the mother's stomach to find the breast when in this position.
    I think that it is a shame that new mums are still repeatedly taught that the 'nose to nipple' 'tummy to mummy' position for breastfeeding is the 'normal' way to breastfeed a baby.

    http://www.midwiferytoday.com/articles/womb.asp

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  11. FWIW, I think it's important that the mother's physiology is also taken into account. I have large, floppy breasts, and my nipples tend to list towards my sides rather than pointing to the front. I love the idea of nursing a newborn with her lying on my chest, between my breasts, but that just wasn't possible with my build. For us, it was either a cradle hold or side-lying, and even then, it was necessary to support my breast when my babies were newborns. While the new research and positioning is probably doable for many women, it's not for everyone, and as with many cases, one-size-fits-all rarely does :)

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  12. thanks for that! i'm a babywearing instructor myself and am having a lot of issues with the cradle hold being promoted as the only safe/ideal position for newborns. will link to your article in my blog if that's ok with you.

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  13. Linking to this is just fine- Thank you for the share, I appreciate it! Could you email me a link to your blog, I would love to read it.

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  14. I'd like to respond to Jan Andrea and a few of the other posters. I am also a BBwearing Educator and Lactation Educator.

    Jan- I have similar anatomy to you, and I had to nurse my firstborn always with a pillow (or several) and always supporting my large (42 K) breasts for the entire feed. I discovered babyled breastfeeding just before my daughter's birth in 2006. I no longer need pillow, or breast support at all!
    The trick to remember is that the baby needs to START in the vertical between the breasts position, and move himself (supported by you)down to the breast. He will place himself in the best position for him, which will look different with each mother baby pair. It usually ends in the baby nursing with his neck and shoulder supported in the crook of moms elbow or along her arm. His body weight will be resting on yours (you need to get really comfy, and lean back) and your arm is just used for light support.
    I think readers have become confused in reading Arie's blog about the need to CARRY babies in a vertical orientation to help prevent and overcome BFing problems VS> the actual practice of babyled breastfeeding, which cannot be done in a carrier at all.
    I'm not saying that we shouldn't nurse in our carriers (although there is some controversy about that) but that you CAN NOT practice babyled techniques in your carrier.
    The most important thing to remember is that for this to work the baby needs to START off upright between the breasts. This way he can use all of his senses to orient himself to seek the breast, latch and nurse effectively. The problem arises when a baby is laying down ( in a cot, carseat or sling) cues to nurse (often late cues) and the mother moves him from this laying position directly to a tummy to tummy nursing position. The baby needs a little foreplay, calmly hanging out between mom's breasts, so he can get in the mood to nurse well. When we miss some of these steps (missing early feeding cues or whacking baby straight onto the target)he can't get it together to nurse well.
    It's all about letting the baby uses his instincts to engage in and direct the nursing process. Mom's job is solely to act as facilitator and guide. That's where optimal CARRYING positions come into play.

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  15. My daughter fusses every time I try to carry her upright facing me between my breasts. She is fine in the cradle hold or facing out. I have tried multiple times to get her to ride in the Mei Tai or even in my ring sling facing in and she always cries. Why would this be?

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  16. Jen, often that is a sign that your baby is ready to be carried on your back!

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