Laid-Back Positioning and Nipple Pain
by Anne Eglash MD, IBCLC, FABM
The laid-back breastfeeding position was first described as biologic nurturing by Suzanne Colson nearly 3 decades ago. The theory is that infants have primitive neonatal reflexes that align with abdominal feeding, such as the stepping, crawling, hand to mouth, arm cycling, and rooting reflexes. Some of these reflexes make it challenging to breastfeed in the traditional cradle or cross-cradle position, such as the arm cycling (‘my baby’s hands keep getting in the way’) or rooting (‘my baby keeps turning her head in the other direction’). The laid-back position involves the parent semi-reclining at an angle of 15-64°, so that the newborn is feeding on their belly rather than on their side or back. When on the abdomen, the primitive neonatal reflexes facilitate optimal breastfeeding behavior. In addition, the entire infant’s body is lying against the parent’s body, which helps the infant use their step and Babinski reflexes to stabilize themselves while breastfeeding. The parent is not flat on their back.
The question is whether the laid-back position helps with nipple pain. Nipple and breast pain are top reasons for difficulty breastfeeding and early weaning. The authors of this week’s study conducted a meta-analysis on this topic. They identified 12 studies with a total of 1936 dyads that focused on the effectiveness of the laid-back position on nipple pain and parental comfort. The meta-analysis concluded that laid-back breastfeeding position prevents nipple pain due to trauma.
- The laid-back breastfeeding position was associated with improved maternal comfort compared to other commonly used positions such as side-lying, cradle or cross-cradle.
- Laid-back nursing enables infant self-attachment to the breast.
- Laid back nursing typically stops when the infant has good head control, at around 3 months.
See the Answer
The importance of breastfeeding for maternal and child health is agreed upon worldwide. However, lactation-related nipple problems are common and are important factors affecting breastfeeding. Multiple studies recommended laid-back breastfeeding, but they are of various levels of quality, and the results are inconclusive.
We systematically searched the following twelve databases from inception to January 28,2020: Cochrane Library, EMBASE, Medline, Ovid, PubMed, Web of Science, CINAHL, Scopus, Chinese National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), WanFang, and VIP. All studies regarding laid-back breastfeeding or biological nurturing were considered, regardless of whether they were randomized controlled trials. Two trained investigators independently evaluated the quality of the selected articles and screened the data. All the data were analysed separately using Review Manager Version 5.3 and STATA/SE Version 15.1.
A total of 12 studies involving 1936 groups of postpartum women and their newborns were included. The results of the meta-analysis showed that nipple pain (RR = 0.24; 95% CI 0.14, 0.40; p < 0.00001), nipple trauma (RR =0.47; 95% CI 0.29, 0.75; p = 0.002) and correct latching position (RR = 1.22; 95% CI 1.11, 1.33; p < 0.0001) in the experimental groups were all better than those of the control groups, and the differences were statistically significant (p < 0.05), which indicates that the laid-back position has a positive effect on maternal breastfeeding. However, the results of position comfort showed that there was no statistical significance between the two groups (ES = 0.09; 95% CI -0.63, 0.81; p = 0.798).
Compared with traditional breastfeeding positions, the laid-back position has been proven to be related to a decreased incidence of nipple pain and nipple trauma and is seemingly conducive to the use of the correct latching position. It is suggested that the laid-back position is helpful in solving lactation-related nipple problems and can be recommended as a position for breastfeeding. However, no significant difference in position comfort was found between the two groups based on the current evidence, and further studies are still needed to validate these results due to the limitations of the included studies.
This meta-analysis demonstrates that laid-back positioning is associated with a lower risk of lactation-related sore nipples. However, the studies in the meta-analysis did not show that the laid-back position was more comfortable for the parent as compared to other positions. It is possible that this has been inadequately studied.
There is no infant age at which we should advise parents to stop laid-back positioning. My only word of caution based on professional experience is that periodically I have discovered insufficient weight gain at the follow up-visit 1-2 weeks after demonstrating and advising laid-back positioning. I have also seen lactating individuals in the breastfeeding medicine clinic presenting with a recent onset of recurrent plugged ducts in association with a recent change to laid-back positioning. My theory is that for some dyads, the laid-back positioning can make it more difficult for the infant to reach the glandular tissue because the tissue can fall back towards the chest wall, thereby making it harder for the infant to strip the glandular tissue. In these individuals, I would advise careful attention to the angle of recline during feeding.