 So, today we are going to start with the session number 6, one of my favorite session. It is going to be on actual technicality, art of breastfeeding. You know we all know everybody knows that breastfeeding is important, everybody knows actually and it is not that mothers do not try, they do try okay and I have this experience in US, I have this experience in India with the educated mothers with you know mothers coming from underprivileged background, they all want to breastfeed their children by and large. But the problem arises when they try to breastfeed and when they are unsuccessful, when they kind of develop nipple pain, breast pain, breast abscess, baby is not latching, you know baby is crying, mothers they do try and when they feel that they are not being able to breastfeed, that is when you know things starts kind of falling apart and that is what kind of I experience to in my own experience and also when I started working in you know slums of Mumbai, of course as a pediatrician I was not taught about breastfeeding at all even in US you know and initially like I would kind of teach mothers whatever that I knew and also reading lot of books and guidelines and you know and somehow you know kind of children were not gaining as much weight and working with this poor mothers, it was very important for me to make them understand proper technicality of breastfeeding so that we could do catch up growth because lot of these babies were born small, you know in India as I mentioned our average birth weight is 2.7 which is you know which is much lower than the world average of 3.2, 3.3 kgs and girls and boys respectively. So we did kind of you know worked on different techniques of breastfeeding. As I mentioned initially what we were doing we were using the cradle hold and somehow I felt lot of kind of problems with that cradle hold and of course you know we were using this amazing software which we had created with the help of one of the very famous software company. So what we were doing whatever we were telling mothers we were documented it on that software and we realized that some advices when we gave it was working some of the advices we gave it was not working you know and I have to tell you this one particular experience that I had almost 4 to 5 years in my learning I had this one baby come to me about 2 weeks old girl child and you know I met this mother in fact she lived in my building and she was she looked kind of very tired and she looked sad and she had this little baby in her hand. So I told her that how is it going with you breastfeeding I had never met her before this was the first time that I met her and she said that ma'am you know I am not even to breastfeed her she cries a lot she just does not latch on to the breast and I am basically starting formula. So I said no before you start formula why did not you come home and I can help you and in fact within just 30 minutes she came home with her little baby 2 weeks old baby you know full term baby born beautifully 3 kilogram weight you know with birth and she came and you know we were I was showing her the cradle hole the traditional hole that you know we generally use cradle hole is basically you know you just basically put the baby on the same side that you want to breastfeed from and you know this is cradle hole and traditionally most the people use this cradle hole. So I told her I said why did not you you know hold the baby this way exactly how you know it is written everywhere and you know when she was trying to breastfeed baby refused to latch refused to latch we tried half an hour I told her exactly C shape hole you know do this do that and baby refused to latch and then we were almost in tears actually you know working on this for 5 years and then when she tried to then I told mother I said that look what we can do you hold the baby and I will try to direct breast in the mouth you know I will try to hold the breast and I will basically kind of contour it in a way so it becomes easier for baby to latch on. So why she was holding it you know so normally we were told the C shape just by intuition or just by succent you know I when baby opened the mouth you know immediately instead of doing a C shape I just held up because I was looking from from top you know and I held the breast from top and I pressed it as soon as I did that baby kind of latched on you know beautifully and I was like for a second I thought that I made a mistake because normally I would tell mothers and no no no C shape C shape hole and here I as soon as baby opened the mouth I did the U shape you know from the top and I immediately went on the internet because it was like a aha moment and I went through so many kind of YouTube videos and you know nowhere it showed U shape everybody was doing traditional hole and this and that but I came across one video where one of the nurse in fact she was an aeratologist from Stanford University you know and she was showing mothers kind of cross griddle hole with holding the breast in the U shape not from the top but from the bottom and I it just I said it occurred to me that what was happening is that when baby was opening the mouth you know what I what basically I had to do is to put my fingers parallel to baby's lips so it could contour and it was easy for baby to latch on you know and baby immediately kept quiet started sucking and you know and that is how basically this different holding of breast and also way to hold the baby also kind of we learnt our period of time and that is when we started seeing good results and since then you know our weight gain has been remarkable almost 1.1 to 1.2 in fact sometime we see 1.5 to 1.6 kg weight gain per month you know so this was my little story that how you know we came we started kind of improvising this cross griddle technique you know cross griddle means you hold the baby from the opposite end you know opposite hand and you latch the baby on so that is what I am going to explain and again over period of time we know we figured out at what points which were very very important for mothers to understand and once we taught those techniques as well as those counseling points you know we started seeing results okay so today my first part is going to be basically you know just 45 points of counseling which is one of the most important aspect of this you know tutorial of this session and of course the whole course so if you can really understand the technicality of cross griddle hold in 45 points you know 90% of your problems will be solved you know 90% of the time okay so to kind of listen to this very carefully watch it and then practically you can just buy a doll and make a breast model at home and you can you know practice it on of course the model but you know also kind of help any mothers in your family who are just delivered or teach any pregnant mothers you know when the baby is born you practice on mother and the baby because more you practice on a live baby and the mother more efficient you will become okay so let us start with the first point of course this is part one and we are going to talk about I will be including part one part two part three you know it is basically a continuous process and I will make it as elaborate as possible and also as simple as possible okay so let us start with cross griddle hold and 45 points of counseling okay now first thing that we want to remember you know we we are always we have this thing in our mind that when is baby ready to breastfeed okay and most of the time mothers feel that oh when baby cries that is when baby is ready to breastfeed one point you want to remember by the time baby cries it is already too late okay so please do not wait for baby to cry okay you what you can do is to understand those early hunger queues okay so early hunger queues so what are those early hunger queues and you know newborn babies or babies who are small in a two months under two months of age is basically you know they will first thing they will do is they will open their eyes they will kind of squam so they will kind of squam okay and they will start looking around they will start looking for breast so they will open the mouth and then they will move around like this okay so that is important second or third point would be basically you know what they do is that in mid-hunger queue they put their hand in the mouth so they will put them hand in the mouth okay and they will basically kind of salivate and they will become a little bit more kind of squarmy so they move a lot okay third stage they become very irritable they become it is a late queue and they become very irritable they start crying and they are very very you know it is very difficult to console them okay so when do you want to breastfeed you want to breastfeed when they are in early hunger queues so in early hunger queues again they will start squarming okay they will open them out and they will start looking for breast so that is what is the most important early hunger queues that you want to understand okay so here now you have a baby who is small and suppose baby does not wake up say within two hours or so okay now again if the baby is small and you know you want to have a ketchup growth then I do recommend that you should basically wake up the baby after two hours gap in the daytime okay so the way you wake up the baby is basically you remove pretty much all those blankets you know you remove cap you remove mittens you remove socks because when the baby is wrapped too many times they are too comfortable and sometimes they just don't want to wake up okay so once you remove all that extra clothing you know baby does get kind of uncomfortable and then they they wake up okay second thing what you want to do suppose if they are not waking up okay even if you remove all the clothes just with one on see you can keep an on see on if it's cold obviously you can put one more layer you know but don't put too many blankets around baby okay when you're waking up the baby second thing what you want to do is to basically make up make the baby sit so what you can do you just make the baby sit on the lap okay put your fingers on the jaw so there is an angle of the jaw so here is the angle okay so you basically put the jaw put the hand around the jaw okay it should not be on the neck it should be on the jaw okay and then and your wrist is basically resting on the chest so the whole body basically the body is resting on the on the on your palm okay and the other hand is just basically behind the back of the baby okay so and then you just kind of tilt the baby a little bit forward okay when you tilt the baby a little bit forward what happens is stomach get pressed so here in this position okay so this is a perfect position to wake up the baby now I like this position a lot even for burping the baby okay because in in us also in our unit we used to burp the baby when small babies we used to burp the baby like this so remember to kind of make the baby sit see here do you see how baby is kind of bend forward little bit you don't need to pat the baby or you don't need to move your hand you know just kind of support the back like this okay and in front it should be like this don't hold it too close just it should be just kind of near ears okay so I am holding it near the ears not on the neck you don't want to put your fingers on the neck because what happens is in the neck you have so you don't want to press your neck baby's neck you know that it will cause problem okay so just on the jaw on the on the back mandible this is a bone called mandible so you want to touch near the mandible okay so now if baby is hungry baby will immediately wake up the first thing baby does when you put them in a sitting position they open the eyes so they open the eyes wide wide open okay and then you kind of stimulate little bit and that's when baby kind of is ready to breastfeed make sure that you don't put the baby on the breast because baby's sleepy if baby's sleepy they will just go back to sleep okay so if baby's not waking up just put the baby back and again you can try and within a half an hour or so now at night I do recommend that baby should be breastfed at least three to four times now at night if baby is not waking up after three hours then I would wake up the baby at around say at the end of three hours you know because you don't want to go too long because then again you know I see that baby's don't then put on good amount of weight okay so that's one important point that I want to discuss so now now mother's preparation okay now what is mother's preparation so before basically kind of holding the baby or touching the baby what mother needs to do is to wash her hands really really important because you know kind of mother has touched so many surfaces you know mother probably changed a diaper mother has done so many other things you want to make sure that she has clean hands before she touches the baby okay so even before she picks up the baby you know on this I mean remember I talked about the early hunger queues so that mother this is just the thought process that mother is going through so this was the thought process that I mentioned that she should know when to start feeding the baby so if she feels this is a time to feed the baby to wake up the baby or baby's squirming the first thing she does is wash her hands so before she touches the baby tell her to wash her hands with soap and water okay little warm water if she has access to warm water that would be great if she doesn't have warm access to warm water then it's fine too so use soap and water wash your hands okay and then tell her to drink one glass of water okay so that's about 8 ounces 240 250 ml of water now this water has to be clean okay so if you have access to filter water of course that's that's the most preferable one but if you don't have filter water what you can do is to just kind of tell mother to boil water and then just you know keep it at a room temperature and then so boiled in kind of room temperature water that she should have it immediately before breastfeeding now why this is important because as you know that you know mothers get very busy okay and when she has a small baby she has to feed every hour and half two hours you know then she may have to do some work at home she may have other children you know lot of what happens she forgets to take care of herself and here in this situation when she is she is probably getting you know 750 to 850 ml of milk and sometime if baby is catching up then they she will get even one to one and a half liter of milk you know so if the latch is good she you know the weight is so good that definitely mother gets more than one liter of milk and if you have twins then she will probably get one and half liters of milk you know so in that scenario even with singleton baby I do recommend mother should sit down relax and drink some water because if she drinks her water what is going to do is she it's going to relax her plus it will hydrate her because as I mentioned they get so kind of worked up that they forget to drink water they forget to eat you know of their food you know mothers they get mad really new mothers you know even worse so just make sure that you know you mentioned to her the kind of council her relax drink water one glass of water take a deep breath you know think about good things because it oxytocin release you know this is the hormone which releases your you know kind of milk from breast you know it releases milk right so that for release of it's called letdown reflex so that letdown reflex you need a hormone called oxytocin okay oxytocin is also called love hormone okay and you need to have that relaxation that's when mother will feel loved she will have this you know kind of motherly feeling and immediately she will relax and the milk will come out okay so for that also I recommend just tell her to tell her to relax think of some good things think of you know if she wants you can listen to some light music if she has access to or you know kind of don't be on phone keep that TV away you know not all those lot of activity surrounding her okay so there we are now she drank water okay now what she has to do she has to basically pick up the baby so if she suppose baby is sleeping on the bed okay of course I do recommend that if mother can sleep on the floor with the baby that would be great because lot of time when the baby is sleeping on the bed there is a risk of rolling rolling down you know so I personally do recommend that you know when the baby is small it's better to kind of be on on the floor on the bed much better so now she's sitting down okay she has a baby next to her so first thing and obviously baby is right there so she doesn't need to walk and get the baby but if baby say in the crib or say in the Jhula she will have to bring the baby okay she will have to kind of put the baby next to her while she's preparing to breastfeed okay but remember she has to touch the baby only while after washing her hands and drinking some water okay so now here I've got the baby out of Jhula and I'm ready to breastfeed on my bed okay so I'm going to put the baby in front of me okay and I'm going to prepare myself the way I'm going to prepare myself is first I'm going to find a comfortable position to sit okay so if it is a bed then I can sit on the bed I have to make sure that I have a pillow behind my back okay if I don't have a pillow at least I need to have a wall or a kind of you know a board of bed where I can rest pillow will be great because that will kind of give me comfort on my back okay say for example I'm a mother so and then another thing what I want to do is I want to kind of relax kind of fold my you know legs if I'm sitting on the chair then I can put my legs down but I want to make sure there is a support on my under my feet okay because the feet needs to be supportive if it's dangling in the air it could be very uncomfortable for the mother so make sure that we have a support under the under the feet okay so here now I'm ready to breastfeed here I'm sitting down with my legs folded with back supported back straight very important that you keep your back straight it should not be drooping down it should not be very kind of stressed you know just relax okay and then just prepare yourself okay now next point would be to open the clothes okay so one thing which is very very crucial most of the mothers that we see they have this habit of wearing bra and shirt which are basically not front open lot of time you know they wear a kurti but then they just lift up the kurti and lift up the bra so what happens like for example I'm going to show you on this breast model so here is the breast model and what is happening is mother is kind of lifting up the bra so now that tight bra is sitting on the breast okay it is basically kind of denting on the breast what is happening when you have something which is pressing on the breast so here we have basically kind of you know milk is formed in the alvuli over here and then milk is kind of flowing out or kind of getting collected in the collecting duct okay so when you have a something pressing on the collecting duct duct means like a canal where the milk is coming out okay and if something is pressing on the duct what will happen the milk will form but it is not flowing out so now the milk will continue to form in that kind of round you know cells I mean I am not going to use too many of these milk terms because I know many of you are not medical doctors or you know nurses so again you know when the milk is forming and then and that milk flow does not have a proper kind of way to come out then milk will continue to form and then it will become bigger and bigger and that area will become in flame it will become red because that milk is not flowing out it just collecting in one space okay now what will happen mother will kind of feel the swelling in the breast and then if suppose that swelling is not relieved then what will happen eventually the infection will set in once the infection sets in then they develop breast abscess and once the breast abscess develops then you know obviously she has to go to surgeon surgeon will kind of cut the you know you know abscess remove you know pass from it and it becomes so painful and many times then mothers stop breastfeeding on that side okay so this is another very important point and our 45 points we have created this is so that to prevent any complications in the future okay so this is another important point is to tell mothers that not to press anything on the breast it should not there should not be any tight clothing there should not be any tight bra if she wants to breastfeed tell her to buy clothes which has buttons till the navel and she has to remove each and every button okay and then basically make sure that she does not wear bra if possible but if she even wear bra she if she wears bra then she can just remove the button and keep it completely open at least till while she is breastfeeding you know at that for a for say 30 minutes 40 minutes when she is breastfeeding tell her to just remove it is much easier to do that okay then she won't develop any of this complication okay so now she is prepared she is she's removed her breast you know she has opened her breast nothing is pressing on the breast now she's going to take the baby okay so here it is that here she's going to take the baby okay and then she's going to you know kind of remove all the clothes and just keep one on c or just one pair of clothes if it's cold then of course second layer is fine cap is also okay but I prefer that while mother is latching the baby at least well she's learning how to latch you know remove the cap because it will be much easier for her to you know to kind of hold the baby and learn how to latch the baby or how to position the baby okay so that's that's really important so again remove all the blankets remove cap you know and then wake up the baby by putting the baby in a in a sitting position you know kind of hold it you know a little bit forward and then now she's ready so now what she's going to do so here is the baby I'm going to first thing what I'm going to do now remember that baby does not have neck control in first two months of age okay so she will have to continue holding the head okay so that she baby does not have a bubbly neck okay so here now what she's going to do she's going to basically hold the baby from the back okay and then here she's going to support okay with her with her elbow joint and immediately hold it like this okay now I'm going to discuss this this is called positioning of the baby because mother is now ready to breastfeed okay so mother's preparation is done now what she's doing she's now positioning the baby because this is this is very important aspect because here now what we're doing we are landing the baby to be ready to breastfeed so this is called landing the baby also called positioning of the baby okay so now this is the cross cradle hold in cross cradle hold what happens suppose I'm going to breastfeed from left side okay that means this hand is going to be open okay but I'm going to hold the baby with the opposite hand this is called cross cradle so the hand which is in cross to the breast that I'm going to breastfeed from I'm holding the baby from that side that's why it's called cross cradle so now first thing what I'm going to do I'm going to put this baby's legs under my armpit it should be really kind of embedded make sure that it is held tight because a lot of what happens if if it is not held tight what happens baby keeps slipping when baby keeps slipping then it becomes very difficult for baby to latch on just by mouth okay so to have a good latch latch means mookie pakar it's like you know how holding the breast with the mouth okay so for that to have a good holding of breast by baby's mouth you want to have a perfect position if there is a perfect position it will be very easy for mother to latch the baby it'll be very easy for baby to get the milk transfer okay so first thing you want to do is you lift the legs up under the armpit okay and you basically what you can do is to put baby's hip little bit on elbow joint so this is what you want to do is put the elbow joint just at the angle of the elbow okay so here this is ready and make sure that both the legs are held properly now look at the position of baby okay now position of baby is absolutely horizontal do you see this is absolutely horizontal lot of time when I see mothers they do this now this is this is not horizontal this is diagonal so you don't want to diagonal you know baby you want to have absolutely horizontal position okay here what I'm doing now look at this now there are four important points of positioning remember that it's WHO for positioning point one is that baby should be in a straight line so do you see baby is completely in the straight line what do you mean straight line straight line means the neck I mean the the ears so here's your ears okay here's your ears then your shoulder and your hip they all are in the straight line so here in this in this position you know suppose this is a straight baby okay this is a straight baby so here in straight baby what is happening ears shoulder joint and your hip joint is in the straight line okay so exactly when I put this baby like this so same thing ears shoulder joint okay this is shoulder joint and your hip joint and the straight line so this is what I mean by straight line okay many times what happens babies are put like this now imagine you're eating food and if you're putting your head sideways and you're eating you will not be able to swallow you'll not be able to eat but when you see many mothers they breastfeed the baby like this so the the shoulders are on the side so the position is like this ears are in front okay shoulders on side and the hip is on the side and this is how so many mothers breastfeed so if you now look at any mother immediately you should look at it whether whether it's in the straight line or not okay so this is how many mothers breastfeed it's it's so common and that's why so many mothers they can't even uh babies can't even breastfeed it's like we cannot eat like this sideways okay we have to keep our body straight similarly same thing happens so you make sure that baby is in straight line so here baby is in straight line now okay and if I bend it backward there you go so this is the straight line of baby's body okay one more time ears shoulder joint and your hip joint straight line okay all right now what is happening so now baby is in a straight line now there should be full body support okay imagine while you're eating imagine that you're eating adults are eating and you're hanging in the air you will not be able to swallow you won't be able to it could be you know it's kind of very scary situation where you don't have support right what support do we have we have gravity support right so when you have a gravity support basically you sit uh you know you have you can sit properly and you can eat well right similarly here baby's against the gravity means if you don't hold the baby baby will immediately fall right so in this position you want to make sure that you hold the baby full body support is extremely important okay so what you can do full body support look the legs are supported right the hip is supported right and back is supported with my hand and the neck you know neck just the back part of the head is supported also right so this is important that keep the body full body support is extremely important okay all right so that is your second point so one more point in positioning is like when you bring the baby uh you know to the breast okay so we already spoke about a straight line you know tummy to tummy or chest to chest and then nose to nipple I would say neck to nipple one more thing you want to make sure that many times mother has this habit of kind of drooping forward okay so kind of tell mother not to bend forward you know lot of time what happens is baby is in kind of on the pillow and she's bending forward what she has to do she has to sit straight and bring baby up okay so that is important that is to bring baby up don't droop down don't kind of stoop down okay second thing is um when you're holding the baby this where you hold the baby from head is very important many times what mothers do they hold the baby like this this is not the way to hold because what happens when you press the head like this again the neck will get bent forward okay so you don't want to have a neck forward like this you know you want to have a neck backward so the way you hold it you want to kind of see there is there are two bones over here okay so you want to basically uh mastoid bones they are called so you basically touch or hold on the mastoid bone and then put your fingers just around it not not on the back back of the head okay and then you kind of bring the baby a near to nose so near to nose why near to nose so that your your neck is bent forward if you bring nose to nipple what happens basically you're you know your your uh head would be straight you know your neck would be straight you want to bend it a little bit backward okay so you bring the neck baby a little bit downward so that way when I open the mouth that's when the lower part of the roller core in the mouth I will again discuss it uh why that near to nipple is very important because that is called landing of the baby okay all right third point you keep the baby so close to the mother okay you tell mother that keep the baby is uh kind of chest close to mother's chest because if baby is close to mother's chest it will be so much easier for baby to latch on well because if baby is too far like you know for example if the neck is twisted then what will happen the the the chest is facing up it should not be facing up it should be facing the mother okay so baby should be extremely close to the mother okay and this is how basically they will come now the fourth point of positioning is nose to nipple now that is also again WHO point very very important nose to nipple but when you bring the baby to the nipple you want to make sure that uh nose is kind of it's near to nipple okay now what is this near to nipple? near to nipple is uh what you can do is suppose for example you're bringing the baby to the breast okay to the nipple then the the nose the near of the nose is facing the uh nipple okay so that is very important I will talk about it later why it is important so here for example I'm going to show you again okay so in this position baby's neck is extended okay and baby's facing the breast directly okay baby's not facing up like this make sure that baby's face is not looking at the mother again when we're eating food we always look at the uh uh you know the the dish we don't look up right we look up when we eat we always look in in the plate so mothers baby's plate is mother's breast so let baby look directly at the uh breast okay and then you uh look you ask but the baby to look up not you can't ask my baby but just basically what you want to do is you uh lift up baby's neck backward now why why is it important to lift up the baby a little bit backward does anybody uh I'm going to explain to you why it is important to kind of uh lift baby's neck backward this is because what happens is while you're drinking water okay so when you drink water remember that we always kind of lift up our neck a little bit and then drink water right so if you have a bottle you always kind of lift up your neck and then drink water right when we if we have water and if we kind of say put our head forward we will not be able to swallow this is really really important okay because if we if we don't do that you know we will be able to uh you know if we don't uh extend our neck then we won't be able to swallow similarly when you're bringing the baby to breastfeed it's important that we extend the neck backward okay so here it is extend the neck backward okay and this is how it should be do you see and make sure that the near of the nose is in the line of nipple if it goes too high up like if it's coming too high up like this what will happen then baby will have to bend forward okay to breastfeed so you do not bring the baby too high up bring it baby a little bit lower the baby has to extend her neck okay so in this position you pull the baby's leg a little bit downwards you know towards the other side okay so baby will be able to extend the neck or you will have to help baby to extend the neck and then to reach out basically baby will kind of latch on okay so this was the two two parts that we talked about first part was mother's uh you know uh position mother's readiness second thing is baby's position so this is where we complete our you know first part of how to position the baby to the breast okay thank you so much