The sandwich technique

What is the sandwich technique for latching?

The sandwich technique is an important tool that can help the baby latch onto the breast and breastfeed effectively. To use the technique, after lining the thumb up with the baby’s nose, push a little breast skin forward to the areola and flatten the breast slightly using the pads of the pointer finger and thumb. This makes it easier for the baby to create a good latch and hold the nipple in the right place. The sandwich technique can be helpful for sore nipples or if the baby has latching problems or is premature, newborn and weak, or sick and does not breastfeed effectively. It should not be used if the nipples are inverted, if plugged ducts develop, or it is not helpful. The laid-back hold is an alternative to the sandwich technique.

A) Why the sandwich technique is helpful

The sandwich technique with the baby in the under-arm hold breastfeeding on the right breast. The mother's thumb lines up with the baby's nose. She uses her thumb and pointer finger to slightly flatten the breast and to push the skin of the breast toward the areola.

Latching happens when the baby brings the nipple and the tissue just behind the nipple (the nipple root) into the mouth and creates suction to hold them in place.

The nipple root needs to be soft enough to accommodate the baby’s tongue, palate, and upper gum. Some mothers have a nipple root that is firm or not stretchy.

The sandwich technique softens the nipple root and makes it stretchier thereby avoiding the following problems.  

  • The baby creates excess suction:
    • If the nipple root is firm, babies need to increase the amount of suction to stay latched which can cause nipple pain and even damage. 
  • The nipple is not far enough into the baby’s mouth: 
    • If babies cannot create enough suction or they cannot stretch the nipple root enough, the nipple will not be back far enough in their mouth, resulting in painful, compressed nipples (McClellan 2015). 
  • The baby cannot establish or maintain the latch or tires quickly: 

B) Describing the sandwich technique

To use the sandwich technique, mothers flatten the breast slightly while pushing the skin of the breast towards the baby. This is done using the pads of the pointer (index) finger and thumb.

It’s called the sandwich technique because it reshapes the breast and aligns it the way a sandwich is aligned when you put it into your mouth. In the wrong direction, it is impossible to eat.

The sandwich technique is best combined with the cross-cradle and under-arm holds.

The sandwich technique is more awkward when the baby is in the cradle, side-lying, or laid-back holds and can leave your arm and hand in an uncomfortable position.

C) Reasons for using the sandwich technique

The sandwich technique is an important tool. It is:

  • Effective.
  • Immediately available.
  • Unlikely to cause other problems when properly done.
  • Used to fix a number of problems.

D) When to use the sandwich technique

The sandwich technique can be helpful if:

  • You have sore or damaged nipples.
  • The baby has latching problems.
  • The baby is:
    • Premature.
    • Newborn and sleepy.
    • Sick and cannot breastfeed effectively.

Some babies cannot latch onto the breast because they don’t yet have the skills. They may need a little time to learn. This type of latching problem is not because of a problem with the breast. The sandwich technique can make the nipple root easier to latch onto but won’t fix the baby’s lack of skills.

E) When not to use the sandwich technique

Do not use the sandwich technique in the following situations.

1) If you have inverted nipples

Occasionally latching problems can be caused by the mother having inverted nipples. In this case, the sandwich technique is unlikely to help the baby latch.

Some mothers have a partially inverted nipple caused by a thick cord running from deep in the breast to the nipple. When using the sandwich technique, the fingers and thumb will press on the cord, making it even tighter and the baby will have even more trouble latching.

To understand the effect of the sandwich technique on an inverted nipple, do the pinch test with and without using the sandwich technique. The results of the pinch test with the sandwich technique should show that the nipple root is softer, more stretchy, and needs less pressure to hold. Do not use the sandwich technique if the nipple moves back into the breast or the nipple root is firmer, less stretchy, or harder to grab using the pinch test.

If the nipple moves inward when using the sandwich technique, avoid it and simply hold the breast as lightly as possible when latching the baby.

2) If you develop a plugged duct

Milk ducts are easily compressed, so you may think the sandwich technique would cause plugged ducts (Geddes 2007). Interestingly, we have found that this is rarely a problem. If you do develop a plugged duct, you should address it and avoid the sandwich technique.

3) If the sandwich does not help

The sandwich technique is most helpful if the breast or areola is firm. As the baby grows, the breast becomes softer and the areola becomes stretchier, eliminating the benefit of the sandwich technique.

F) Alternative to the sandwich technique

An alternative to the sandwich technique is to use the laid-back hold and not hold the breast. This hold allows the breast tissue to fall back against the chest wall, softening the nipple root.

Mothers who are already in pain may find the lack of control over the baby's head and latch causes anxiety and possibly more pain.

References

Geddes DT. Inside the lactating breast: the latest anatomy research. J Midwidery Womens Health. 2007 Nov-Dec;52(6):556-63

McClellan HL, Kent JC, Hepworth AR, et al. Persistent Nipple Pain in Breastfeeding Mothers Associated with Abnormal Infant Tongue Movement. Int J Environ Res Public Health. 2015 Sep 2;12(9):10833-45