Much of the information that has been taught to and by healthcare practitioners about what constitutes “normal” or “ideal” breastfeeding is wrong (Ogburn et al. 2011).

Let that soak in for a moment. Operationally, this means that if a new mother has breastfeeding concerns—as 92 % of nursing mothers in the United States do (Wagner et al. 2013)—she is likely to receive advice that is misguided, misleading, or confusing. This proliferation and dissemination of misinformation by inadequately trained practitioners has contributed to a culture of breastfeeding failure. As a result, the breastfeeding rates in the United States are less than half of those globally. While 79 % of mothers in the United States start out breastfeeding their newborns, only 40 % are exclusively breastfeeding at 3 months and that drops to 18.8 % at 6 months (CDC Breastfeeding Report Card 2013). In many countries in Africa, where the infant mortality rate is 31 per thousand births, although over 95 % of women begin breastfeeding, only 33 % of infants are exclusively breastfed by 6 months (WHO-1: Global Data Bank on Infant and Young Child Feeding). This is significantly more than in the United States, but hardly stellar rates for a part of the world where successful breastfeeding is a matter of life or death.

It is critically important that we, as healthcare professionals, examine why breastfeeding rates are so dismally low. It certainly can’t be blamed on lack of encouragement. In 1991 The World Health Organization (WHO-3) and the United National Children’s Fund (UNICEF) launched a global program called the Baby Friendly Hospital Initiative that rewards and encourages hospitals to provide the highest levels of support for infant feeding and bonding between mother and infant. In their statement, entitled Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, they illustrate the Ten Steps to Successful Breastfeeding (WHO-2). While the intentions are good, these types of initiatives tend to serve merely as talking points for the concept of breastfeeding—why breastfeeding is the best and healthiest option for mother and baby, and how healthcare practitioners can encourage mothers to breastfeed exclusively. Any information provided about how to breastfeed properly is frequently confusing or, in some cases, wrong (Pound et al. 2012).

I’ve heard many first-time mothers joke that they wish their infant came with a set of instructions. Is this really a joke? Or is it, perhaps, a subtle call for help? We devote more instruction hours to teaching teenagers how to drive a car than we do helping women feel more confident about caring for a tiny human being. Why is that? Some might argue that breastfeeding is natural, and therefore it should happen automatically. It is true that breastfeeding is natural, but “natural” doesn’t mean automatic, simple, or certain (Bergmann et al. 2014). Childbirth is another “natural” human process, a true miracle of nature. And yet, birthing is the second leading cause of death in women of childbearing age worldwide. Few of us would forego—or recommend that a patient forego—medical intervention in preference of “natural” childbirth if the baby or mother were in danger. Breastfeeding is no different. Not all infant-mother pairs “fit” easily, as evidenced by the need for wet nurses in the years before formula became available. But for the most part, despite all the statistics and the quiet, joking insecurity, the experience of breastfeeding has largely been left up to nature (Geddes 2013).

One of the ways in which current breastfeeding instruction gets it wrong is in its reliance on subjective interpretation of infant behaviors. For example, Li et al. (2008) examined the reasons why mothers discontinued breastfeeding. Between 44 and 56 % of mothers believed their babies were not satisfied from nursing alone, and 47 % felt that their babies self-weaned after the third month because the babies lost interest in nursing. Those reasons are subjective, based solely on what the mothers believed their babies were trying to tell them through their behaviors. But imagine if we could dispel those myths and replace them with objective information about how breastfeeding can and should work for the majority of women who wish to breastfeed…and then provide clinically proven ways to increase the odds of breastfeeding success.

Of course, it is meaningless to instruct healthcare providers to show mothers how to breastfeed if the providers themselves haven’t had appropriate training. While it is desirable for hospitals and pediatric staff to encourage breastfeeding and implement the Ten Steps, we have yet to examine what happens when breastfeeding doesn’t work even if all the rules are followed. There is a large gap between breastfeeding goals—of a mother, a country, or an organization—and breastfeeding success rates past 3 months (Neifert and Bunik 2013; Ramakrishnan et al. 2014).

I posit that 80–90 % of mothers can breastfeed successfully. I have seen those numbers in my own practice, where I deal specifically with cases of “failed” breastfeeding. What this requires, however, is a clear understanding of the objective, medical processes involved in breastfeeding, and a shift away from subjective terminology and measures.

Breastfeeding is a complex phenomenon masquerading as a simple, singular act.

First, breastfeeding involves two people: the mother—baby dyad. If there is a problem, there is no medical specialty that addresses evaluation and treatment. There are obstetricians before the baby is born, a primary care physician or gynecologist for the mother after the baby is born, and a pediatrician for the baby. By the time a breastfeeding mother and infant arrive in my office, they have been seen by many health care practitioners, but not one medical expert who specializes in breastfeeding.

Second, many experts (and all first-time mothers) have no frame of reference with which to evaluate breastfeeding advice because they, themselves, have never done it. Imagine trying to learn to ski based on instructions written by someone who has only watched the sport on television—any success would likely be due to luck rather than valuable guidance. Conversely, one person’s subjective experience nursing cannot necessarily be extrapolated to fit the needs of a diverse group of individuals. Even mothers who have nursed more than one baby can have a different experience each time.

Finally, despite the highly tactile nature of breastfeeding for mothers and infants, most of what goes on during nursing is internal and invisible. To the outside observer, it seems like a natural coupling of parts, but breastfeeding is an intricate and intangible biological dance. Therefore, much of what we pass off as knowledge about the process is little more than inference based on external—and therefore indirect—observations. From that limited perspective, experts draw conclusions about a baby’s behavior or a mother’s feelings, and that speculation has informed our expectations of what is “normal” during breastfeeding. The more cynical among us might call it a science of guesstimates.

When it comes to the health of mothers and babies, we want better than educated guesses. But medical knowledge has been hampered by a reliance on describing the typical breastfeeding experience. Until recently, no one was quite sure what was happening, how it happened, or why it happened that way. We now know that what commonly happens during nursing is not necessarily what is supposed to happen. Thanks to technological advances, we have a better understanding of what occurs in that invisible space, so we can better help mothers and babies successfully breastfeed.

There are three basic and essential components to successful nursing:

These three factors are intricately interlaced, with fulfillment of each dependent on the other two. For example, if a baby cannot properly transfer milk, he will eventually stop going to the breast for nourishment, and the mother’s milk supply will dwindle. If she lets her supply dwindle, then even though the baby can transfer milk, he will not get the reward of his efforts and will eventually learn to avoid the breast and choose other food sources.

A perfect latch results in the most efficient milk transfer, which predicates every other outcome in breastfeeding. If a baby cannot latch on correctly and transfer milk efficiently, then none of the “rules” of breastfeeding apply. Until “perfect” is understood, it is impossible to effectively evaluate problems that occur in breastfeeding. This is a general overview of what the ideal latch should look like: