New study shows that a brief gestalt intervention immediately improves breastfeeding babies' suck. Dr Pamela Douglas 5_2_22

Can we empower breastfeeding women through experimentation with some simple physical strategies to resolve their own nipple pain and baby’s fussing at the breast? The findings of a small new Australian case series published this week in BMC Pregnancy and Childbirth suggest this may be the case.

All clinical guidelines agree that getting the fit and hold (or latch and positioning) right in breastfeeding is fundamental to either preventing or helping with problems such as nipple pain or a baby’s fussy behaviour at the breast. But quite remarkably in an era of stunning biomedical innovation, the fit and hold interventions breastfeeding women receive when they seek help remain based upon theories and opinion only. (The laid-back approach does modestly reduce the risk of nipple pain if implemented from immediately after birth, but doesn't help as an intervention once a woman begins to experience pain.(1,2))

Research into how best to resolve breastfeeding problems is still in its infancy. Funding for research into clinical breastfeeding support is hard to find, and the field is marked by widespread conflict of interest and inter-professional conflict. This includes social media movements by breastfeeding advocates and influencers which silence dissent.

Worse, women are breastfeeding in the midst of a dramatic worldwide increase in overdiagnosis and overtreatment, right across the health sector.(3,4) Breastfeeding women with nipple pain are often diagnosed with mammary candidiasis, though this is rarely the case. Widely-prescribed long courses of antifungal treatments have not been shown to be any more helpful than the passage of time.(5) Frenotomy rates have increased between 420%-3710% in Australia over a ten-year period, similar to exponential increases in frenotomy rates in Denmark, Canada, and the United States and elsewhere, consistent with patterns overtreatment.(6-9) Yet the evidence is clear that the diagnoses of posterior tongue-tie and upper lip-tie lack any anatomic or functional basis.(10-14)

Over the past two decades, ground-breaking ultrasound and vacuum studies from the Geddes Hartmann Human Lactation Research Group at The University of Western Australia have taught us how babies suck and swallow at the breast, lately corroborated by MRI.(15-18) Now the Human Lactation Research Group has collaborated with our Queensland-based health promotion charity, Possums & Co., which translates research-based findings into the real world of breastfeeding support in the clinic. The steps in our gestalt approach to fit and hold (pronounced ‘ger-shtolt’) were first published in 2017, building on the laid-back breastfeeding approach.(19) It remains the only fit and hold approach developed from an evidence-based understanding of the biomechanics of infant suck.(17) The gestalt method includes some straightforward evidence-based psychological strategies, too, to support embodiment or mind-body connection.(20)

In our new case series, the baby’s mouth and tongue were imaged by ultrasound before and after a brief gestalt intervention in five breastfeeding pairs.(21) Three of the mothers had persistent nipple pain; three babies had been diagnosed with tongue-tie; one baby had received laser frenotomies; and one pair had no breastfeeding problems. All except the mother without problems had been previously supported by International Board Certified Lactation Consultants (IBCLCs).

Our findings showed that the babies’ tongue shape and movement during suckling changed significantly after a brief gestalt intervention, including in the mother with no problems. The same changes have been demonstrated in other ultrasound analyses of breastfeeding pairs to be associated with less pain and improved milk transfer.(15, 22) Interestingly, the tongue shape and movement changes after a gestalt intervention were the same as the changes measured by ultrasound after a frenotomy in another 2013 case study.(23)

Can we empower breastfeeding women to resolve their own nipple pain and their baby’s unsettled behaviour at the breast? Can we protect breastfeeding babies from unnecessary and expensive oral surgery and bodywork exercises? Certainly this is what I and my IBCLC and breastfeeding medicine colleagues who are upskilled in the gestalt method find, day after day. And although only a first step, this small study demonstrates that through experimentation with some simple physical strategies, we can empower women to improve the way their baby sucks with immediate effect.

But breastfeeding women deserve to have this question answered properly, through funding for research which compares outcomes from a gestalt intervention with other approaches.

Dr Pamela Douglas

Blog 5 May 2022

References

1. Wang Z, Liu Q, Min L, Mao X. The effectiveness of laid-back position on lactation related nipple problems and comfort: a meta-analysis. BMC Pregnancy and Childbirth. 2021;21:248.1 Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1-11.
2. Svensson KE, Velandia M, Matthiesen A-ST, Welles-Nystrom BL, Widstrom A-ME. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal. 2013;8:1.
3. Treadwell J. Overdiagnosis and overtreatment: generalists - it's time for a grassroots revolution. Journal of General Practice. 2016;66(644):116-117.
4. Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1-11.
5. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health. 2021;17:DOI: 10.1177/17455065211031480.
6. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018;208(2):88-89.
7. Ellehauge E, Jensen JS, Gonhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.7 Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.
8. Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40
9. Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.
10. Mills N, Keough N, Geddes DT, Pransky S. Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy. 2019;32:824-835.
11. Fraser L, Benzie S, Montgomery J. Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain. BMJ. 2020;371:m3928
12. Nakhash R, Wasserteil N, Mimouni FB, Kasierer YM. Upper lip tie and breastfeeding: a systematic review. Breastfeeding Medicine. 2019;14(2):83-87.
13. Shah S, Allen P, Walker R, Rosen-Carole C, McKenna Benoit MK. Upper lip tie: anatomy, effect on breastfeeding, and correlation with ankyloglossia. Laryngoscope. 2020:doi:10.1002/lary.29140.
14. Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.
15. Geddes DT, Sakalidis VS. Ultrasound imaging of breastfeeding - a window to the inside: methodology, normal appearances, and application. Journal of Human Lactation. 2016;DOI:10.1177/0890334415626152.
16. Mills N, Lydon A-M, Davies-Payne D, Keesing M, Mirjalili SA, Geddes DT. Imaging the breastfeeding swallow: pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology. 2020;5:572-579.
17. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
18. Geddes DT, Gridneva Z, Perrella SL, Mitoulas LR, Kent JC, Stinson LF, et al. 25 years of research in human lactation: from discovery to translation. Nutrients. 2021;13:1307.
19. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
20. Whittingham K, Douglas PS. "Possums": building contextual behavioural science into an innovative evidence-based approach to parenting support in early life. In: Kirkaldy B, editor. Psychotherapy in parenthood and beyond. Turin, Italy: Edizioni Minerva Medica; 2016. p. 43-56.
21. Douglas PS, Perella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(94):https://doi.org/10.1186/s12884-12021-04363-12887.
22. McClellan HL, Kent JC, Hepworth AR, Hartmann PE, Geddes DT. Persistent nipple pain in breastfeeding mothers associated with abnormal infant tongue movement. International Journal of Environmental Research and Public Health. 2015;12:10833-10845.
23. Garbin CP, Sakalidis V, Chadwick LM, Whan E, Hartmann PE, Geddes DT. Evidence of improved milk intake after frenotomy: a case report. Pediatrics. 2013;132:e1413.