Eight-week-old Jamal who'd previously been unable to feed from his generous-breasted mother has a long drink at her breast then falls asleep in our consultation

When Jemima's newborn wouldn't come onto the breast, she received a lot of unhelpful advice

Disclaimer: the case below is an amalgam of multiple cases that have presented to me, and is not derived from any specific or identifiable mother-baby pair who have seen me as patients. Needless to say, all names are fictional.

"Let's say that the pump and I have become close friends," Jemima tells me, wryly. Her firstborn, Jamal, is eight weeks old.

"But he latched and stayed on the breast for a whole 20 seconds the other day," she exclaims, "the longest by far he's stayed on in his entire little life! We even took photos!" Her husband, sitting by her side on my two-seater couch, brings out his phone to show me.

Jemima has seen a number of lactation consultants, three from the hospital, one at a clinic, and one who home-visits. They've worked very closely with her, in appointments up to two hours long. She's tried every possible position. After breastfeeding assessments, each of the lactation consultants have told her there's no positioning problem.

Little Jamal had a scissors frenotomy on his third day of life. However, the problems with coming on to the breast persisted, and the lactation consultants explained that the initial snip wasn't deep enough. They advised a deep scissors frenotomy by a different doctor, which Jemima and her husband, in desperation, proceeded with in his third week of life. Jemima tells me that the lactation consultants also told her she had big breasts and flat nipples, and that her baby had a recessive chin.

When I first see her, Jemima is feeding Jamal expressed breast milk by the bottle, as well as 50 or 60 mls of formula every few days. The baby's weight gain, and urine and stool output are normal. Jemima still tries to offer him the breast directly at least two or three times a day. She says that a nipple shield doesn't help because he has to work too hard at the shield to get milk through - she's been told he is a lazy sucker. When she brings him close to the breast in my consulting room, he begins to cry.

Baby Jamal has a conditioned dialling up at the breast. Jemima's breast is generous. She has not been able to find a stable position for her baby at her breast, from birth.

I work with her to apply the gestalt method. By the end of our consultation, this same little one who has not breastfed for longer than 20 seconds previously, has swallowed substantial amounts of milk directly from his mother (which I know because of the swallowing sounds we hear in tandem with his jaw movements) and is asleep at the breast. Jemima keeps looking up at her husband in amazement.

"I can't believe it," she murmurs, lightly caressing her little one's downy hair, gazing up at her husband, shaking her head just a little. "Can you believe it?" Her husband is tearing up.

You can find out about breastfeeding when your breasts are generous starting here.

How Jemima's baby was able to drink well from the breast and then fall asleep at the breast, for the very first time

The problem	What I did or suggested	Why this worked
Landing pad encroachment	Semi-reclined positioning	Landing pad encroachment by the abdomen results in breast tissue drag; lying back at 45 degree angle helped expose the landing pad
	Two rolled up facecloths to expose the landing pad	Landing pad encroachment by the abdomen results in breast tissue drag; facecloth use exposed the landing pad
Conditioned dialling up at the breast - strategy used in consultation	Nipple shield use	Accustomed to silicon contours of bottle teat, so baby was more likely to come on and have positive experience at the breast
Conditioned dialling up at the breast - strategies for daily life	Enjoy time when he is sleeping at breast	Enjoy time when he is sleeping at breast
	Grow positive experiences, never coerce if baby is dialing up	Avoids reinforcing negative associations
Nipple and breast tissue drag	Held woman's forearm as she practiced dropping baby to level of nipple with vertical micromovement, experimented with angle control and horizontal micromovements	Eliminated breast tissue drag
Mother's upper arm shorter relative to breast fall, holds baby higher than nipple (even with landing pad exposure)	Baby's head rests on woman's wrist; paddle hand	Eliminated breast tissue drag, gives woman control of micro-movements
Baby's lower arm caught between baby and mother's body	Gently ease lower arm to wrap around mother's side	Helps the baby get low enough to avoid breast tissue drag. Otherwise eyes tend to be looking towards floor. Once arm is wrapped, baby's eyes looked up somewhat, towards ceiling
Breast falls out to the side	Ease breast forward before bringing baby on and stabilise forward with upper arm	Baby doesn't have to go so far out to the side, which tends to promote tilting head forward, which makes it hard for baby to drop jaw and swallow comfortably
Angle at face-breast interface causes breast tissue drag	'Down and in and control the angle'	Baby's eyes looked at an angle that slopes up towards ceiling somewhat
Although Jemima didn't need to do this, some women in this situation find it easiest if they lift and shape the breast	Education about the high risk of breast tissue drag and how to avoid this if she uses this lift and shape technique	The woman lifts and shapes breast but minimises possibility of breast tissue drag, careful micromovements once baby is on, splinting the breast with the baby's face

Recommended resource

What works best for you and your baby when you have a generous breast

How to roll up a facecloth to better expose the landing pad of a womans breast

Why it's best not to shape your breast with your hand although some women need to