What does the research tell us about approaches to fit and hold currently used for breastfeeding support?

The foundational importance of laid-back or baby-led breastfeeding

The physiologic or mammalian approach to breastfeeding initiation, including skin-to-skin contact postpartum, has been a major advance in the field of clinical breastfeeding support over the past two decades, with positive impacts on breastfeeding outcomes.1-4

Teaching the biological nurturing approach to fit and hold preventatively modestly decreases the prevalence of nipple pain but doesn’t impact on breastfeeding rates

Whilst biological nurturing methods are foundational, they are not enough to prevent nipple pain in most women, or to resolve latching problems once they emerge.

• A 2021 meta-analysis review of studies investigating ‘biological nurturing’ or ‘laid-back breastfeeding’ as a preventative approach, finding 11 Chinese RCTs and 1 Italian RCT. The overall results showed that when women are taught to use baby-led or laid-back breastfeeding in hospital in the first three days after the birth, the incidence of nipple pain and damage decreases for up to 8 weeks.5

• The Italian RCT which had been included in this meta-analysis randomised 180 women at birth to either biological nurturing or a control group using WHO/UNICEF usual care approaches to fit and hold. This study showed decreased nipple pain and damage, engorgement, and mastitis during the hospital stay, and 58% decrease in cracked nipples at discharge, in the intervention group. At one week, there was a 60% decrease in incidence of cracked nipples. But biological nurturing made no difference in the rates of nipple shield use (10-20%), breast problems at 30 days post-birth, or in rates of exclusive breastfeeding at 4 months.6

• A 2021 Chinese randomised controlled trial (RCT) (which wasn't included in the 2021 meta-analysis) of 504 pairs demonstrated that implementing baby-led self-attachment from birth resulted in a 12% increase in exclusive breastfeeding at day 3, and an 8 % and 5% decrease in the number who reported nipple pain at 3 days and 3 months postpartum, respectively.7

Biological nurturing or baby-led approaches are demonstrated in these studies to be foundationally important for prevention of breastfeeding difficulties from birth, but nevertheless have only modest effects overall.

Baby-led approaches have not been demonstrated to be effective therapeutic interventions for emergent breastfeeding problems

The Karolinksa Institute in Sweden conducted a randomised controlled trial of 103 mothers whose babies aged 1-6 weeks had severe latch-on problems, and showed that skin-to-skin contact did not increase the likeliihood that the infant would latch on to the breast.8

This is why the gestalt method of fit and hold

• Includes the principles of the biological nurturing approach, but

• Also integrates a range of strategies for optimising the biomechanics of infant suck.9, 10, 11

Women prefer to use the cradle hold to football hold after ceasarian section

Mothers might be advised to use the football hold after a caesarian section birth, because the breastfeeding support professional is concerned to protect her abdominal wound.

However, a 2021 study crossover designed study of 67 breastfeeding primiparous women who underwent caesarean section instructed the women to apply both the cradle hold and the football hold positioning techniques sequentially from 24 hours postbirth.12

This study showed that the mothers preferred to use the cradle hold rather than the football hold after caesarian section by the time of discharge. This was the case even though incisional pain was increased with cradle hold. The LATCH score for breastfeeding was significantly improved with the cradle hold position.12

Cross-cradle hold increases risk of nipple pain

The cross-cradle hold requires women to shape their breast with one hand as they hold the baby with the other hand supporting the baby's neck, back, and armpit to bring the infant on. This approach should be avoided (other than when bringing a baby onto a nipple shield, after which the woman quickly moves into the gestalt method, which includes an adaptation of the cradle hold).

• In 2002, a prospective cohort study of 1171 new mothers in Bristol, UK, found that when hospital midwives were taught and applied this technique, the rate of breastfeeding increased at six weeks post-birth.13

• But a 2016 Australian study of 653 pairs showed that this same technique worsened the incidence of nipple pain fourfold.14

Five other studies examining links between fit and hold and nipple pain or breastfeeding problems

• A 2003 Latvian study of 95 breastfeeding women found no difference between a mother’s level of reported pain and infant head or body position, or breastfeeding dynamic attributes of the baby. But clinical indicators used to signify optimal breastfeeding were not based on a model of suckling biomechanics.15

• A 2004 observational study in the US, which lacked a control group, found that damaged nipples healed after helping the mother attach her baby with visible and everted lips.16 However, infants don't need evert their lips when they are breastfeeding successfully (discussed below), and visible everted lips can be a sign of nipple and breast tissue drag.

• A 2017 Brazilian systematic review of factors associated with nipple trauma in lactation concluded that incorrect handling during breastfeeds contributed.17 This latter study used the UNICEF Baby Friendly Hospital breastfeeding management strategies of lips facing out and more areola above the baby’s mouth as ‘gold standard’ for fit and hold. Again, infants don't need to evert their lips when breastfeeding successfully (discussed below), and visible everted lips can be a sign of nipple and breast tissue drag.

• The Thompson method is discussed in detail here. A well-conducted evaluation of a large, hospital-wide implementation of the Thompson Method in Brisbane, Australia, did not demonstrate positive effects.18

Baby's lips don't need to evert (or flange or take a 'k' shape) for effective breastfeeding

Most guidelines on nipple pain advise the clinician to look for wide-open mouth with lips turned out, assuming this helps the baby take a wide mouthful of breast and rest close to the mother’s body without biting or clenching the jaw at the breast.19, 20

But in 2020 Mills et al conducted Magnetic Resonance Imaging analysis of eight successfully breastfeeding babies, whose mothers were pain free. Their findings corroborated the gestalt biomechanical model, showing that infant lips are usually neutral during breastfeeding, not everted or in a ‘special k’ shape.21

In the gestalt model, women experiencing pain apply strategies developed to address the mechanical effects of conflicting intra-oral vectors of force, so that the infant’s lips are no longer visible. More breast tissue is then drawn up into the baby’s mouth to distribute the mechanical load and protect the nipple epithelium and stroma from high stretching forces.9-11

Recommended resources

All agree that fit and hold problems are the most common cause of nipple pain. So why isn't every woman shown how to prevent it, or how to do a quick and early repair?

The belief that 'there is no right way to breastfeed, only your way' doesn't help breastfeeding women (and may cause harm)

What does the research tell us about skin-to-skin contact or Kangaroo Mother Care for term infants?

The Thompson method: a large hospital-wide study found no improvement in breastfeeding outcomes

An ultrasound study shows that a brief gestalt intervention immediately improves the suck of breastfeeding babies who fuss at the breast or who cause maternal nipple pain

Selected references

1. Schafer R, Watson GC. Physiologic breastfeeding: a contemporary approach to breastfeeding initiation. J Midwifery Womens Health. 2015;60:546–53.

2. Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev. 2008;84:441–9.

3. Smillie CM. How infants learn to feed: a neurobehavioral model. In: Watson CG, editor. Supporting sucking skills in breastfeeding infants. New York: Jones and Bartlett Learning; 2016. p. 89–111.

4. Moore ER, Berman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016(Issue 11. Art. No.: CD003519. https://doi.org/10.1002/14651858.CD14003519.pub14651854.

5. 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.

6. Milinco J, Travan L, Cattaneo A, Knowles A, Sola VM, Causin E, et al. Effectiveness of biological nurturing on early breastfeeding problems: a randomized controlled trial. International Breastfeeding Journal. 2020;15(1):21.

7. Yin C, Su X, Liang Q, Ngai FW. Effect of baby-led self-attachment breastfeeding technique in the postpartum period on breastfeeding rates: a randomized study. Breastfeeding Medicine. 2021;April 27:doi: 10.1089/bfm.2020.0395.

8. 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.

9. 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;58:145–55.

10. 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):509–18.

11. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(1):94. DOI: 10.1186/s12884-12021-04363-12887.

12. Pehlivan N, Bozkurt OD. Comparison of cradle hold versus football hold breastfeeding positions after cesarean section in primiparous mothers. Breastfeeding Medicine. 2021;16(11):904-908.

13. Ingram J, Johnson D, Greenwood R. Breastfeeding in Bristol: teaching good positioning, and support from fathers and families. Midwifery 2002;18:87-101.

14. Thompson RE, Kruske S, Barclay L, et al. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth 2016;29:336-44.

15. Blair A, Cadwell K, Turner-Maffei C, et al. The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples Breastfeeding Review 2003;11(3):5-10.

16. Cadwell K, Turner-Maffei C, Blair A, et al. Pain reduction and treatment of sore nipples in nursing mothers. Journal of Perinatal Education 2004;13(1):29-35.

17. Dias JS, Vieira TDO, Vierira GO. Factors associated to nipple trauma in lactation period: a systematic review. Revista Brasileira de Saude Materno Infantil 2017;17(1):27-42.

18. Allen J, Germain J, O'Connor M, Hurst C, Kildea S. Impact of the Thompson method on breastfeeding exclusivity and duration: multi-method design. International Journal of Nursing Studies. 2023;141:104474.

19. Amir LH, Bearzatto A. Overcoming challenges faced by breastfeeding mothers. Australian Family Physician 2016;45:552-56.

20. Berens P, Eglash A, Malloy M, et al. Persistent pain with breastfeeding: ABM clinical protocol #26. Breastfeeding Medicine 2016;11:46-56.

21. Mills N, Lydon A-M, Davies-Payne D, et al. Imaging the breastfeeding swallow: pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology 2020;5:572-79.