Management of the spectrum of breast inflammation in lactation. Principle #2: eliminate problematic mechanical forces

A. Eliminate conflicting intra-oral vectors of force during milk removal which cause lactiferous duct compression

The gestalt biomechanical model of infant sucking proposes that multiple factors relating to the fit between the baby’s and mother’s anatomies may create intra-oral vectors of force which conflict with the direction of vacuum generated by mandibular depression, resulting in ‘breast tissue drag’, which is associated with

1. Nipple discomfort, pain or damage

2. Unsettled infant behaviour at the breast

3. Increased risk of breast inflammation.1-3

The tongue is a muscular hydrostat which changes shape without changing volume

In the gestalt model, the tongue is understood to be a supple, adaptive organ which dynamically responds to and moulds around available intra-oral nipple and breast tissue, rather than as a forcible driver of nipple compression and nipple shape.

Elimination of conflicting vectors of force intra-orally (that is, elimination of ‘breast tissue drag’) allows peak vacuum to achieve optimal intra-oral breast tissue volume.1-3

With maximum intra-oral breast tissue volume, the mechanical force of the vacuum defuses over the largest possible epithelial area of the nipple-areolar-complex and breast skin.

The gestalt biomechanical model of breastfeeding proposes that bending and stretching mechanical loads compress lactiferous ducts in the glandular tissue, which are predominantly located directly behind the nipple, and which have been demonstrated in ultrasound studies to compress under even very light touch.5, 6

Two-thirds of alveolar glandular tissue lies within a three-centimetre radius of the nipple. Combined with frequent and flexible breastfeeds, optimal intra-oral breast tissue volume and elimination of breast tissue drag result in optimal milk transfer, infant satiety, and weight gain.1-3, 7-12

Because clinical breastfeeding support remains a research frontier, interventions women typically receive for fit and hold (also known as latch and positioning) are based upon experience or opinion.13-17

B. Avoid focussed deep pressure on the breast

Lactating women with new breast lumps have over the past 15 years been advised to engage in lump massage, to massage out the hypothesised blockage in the duct caused by sticky milk or a biofilm.

However, lump massage causes micro-vascular trauma and haemorrhage in the tense, highly vascular stroma of an inflamed lactating breast. Increased stromal swelling places further pressure on ducts, worsening intraluminal backpressure and inflammation. For this reason, lump massage and vibration risk worsened inflammation, tissue necrosis, and abscess.24

C. Avoid other prolonged external pressures on the breast

From the perspective of the mechanobiological model, external applications of pressure upon the lactating breast increase the risk of breast inflammation due to mechanical compression of ducts, which increases upstream intra-ductal and intra-alveolar backpressure over time.18 For this reason, the following should be avoided

• Therapeutic Breast Massage or Manual Lymphatic Drainage. You can read about why this massage is best avoided here.

• Squeezing, shaping, or compressing the breast during breastfeeds

• Finger on breast to prevent breast occluding infant’s nostrils

• Restrictive or ill-fitting bra or garment

• Sleeping on stomach with pressure on the breast

• Bruising of the breast, for example, from an infant’s kick

• Use of mechanical pump in a way that places asymmetric pressure or drag on breast tissue

• Positioning infant with chin or nose pointing towards area of inflammation (which misunderstands biomechanics of milk transfer and risks worsened breast tissue drag)

• Be alert to the risks of the constant occlusive pressure that might be applied to lactiferous ducts by the wearing of

  • Silverettes

  • Breast shells

  • Wearable pumps

  • Hakaas.

References

1. 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.
2. 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.
3. 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(94):https://doi.org/10.1186/s12884-12021-04363-12887.
4. Mills N, Pranksky S, Geddes DT, Mirjalili SA. What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clinical Anatomy. 2019:doi:10.1002/ca.23343.
5. Geddes DT. Ultrasound imaging of the lactating breast: methodology and application. International Breastfeeding Journal. 2009;4:doi:10.1186/1746-4358-1184-1184.
6. Mortazavi N, Hassiotou F, Geddes DT, Hassanipour F. Mathematical modeling of mammary ducts in lactating human females. Journal of Biomechanical Engineering. 2015;137(7):071009.
7. Ramsay DT, Kent JC, Owens RA, Hartmann PE. Ultrasound imaging of milk ejection in the breast of lactating women. Pediatics. 2004;113:361-367.
8. Geddes DT. The use of ultrasound to identify milk ejection in women - tips and pitfalls. International Breastfeeding Journal. 2009;4(5):doi:10.1186/1746-4385-1184-1185.
9. Ramsay DT, Kent JC, Hartmann RA, Hartmann PE. Anatomy of the lactating human breast redefined with ultrasound imaging. Journal of Anatomy. 2005;206:525-534.
10. Geddes DB. The anatomy of the lactating breast: latest research and clinical implications. Infant. 2007;3(2):59-61.
11. Ramsay DT, Kent JC, Hartmann RA, Hartmann PE. Anatomy of the lactating human breast redefined with ultrasound imaging. Journal of Anatomy. 2005;206(525-534).
12. Geddes DT, Sakalidis VS. Ultrasound imaging of breastfeeding - a window to the inside: methodology, normal appearances, and application. Journal of Human Lactation. 2016;32(2):340-349.
13. Gavine A, MacGillivray S, Renfew MJ, Siebelt L, Haggi H, McFadden A. Education and training of healthcare staff in the knowledge, attitudes and skills needed to work effectively with breastfeeding women: a systematic review. International Breastfeeding Journal. 2017;12(6):DOI 10.1186/s13006-13016-10097-13002.
14. Wood N, K, Woods NF, Blackburn ST, Sanders EA. Interventions that enhance breastfeeding initiation, duration and exclusivity: a systematic review. MCN. 2016;41(5):299-307.
15. Boss M, Saxby N, Pritchard D, Perez-Escamilla R, Clifford R. Interventions supporting medical practitioners in the provision of lactation care: a systematic review and narrative analysis. Maternal and Child Nutrition. 2021:e13160.
16. Boss E. Normal human lactaton: closing the gap. F1000Research. 2018;801.
17. Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine. 2021;16(4):349-350.
18. Douglas PS. Re-thinking benign inflammation of the lactating breast: a mechanobiological model. Women's Health. 2022;18:https://doi.org/10.1177/17455065221075907.