Key management principle #1. Eliminate repetitive mechanical microtrauma for prevention and management of nipple pain and wounds

Optimise fit and hold to eliminate conflicting intra-oral vectors of force during breastfeeding

Studies examining the causes of lactation-related nipple pain and clinical management and clinical protocols universally agree that poor infant positioning or latch is the most common cause of nipple pain. Guidelines advise that suboptimal fit and hold should be addressed before any other treatment is instituted.1-6

Yet the way an infant fits into the maternal breast and body, which has direct impact upon the biomechanics of suckling, remains an omitted variable bias in almost all nipple pain research. Commonly taught approaches to fit and hold when problems emerge rely upon outdated biomechanical models of infant suck.7

Much of what is offered women with breastfeeding difficulty, including interventions for fit and hold, is based upon experience or opinion.8-12 You can find out about this here.

The failure of current approaches to fit and hold to effectively resolve repetitive biomechanical microtrauma during breastfeeding has lead to widespread overmedicalisation and overtreatment of both breastfeeding women and their babies, risking unintended outcomes. You can find out about this here.

• In 2015, Kent et al reported that 42% of cases presenting to the Breastfeeding Centre of Western Australia showed lack of improvement with fit and hold and other interventions offered by IBCLCs, noting that though some studies claim to show that certain fit and hold interventions improved nipple pain outcomes,24-26 other studies could not replicate these findings.27-29 The authors observed: “Nipple pain is often attributed to suboptimal positioning and attachment of the infant although conclusive evidence is yet to be provided regarding which aspect(s) of positioning may be most important.” The IBCLCs went on to diagnose ankyloglossia and palatal anomaly in 36% of the infants of women presenting with nipple pain.3

• Given the international evidence demonstrating overdiagnosis of ankyloglossia, and the normality of a wide variety of palatal contours, the NDC Clinical Guidelines propose NDC proposes another explanation: that scientific investigation of the elements of fit and hold which impact on maternal pain remains a research frontier.

Applying the mechanobiological model, this article proposes that although laid-back or baby-led breastfeeding methods are essential from birth, they do not integrate new knowledge about the biomechanics of infant suck in order to address the mechanical forces that cause nipple pain and damage. That is, the biological nurturing approaches are not enough to prevent breastfeeding problems for many women. You can find out about biological nurturing or laid back breastfeeding here.

The gestalt method is the only available clinical approach to fit and hold which integrates the principles of laid-back or baby-led breastfeeding with an evidence-based model of the biomechanics of infant suckling, translated into a reproducible, flexibly applied clinical intervention.38-40

Normal maternal and infant anatomies are highly variable

Human anatomy including infant tongue length, mandibular shape, and palate contour and height, and maternal breast, nipple, areola, upper and forearm length, and abdominal contour are highly variable.

Labelling, that is, medicalising or pathologizing, the wide range of normal maternal and infant anatomy disempowers and discourages breastfeeding women, and unnecessarily exacerbates parental anxiety.

In the gestalt model, it is understood that certain normal anatomic variations may increase vulnerability to the emergence of problems in the complex adaptive system of the breastfeeding mother-baby pair. This emphasises the importance of preventative and management approaches to fit and hold which optimise intra-oral breast tissue volume and eliminate breast tissue drag.38-40

Infant oral connective tissues including the lingual and labial frenula also display wide anatomic variability which are currently pathologized and inappropriately treated with either surgery or courses of bodywork therapy.

• The normal spectrum of labial frenula anatomy is not linked with breastfeeding problems, and should not be pathologised as restricted or ‘tied’.41-43

• There is no anatomic or functional basis for the diagnosis of posterior tongue-tie.44-46

The latter two diagnoses are examples of overmedicalisation of breastfeeding problems, resulting in exponential increase in unnecessary infant oral surgery and bodywork exercises.14 18 19 22 23 47-49 Studies which claim to show benefits of frenotomy for diagnoses of posterior or upper lip ties are methodologically flawed, demonstrating bias.50 51

Unintended consequences of frenotomy include infant pain, haemorrhage, worsened feeding, oral aversion, damage to lingual nerve branches altering tongue sensation, sublingual mucocoele, and weight loss.52-56

The gestalt model proposes that behaviours during breastfeeding of fussing, back-arching, pulling off the breast and ‘shallow latch’ are all signs of suboptimal fit and hold and are not attributable to infant oral connective tissue restrictions, neurological weakness or motor dyscoordination.38-40 57

Maternal anatomic variation and nipple pain

Certain poorly defined anatomic variations have been shown in preliminary studies to have links with breastfeeding problems, including nipple pain.

• A 2009 Iranian study showed that 50 newborns of mothers with flat nipple, inverted nipple, large breasts and/or large nipples had a mean decrease in weight by day seven compared to 50 newborns whose mothers did not have these breast variations.58

• A 2013 Thai study of 449 women showed that nipple lengths of less than 7 millimetres were associated with less success in bringing baby to the breast and initiating breastfeeding in the first 24 hours, but no conclusions about breastfeeding success or capacity to latch after the first day could be drawn.59

• In 2020, Ventura et all studied 119 women in a US breastfeeding centre, showing that various combinations of wider, longer nipples and denser areolas were associated with difficulty latching, sore nipples, low milk supply, and slow infant weight gain.60 But there is no reliably established link between nipple shape and breastfeeding failure.

This paper proposes that multiple morphological factors interact with multiple modifiable biomechanical factors to determine an infant’s capacity to transfer milk efficiently from his or her mother’s breast, without causing her pain. The gestalt model applies a complexity science perspective to clinical breastfeeding support, which aims to optimize intra-oral breast tissue volume across the wide diversity of maternal and infant anatomies. In this way, anatomic and other vulnerabilities within the complex adaptive system of the mother-baby pair are compensated for, because the protective effect of multiple other factors is optimised.38-40 57

Eliminate conflicting vectors of force during mechanical milk removal

Conflicting vectors of force (breast tissue drag) applied to the nipple during pumping may cause persistent nipple pain and damage.

Hands-free mechanical milk removal, with pump flanges supported in an elastic band, may increase the risk of breast tissue drag and epithelial damage. Mechanical milk removal may also result in an erythematous, slightly swollen ring rash on the areola, a sign that the areola is repetitively drawn into the flange and exposed to friction. Pain-free, thickened discoloration and hyperkeratosis of the nipple face, caused by repetitive ischemia, may result from exclusive pumping.

The following strategies aim to minimise damage to nipple-areolar complex skin and nipple stroma during mechanical milk removal.

• Ensure nipple moves freely without rubbing on inside of the flange tunnel, and that minimal areola is drawn up into the tunnel;

• Invite a woman to experiment between different sized flanges;

• Invite her to experiment with different flange options e.g. Pumpin’ Pals or Milkdrop cushions;

• Hand express one breast while pumping the other, and change over the next time;

• Pump on lowest effective vacuum setting and for short periods of time e.g. 10 minutes, because frequent short pumping is more effective in milk removal and milk generation than less often, longer periods;63

• Don’t use hands-free pumping, in order to eliminate breast tissue drag which conflicts with the direction of the vacuum;

• Apply olive oil as lubricant.

References

1. Berens P, Eglash A, Malloy M, et al. Persistent pain with breastfeeding: ABM clinical protocol #26. Breastfeeding Medicine 2016;11:46-56.
2. Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014(12):doi:101.1002/14651858.CD007366.pub2.
3. Kent JC, Ashton E, Hardwick C, et al. Nipple pain in breastfeeding mothers: incidence, causes and treatments. International Journal of Environmental Research and Public Health 2015;12:12247-63.
4. Santos KJ, Santana GS, Vierira TdO. Prevalence and factors associated with cracked nipples in the first month postpartum. BMC Pregnancy and Childbirth 2016;16:209.
5. 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.
6. Amir LH, Beaza C, Charlamb J, R, et al. Identifying the cause of breast and nipple pain during lactation. BMJ 2021;374:n1628.
7. Watson Genna C, editor. Supporting sucking skills in breastfeeding infants. Burlington, MA: Jones and Bartlett Learning, 2016.
8. Gavine A, MacGillivray S, Renfew MJ, et al. 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/s13006-016-0097-2.
9. Wood N, K, Woods NF, Blackburn ST, et al. Interventions that enhance breastfeeding initiation, duration and exclusivity: a systematic review. MCN 2016;41(5):299-307.
10. Boss M, Saxby N, Pritchard D, et al. Interventions supporting medical practitioners in the provision of lactation care: a systematic review and narrative analysis. Maternal and Child Nutrition 2021:e13160.
11. Boss E. Normal human lactaton: closing the gap. F1000Research 2018;801
12. Stuebe AM. We need patient-centred research in breastfeeding medicine. Breastfeeding Medicine 2021;16(4):349-50.
13. 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.
14. Prevost P, Gleberzon B, Carleo B, et al. Manual therapy for the pediatric population: a systematic review. BMC Complementary and Alternative Medicine 2019;Mar 13:doi:10.1186/s12906-019-2447-2.
15. Schwerla F, Daake B, Moeckel E, et al. Osteopathic treatment of infants in their first year of life: a prospective multicenter observational study (OSTINF study). Complementary Medicine Research 2021;28(5):395-406.
16. Prevost P, Gleberzon B, Carleo B, et al. Manual therapy for the pediatric population: a systematic review. BMC Complementary and Alternative Medicine 2019;19(1):doi:10.1186/s12906-019-2447-2.
17. Herzhaft-Le Roy J, Xhignesse M, Gaboury I. Efficacy of an osteopathic treatment coupled with lactation consultants for infants' biomechanical sucking difficulties: a randomized controlled trial. Journal of Human Lactation 2017;33(1):165-72.
18. Kapoor V, Douglas PS, Hill PS, et al. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA 2018:88-89.
19. Wei E, Tunkel D, Boss E, et al. 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%2F0194599820925415.
20. 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;17:17455065211031480.
21. Ellehauge E, Jensen JS, Gonhoj C, et al. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal 2020;67(5):A01200051.
22. Dixon B, Gray J, Elliot N, et al. A multifaceted programme to reduce the rate of tongue-tie release surgery in newborn infants: Observational study. international Journal of Pediatric Otorhinolaryngology 2018;113:156-63.
23. Herzhaft-LeRoy J, Xhignesse M, Gaboury I. Efficacy of an osteopathic treatment coupled with lactation consultations for infants' biomechanical sucking difficulties: a randomized controlled trial. Journal of Human Lactation 2016;33(1):165-72.
24. 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.
25. Darmangeat V. The frequency and resolution of nipple pain when latch is improved in a private practice. Clinical Lactation 2011;2(3):22-24.
26. Righard L, Alade MO. Suckling technique and its effect on success of breastfeeding. Birth 1992;19(4):185-89.
27. Henderson A, Stamp G, J P. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth 2001;28:236-42.
28. De Oliveira LD, Giugliani ERJ, do Espirito Santo LC. Effect of intervention to improve breastfeeding technique on the frequency of exclusive breastfeeding and lactation-related problems. Journal of Human Lactation 2006;22:315-2321.
29. Labarere J, Bellin V, Fourny M, et al. Assessment of a structured in-hospital educational intervention addressing breastfeeding: a prospective randomised open trial. BJOB 2003;110:847-52.
30. Schafer R, Watson Genna C. Physiologic breastfeeding: a contemporary approach to breastfeeding initiation. Journal of Midwifery and Women's Health 2015;60:546-53.
31. Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev 2008;84:441-49.
32. Smillie CM. How infants learn to feed: a neurobehavioral model. In: Watson CG, ed. Supporting sucking skills in breastfeeding infants. New York: Jones and Bartlett Learning 2016:89-111.
33. Moore ER, Berman N, Anderson GC, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2016(Issue 11. Art. No.: CD003519):DOI: 10.1002/14651858.CD003519.pub4.
34. Wang Z, Liu Q, Min L, et al. The effectiveness of laid-back position on lactation related nipple problems and comfort: a meta-analysis. BMC Pregnancy and Childbirth 2021;21:248.
35. Milinco J, Travan L, Cattaneo A, et al. Effectiveness of biological nurturing on early breastfeeding problems: a randomized controlled trial. International Breastfeeding Journal 2020;15(1):21.
36. Yin C, Su X, Liang Q, et al. Effect of baby-led self-attachment breastfeeding technique in the postpartum period on breastfeeding rates: a randomized study. Breastfeeding Medicine 2021:doi:10.1089/bfm.2020.0395.
37. Svensson KE, Velandia M, Matthiesen A-ST, et al. 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.
38. 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.
39. 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.
40. 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/s12884-021-04363-7.
41. Nakhash R, Wasserteil N, Mimouni FB, et al. Upper lip tie and breastfeeding: a systematic review. Breastfeeding Medicine 2019;14(2):83-87.
42. Shah S, Allen P, Walker R, et al. Upper lip tie: anatomy, effect on breastfeeding, and correlation with ankyloglossia. Laryngoscope 2020:doi:10.1002/lary.29140.
43. Douglas PS, Cameron A, Cichero J, et al. Australian Collaboration for Infant Oral Research (ACIOR) Position Statement 1: Upper lip-tie, buccal ties, and the role of frenotomy in infants Australasian Dental Practice 2018;Jan/Feb 144-46.
44. Van Biervliet S, Van Winckel M, Velde SV, et al. Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted. European Journal of Pediatrics 2020;https://doi.org/10.1007/s00431-020-03705-5
45. LeForte Y, Evans A, Livingstone V, et al. Academy of Breastfeeding Medicine Position Statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine 2021;16(4):278-81.
46. 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.
47. Joseph KS, Kinniburg B, Metcalfe A, et al. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open 2016;4:e33-e40.
48. Ellehauge E, Schmidt Jensen J, Gronhoj C, et al. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal 2020;67(5):A01200051.
49. Walsh J, Links A, Boss E, et al. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997-2012. Otolaryngology Head and Neck Surgery 2017;156(4):735-40.
50. Ghaheri B, Lincoln D, Mai TNT, et al. Objective improvement after frenotomy for posterior tongue-tie: a prospective randomized trial. Otolaryngology - Head and Neck Surgery 2021:doi: 10.1177/01945998211039784.
51. Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation 2017;33(3):519–23.
52. Heaton PJ. Posterior tongue tie and lip tie - division of tongue-tie: surgical complications. BMJ 2021;372:n8.
53. Kim DH, Dickie A, Shih ACH, et al. Delayed hemorrhage following laser frenotomy leading to hypovolemic shock. Breastfeeding Medicine 2021;16(4):346-48.
54. Hale M, Mills N, Edmonds L, et al. Complications following frenotomy for ankyloglossia: a 24-month prospective New Zealand Paediatric Surveillance Unit study. Journal of Paediatrics and Child Health 2019;56(4):557-62.
55. Mills N, Keough N, Geddes DT, et al. Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy 2019;32:824-35.
56. Solis-Pazmino P, Kim GS, Lincango-Naranjo E. Major complications after tongue-tie release: a case report and systematic review. International Journal of Pediatric Otorhinolaryngology 2021;1(138):110356.
57. Crawford E, Whittingham K, Pallett E, et al. An evaluation of Neuroprotective Developmental Care (NDC/Possums Programs) in the first 12 months of life. Maternal and Child Health Journal 2022;26(1):110-23.
58. Vazirinejad R, Darakhshan S, Esmaeili A, et al. The effect of maternal breast variations on neonatal weight gain in the first seven days of life. International Breastfeeding Journal 2009;4(13):doi:1186/746-4358-4-13.
59. Puapornpong P, Paritakul P, Suksamarnwong, et al. Nipple pain incidence, the predisposing factors, the recovery period after care management, and the exclusive breastfeeding outcome. Breastfeeding Medicine 2017;12:169-73.
60. Ventura AK, Lore B, Mireles O. Associations between variations in breast anatomy and early breastfeeding challenges. Journal of Human Lactation 2021;37(2):403-13.
61. Douglas PS. Special Edition: Tongue-tie Expert Roundtable. Clinical Lactation 2017;8(3):87-131.
62. O'Shea JE, Foster JP, O'Donnell CPF, et al. Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews 2017(3):Art. No.:CD011065.
63. Douglas PS. Re-thinking benign inflammation of the lactating breast: classification, prevention, and management. Women's Health 2022;18:17455057221091349.