The gestalt method: developed from clinical experience and ultrasound and vacuum studies, corroborated by real-time MRI

The gestalt method is a novel clinical approach

The gestalt method is a novel clinical interpretation of research findings concerning infant suck and swallow in breastfeeding. It has been developed from

• Decades of cinical experience and experimentation, corroborated by

• The findings of two-dimensional ultrasound studies, vacuum studies, and real-time MRI (6).

It both builds on previous, pioneering work concerning the importance of switching on infant mammalian reflexes, but also integrates multiple novel elements.

The infant tongue does not drive nipple compression or nipple shape during suckling

The tongue is a muscular hydrostat which changes shape without changing volume.(1) In the gestalt biomechanical model of infant suck and swallow, the tongue is conceptualised as 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.(2)

The two-dimensional ultrasound measures of the suck cycle are interpreted in the gestalt model as markers of three-dimensional increases in intra-oral breast tissue volume, to which the tongue conforms by changing shape. That is, measured changes of tongue surface or nipple placement relative to other intra-oral anatomic structures and of nipple and breast tissue dimensions, whilst previously interpreted as measures of tongue movement or mobility, are conceptualised in the gestalt biomechanical model as proxy measures of intra-oral breast tissue volume, to which the dorsum of the tongue moulds.(2, 3)

The physical context of breastfeeding (fit and hold) affects infant intra-oral vectors of force during breastfeeding

The gestalt biomechanical model of infant suck and swallow proposes that suboptimal fit between infants’ and their mothers’ diverse anatomies may create a vector of force in the infant’s mouth which conflicts with the directions of vacuum generated during mandibular depression, in the context of the seal formed by the face-breast bury and apposition between the tongue and hard or soft palate. This conflicting vector of force, referred to clinically as ‘breast tissue drag’, results in nipple pain and/or fussy infant behaviour at the breast.(2, 3)

In the gestalt model, 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. The impact of peak vacuum is diffused over the largest possible surface area of the intra-oral nipple-areolar complex and breast. This diffusion of tensile pressure is hypothesised to prevent excessive stretching. That is, it prevents the epithelial damage which may result when a high tensile load is focussed upon a small surface area. Because most alveolar glandular tissue is within a three-centimetre radius of the nipple, optimal intra-oral breast tissue volume optimises milk transfer, satiety, and weight gain.(2-5)

A real-time MRI study corroborates the gestalt model of suck in breastfeeding

The gestalt biomechanical model has been corroborated in 2020 by findings of a real-time MRI series of 12 successfully breastfeeding mother-baby pairs.(6) Real-time MRI confirms that the anterior and mid-tongue track the mandible en bloc; that there is no air in the intra-oral space during sucking and swallowing; that upper lip position is usually neutral during suckling; and that the tongue tip rests on the lower gum without protruding beyond the lips during suckling. Mills et al demonstrate that the infant’s soft palate remains in dynamic apposition with the tongue base, as the latter moves anteriorly and posteriorly. In the swallow phase, the soft palate elevates, allowing the bolus of milk to pass under it.

In the BMC P&C 2022 paper, the terms ‘mandible up’ and ‘maximum mandibular depression’ are used synonymously with tongue up and tongue down, respectively, to emphasise that the infant suck cycle is not driven by independent tongue up and tongue down movements, but that the anterior and mid-tongue move en bloc, in tandem with and tracking the mandible.(6-8) Also, in the BMC P&C 2022 paper, the term ‘nipple and breast tissue dimension’ refers to what has previously been characterised as ‘nipple compression’ or ‘nipple diameter’, in order to acknowledge that, depending on nipple length and width, intra-oral breast tissue typically includes subareolar glandular tissue, and perhaps even more distal glandular tissue, in addition to nipple.(9)

The synonymous terms nipple and breast tissue dimensions, width, or diameter also acknowledge that what has been previously interpreted as compression by the tongue is a change of shape resulting from tensile forces acting on elastic tissue.(2)

The gestalt method addresses positional instability and nipple and breast tissue drag during breastfeeding

In the gestalt model, patterns of infant back-arching, fussing, and pulling off the breast during breastfeeding are understood to commonly result from positional instability, which generates breast tissue drag. The term ‘positional instability’ describes a position in which the infant signals either subtle or significant discomfort, that is, experiences challenges with motoric postural control. A baby who is positionally stable may nevertheless be subject to breast tissue drag, resulting in maternal nipple pain. Therefore, a gestalt clinical intervention aims to stabilise the fit between the infant and his or her mother’s body and breast, which eliminates breast tissue drag.

The gestalt method builds on the foundations of ‘laid-back breastfeeding’ positioning,(10) but integrates a range of other strategies to optimise suckling biomechanics (See ‘Key elements of the gestalt approach to clinical breastfeeding support’, Additional File 1).

This approach has implications for multiple aspects of usual lactation support, including for minimising unnecessary pharmaceutical, surgical and bodywork interventions.(2)

References

1. 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.
2. 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.
3. 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.
4. Geddes DB. The anatomy of the lactating breast: latest research and clinical implications. Infant. 2007;3(2):59-61.
5. 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).
6. Mills N, Lydon A-M, Davies-Payne D, Keesing M, Geddes DT, Mirjalili SA. Imaging the breastfeeding swallow utilising real-time MRI. under review. 2020.
7. 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):340-9.
8. Elad D, Povlovsky P, Blum O, Laine AF, Po MJ, Botzer E, et al. Biomechanics of milk extraction during breast-feeding. Proceedings of the National Academy of Science in the USA. 2014;111:5230-5.
9. Sanuki J, Fukuma E, Uchida Y. Morphologic study of nipple-areola complex in 600 breasts. Aesthetic Plastic Surgery. 2009;33:295-7.
10. 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.