Gestalt Breastfeeding: Helping Mothers and Infants Optimize Positional Stability and Intraoral Breast Tissue Volume for Effective,Pain-Free Milk Transfer

Abstract

In the past decade, biological nurturing and activation of maternal and infant instincts after birth have constituted a major advance in clinical breastfeeding support. Yet, physiologic breastfeeding initiation is not enough to ensure ongoing pain-free and effective breastfeeding for many pairs. Current interventions, including “hands-off” mammalian approaches, do not improve breastfeeding outcomes, including in randomized controlled trials. Back-arching, difficulty latching or staying on the breast, and fussing at the breast are common signs of infant positional instability during breastfeeding. These cues are, however, often misdiagnosed as signs of medical conditions or oral connective tissue abnormalities, and underlying positional instability is not addressed. New clinical approaches are urgently required. This article offers a clinical approach to fit and hold (or latch and positioning)—gestalt breastfeeding, which aims to optimize positional stability and intraoral breast tissue volumes for pain-free effective breastfeeding. The word gestalt (pronounced “ger-shtolt”) means a whole that is more than the sum of its parts. Gestalt breastfeeding builds on the theoretical foundations of complexity science, physiologic breastfeeding initiation, and new understandings of the biomechanics of infant suck elucidated in ultrasound studies. It also integrates simple psychological strategies from applied functional contextualism, popularly known as Acceptance and Commitment Therapy, empowering women to attend mindfully to breast sensations and their infant’s cues. Gestalt breastfeeding can be reproduced for research purposes, including in comparison studies with oral surgery, and has the potential to improve breastfeeding outcomes.

Keywords

breastfeeding breastfeeding difficulties breast pain infant behavior lactation management latch-on

Background

In the past decade, the physiologic approach to breastfeeding initiation, which includes skin-to-skin contact, biological nurturing, and activation of both maternal and infant instincts in the first hours after birth, has constituted a major advance in clinical breastfeeding support (Colson, Meek, & Hawdon, 2008; Moore, Berman, Anderson, & Medley, 2016; Schafer & Watson Genna, 2015; Smillie, 2016; Widstrom et al., 2011). Yet, physiologic breastfeeding initiation is not enough to ensure ongoing pain-free and effective breastfeeding for many pairs over time (Brodribb, Kruske, & Miller, 2013). Although a Cochrane review demonstrated that face-to-face support by trained personnel, whether professional or lay, helps breastfeeding outcomes overall (McFadden et al., 2017), specific clinical interventions, including “hands-off” mammalian interventions, have not been shown to contribute to improved breastfeeding outcomes, including in randomized controlled trials (de Oliveira, Giugliani, & do Espirito Santo, 2006; Forster et al., 2004; Henderson, Stamp, & Pincombe, 2001; Kronborg, Maimburg, & Vaeth, 2012; Kronborg & Vaeth, 2009; Labarere et al., 2003; Svensson, Velandia, Matthiesen, Welles-Nystrom, & Wistrom, 2013; Wallace et al., 2006; Wood, Woods, Blackburn, & Sanders, 2016).

For example, nipple pain affects 34% to 96% of breastfeeding women (Berens, Eglash, Malloy, & Steube, 2016) and is a common reason for breastfeeding cessation (Odom, Scanlon, Perrine, & Grummer-Strawn, 2013). Yet, studies that combine typical approaches to fit and hold with various topical applications for nipple pain show no convincing benefit (Dennis, Jackson, & Watson, 2014). New, theoretically sound approaches to clinical breastfeeding support are urgently required (Wood et al., 2016).

In this discussion, we use the term fit and hold to refer to the way a woman’s highly anatomically variable breast and body and her infant’s highly anatomically variable intraoral cavity, face, and body interact and fit together in breastfeeding (commonly referred to as latch and positioning or attachment and positioning). A woman’s unique anatomy, including breast size and elasticity; abdominal shape; lap length; nipple shape, size, and direction; and upper and forearm length and shape, and her infant’s unique anatomy, including palate contour; oral connective tissue length, attachments and elasticities; tongue length; oral cavity size; and chin recession or shape need to fit together in a way that supports positional stability, nipple protection or healing, and optimal milk transfer. This is particularly important in mother–infant pairs facing anatomic challenges, including (but not limited to) inelastic breast tissue, pendulous breasts, recessed infant mandible, high infant palate, and obesity.

In addition to nipple pain and damage, suboptimal fit and hold results in difficulty latching onto and staying on the breast, back-arching, marathon feeds, excessively frequent feeds, excessive night-waking, fussiness at the breast, excessive crying, poor weight gain, and low supply. Suboptimal fit and hold often remains unidentified or misdiagnosed, including by breastfeeding support professionals, and its signs are misattributed to gastroesophageal reflux disease, allergy, or most recent, oral connective tissue restriction (Douglas, 2013; Douglas, 2016; Douglas & Hill, 2011). The effects of suboptimal fit and hold and other undiagnosed breastfeeding problems on infant behavior may include a conditioned hyperarousal of the sympathetic nervous system, as detailed in the neurobiological model of unsettled infant behavior (Douglas & Hill, 2013). Parents commonly introduce infant formula in response to infant behaviors that typically result from suboptimal fit and hold (Odom et al., 2013; Wasser et al., 2011).

The breastfeeding mother–infant pair is usefully conceptualized as a complex adaptive system (Douglas, Hill, & Brodribb, 2011). Inherent patterns of self-organization emerge out of the multiple feedback loops that operate within the breastfeeding mother–infant complex adaptive system. These are determined by evolutionary history, emphasizing the importance of supporting a woman’s attention to the sensations within her own body and to her infant’s communications or cues. Because of these multiple neurohormonal and behavioral feedback loops, the breastfeeding pair is innately flexible and adaptive, ensuring resilience in the face of perturbation.

From the perspective of complexity science, clinical problems emerge out of multiple unpredictable interactions between coevolving components in the complex adaptive system, rather than from the failure of a single component (e.g., oral connective tissues). Simplistic medicalized interventions (such as proton pump inhibitors, or frenotomy for restricted oral connective tissues in the absence of classic tongue-tie) disempower mothers and risk unintended consequences. The breastfeeding mother–infant complex adaptive system also displays sensitivity to initial conditions, so that small disruptions in the breastfeeding relationship early on, in the first hours, days, or weeks, may have unpredictable and disproportionate effects later (Douglas & Hill, 2013; Douglas et al., 2011).

What Is Gestalt Breastfeeding?

In our specialist breastfeeding clinic, where mother–infant pairs seeking help have often already consulted with multiple breastfeeding support professionals, we have developed an innovative approach for both prevention and repair of breastfeeding problems—gestalt breastfeeding (see Table 1). The word gestalt (pronounced “ger-shtolt”) means a whole that is more than the sum of its parts. Gestalt breastfeeding integrates the theoretical frames of complexity science and physiologic breastfeeding initiation (Schafer & Watson Genna, 2015) with new understandings of the biomechanics of infant suck elucidated in ultrasound studies (Douglas & Geddes, 2017; Geddes & Sakalidis, 2016). In our clinical experience, infants with breastfeeding problems, including those diagnosed with oral ties (in the absence of classic tongue-tie) whose parents seek a second opinion as well as infants with oral aversion or ongoing breastfeeding difficulties after laser or deep scissors frenotomies, quickly respond to this intervention. Gestalt breastfeeding downregulates amplified feedback loops to support the mother–infant complex adaptive system’s empowerment and resilience.

Table 1

Chapter Headings and Subtitles of the Gestalt Breastfeeding Online Program, Accompanied by Explanatory Text, Videos, and Photographs

Chapter title	Heading	Subheading
What is “gestalt” breastfeeding?
	The role of the sympathetic nervous system
	Signs of fit and hold problems
	Experimentation and workability
Step 1: Understanding the biomechanics of effective milk transfer
Step 2: Preparing for relaxed and comfortable breastfeeding
	Preparing your body	A semi-reclined or “deck-chair” position
		Noticing where your breasts and nipples rest without clothing
		The landing pad
		Conscious relaxation
		The generous breast
	Preparing your mind	Noticing sensations while breastfeeding
		It’s normal to feel upset and to have painful thoughts when you face breastfeeding problems
		Clarify your values
		Notice and name your thoughts and feelings
		Anchor your attention in the present moment by deliberately paying attention
		Make room for those difficult thoughts and feelings
		Take actions that align with your values
Step 3: Switching on your baby’s breastfeeding reflexes
	Keep baby dialed down at the breast as best you can
	Baby’s hands are bare and feet supported
	Baby’s chest and tummy are flat against your chest and tummy
	Baby is horizontal across your body
	Your hand supports the baby’s upper back
	Baby’s chin and lower lip plant into the breast
Step 4: Applying the power of micro-movements
	What are micro-movements?
	The sweet spot
	Forearm as lever
	“Snuggle and slide” of baby’s body
	Head tilted back
	Alignment of the spine
Step 5: Gestalt breastfeeding “around the dial”
	Koala position
	Lying down
	On the move
What gestalt breastfeeding isn’t
	Working out what’s going wrong
	Is there need for craniosacral therapy or myofunctional therapy?
Other resources that may be helpful to you
	For parents
	For health professionals

Note. Adapted from http://www.possumsonline.com/programs/gestalt-breastfeeding-online-program.

We offer a mother information and support in five steps, delivered flexibly in response to her needs, so that she is empowered to experiment and discover a fit and hold that works for her and her infant across their unique anatomic configurations. We are careful to avoid ideology (Burns, Schmied, Fenwick, & Sheehan, 2012) and to use words that are nonmechanistic and emotionally neutral or encouraging (see Table 2). A typical intervention starts with observation of the mother–infant pair’s usual fit and hold. (The woman may be invited to demonstrate this fully clothed using a doll if she has severe nipple damage.)

Table 2

Terminology

Preferred term when delivering gestalt breastfeeding	Technical or popular term not used when delivering gestalt breastfeeding
Face-bury	Facio-mandibular to breast symmetry
Mother–baby pair	Dyad
Dialed up	Conditioned SNS [sympathetic nervous system] hyperarousal
Dialed down	Calm
Fit and hold	Latch/attachment and positioning
Fit onto the breast	Latch or attach
Mouth-opening	Gape
Generous breast	Large breast
Delicate breast	Small breast
Lovely round tummy	Fat stomach
Healthy bonding	Attachment (psychological)
Difficult thoughts and feelings	Anxiety and/or depression
Dialed up at the breast	Oral aversion; breast refusal
Sensitivity at the breast	Oral aversion; breast refusal
Workability and experimentation	Natural behaviors or natural breastfeeding
Breast tissue drag in the baby’s mouth	Conflicting vectors that decrease intraoral breast tissue volume

Step 1: Understanding the Biomechanics of Healthy Breastfeeding

Ultrasonography of breastfeeding pairs demonstrates that milk transfer occurs in response to the intraoral vacuum generated by reflex downward excursion of the jaw, at the same time as the mammary ducts contract with milk ejection. The infant tongue moves downward as a single unit in tandem with jaw depression (Douglas & Geddes, 2017; Geddes & Sakalidis, 2016).

The breastfeeding infant’s tongue is most accurately conceptualized as an adaptive, supple organ that molds to fit around available intraoral breast tissue, cushioning it. The shape of the tongue alters in response to the volume of breast tissue in the mouth. The greater the intraoral breast tissue volume, the closer the nipple is to the junction of the hard and soft palate, which protects it from damage. The tongue does not grasp the breast. The tongue also does not need to extend beyond the lower gum, lateralize, or lift independently during sucking (Douglas & Geddes, 2017; Geddes & Sakalidis, 2016).

Positional stability requires the elimination of conflicting intraoral vectors of force. Conflicting vectors are commonly created, for example, by the weight of the breast tissue pulled downward by gravity or by breast tissue drag off to the side because the infant’s head is positioned too far toward the ipsilateral maternal arm. Conflicting vectors compromise intraoral breast tissue volume. In the context of positional stability, the intraoral vacuum draws incrementally more breast tissue into the oral cavity with each drop of the jaw, until the mouth is full of breast tissue and the jaw is wide open (Douglas & Geddes, 2017).

When an infant’s position is unstable, she or he has difficulty latching on, fusses and pulls off the breast, back-arches, or seems to refuse to feed. Conflicting vectors of force are being generated, so that there is drag on the intraoral breast tissue. Positional instability results in suboptimal intraoral breast tissue volume, which may result in poor milk transfer and nipple pain (Douglas & Geddes, 2017).

Step 1 includes a short demonstration video illustrating the biomechanics of healthy infant suck. A knitted breast is used to illustrate the problem of breast tissue drag, the desired outcome of optimal intraoral breast tissue volume, and symmetrical face–breast bury. The breastfeeding support professional then helps the mother–infant pair experiment with Steps 2 through 4 in an iterative and flexible way. Many techniques popularly used in clinical breastfeeding support are not used in gestalt breastfeeding, because they interfere with the infant’s breastfeeding reflexes and intraoral breast tissue volumes (see Table 3).

Table 3

Popular Techniques That Are Not Used in Gestalt Breastfeeding

Technique to be avoided	Rationale
Breastfeeding pillows supporting the infant’s body	Interferes with activation of breastfeeding reflexes; risks conflicting vectors (infant too high relative to breast)
Visible lips	If lips are visible, intraoral breast tissue volume is compromised
Pulling breast tissue back to check lips	Creates a conflicting vector and draws breast tissue out of oral cavity
Flanged lips (“flip them out”)	Lips are neutral during breastfeeding and do not need to flange; pulling lips out or having them visible compromises intraoral breast tissue volume
Hand or fingers on back of infant’s head or neck	Interferes with breastfeeding reflexes; may trigger back-arching; flexes cervical spine and interferes with intraoral breast tissue volume
Sitting upright	Gravity creates a conflicting vector, intraoral breast tissue volume is compromised, and infant pulls off or slips off the breast and fusses
Leaning forward	Gravity creates a conflicting vector, intraoral breast tissue volume is compromised, and infant pulls off or slips off the breast and fusses
Lifting breast, shaping breast (c-hold, sandwich hold)	Conflicting vectors created when mother lets go of breast, compromising intraoral breast tissue volume
Pushing breast into infant’s mouth	Conflicting vectors created when mother lets go of the breast, compromising intraoral breast tissue volume
Traction on skin of breast to lift nipple and areolar up level with infant’s mouth	Conflicting vectors created when mother lets go of the breast, compromising intraoral breast tissue volume
Taking infant off breast if attached shallowly	Risks conditioned sympathetic nervous system hyperarousal at breast
Breast massage while breastfeeding	Conflicting vectors created, which compromise intraoral breast tissue volume
Pumping while breastfeeding	Unable to optimize fit and hold
Persisting if infant is fussing	Risks conditioned sympathetic nervous system hyperarousal at breast
Bra or clothing touching infant’s face	Interferes with activation of breastfeeding reflexes
Infant wrapped for feeds	Interferes with activation of breastfeeding reflexes
Infant’s hands between bodies	Interferes with activation of breastfeeding reflexes; creates conflicting vectors and compromised intraoral breast tissue volume
Counting sucks and swallows	Interferes with mother’s capacity to relax and attend to breast sensations and infant cues
Lie back to control high milk flow	Lying back helps infant coordinate suck–swallow–breathe due to optimized positional stability, but this does not affect milk flow, since flow depends on intraoral vacuum and mammary duct contraction only
Football hold	Planes of contact not parallel and head tilt compromised, so that intraoral breast tissue volume is compromised

Step 2: Preparing Body and Mind for Comfortable Breastfeeding

The semireclined position helps activate the infant’s breastfeeding reflexes and allows the woman’s body and shoulders to relax, as her lap opens up (Colson et al., 2008; Schafer & Watson Genna, 2015; Smillie, 2016). Breastfeeding often improves in the semireclined position, but this is not because gravity slows down milk flow. Milk flow depends on the vacuum generated intraorally in tandem with mammary duct contraction. Breastfeeding improves in the semireclined position because the infant is more positionally stable and better able to coordinate sucking, swallowing, and breathing (see Figure 1).

Figure 1.

The semireclined position in gestalt breastfeeding, with good spinal alignment and face–breast bury. If the mother were to tuck the infant’s pelvis further under her left breast and around her body, further extension of the neck would occur, but this fit and hold was proving workable for her and the infant.

The breast needs to be exposed so that a circular “landing pad” with an approximately 5-cm radius about the nipple and areola is available for the face–breast bury. The landing pad, and therefore the breastfeeding reflexes, can be compromised by encroachment of bras and clothing, by an upper arm held too close, or by the way in which a pendulous breast and nipple fall in relation to the abdomen.

Teaching a woman to lift and shape her breast increases the risk of nipple pain 4-fold (Thompson et al., 2016). This is because when she lets go of the breast, a vector of force is generated by the downward pull of gravity on the breast, which conflicts with the direction of the intraoral vacuum. Sometimes, the breast requires the support of a folded cloth underneath to expose an adequate landing pad. Occasionally, women with very generous breasts or downward pointing nipples need to lift the breast a little with their hand to expose an adequate landing pad. These women require careful education about the risk of generating a conflicting vector of force and how to use the infant’s face to carry the weight of the breast once they let go, so that there are no vectors of force conflicting with the intraoral vacuum, compromising intraoral breast tissue volume and positional stability (see Figure 2).

Figure 2.

This mother with a generous breast presented with severe nipple pain and damage. She achieved pain-free effective breastfeeding by experimenting with the principles of gestalt breastfeeding. She is in a very reclined position, which does not show in this photo. Although the infant has some lateral flexion of the neck, due to the way the mother’s capacity to use her forearm as head support is constrained by the need to support her breast, she has found a fit and hold that is workable for them.

Breastfeeding problems are linked with maternal distress and anxiety, predisposing to mood changes (Dias & Figueiredo, 2015). Gestalt breastfeeding integrates applied functional contextualism (popularly known as Acceptance and Commitment Therapy), a third wave behavioral psychology (Whittingham & Douglas, 2016). Women are empowered to use strategies of conscious muscle relaxation, in particular of the shoulders and arms; deep breathing; cognitive defusion from difficult thoughts; “making room for” difficult feelings; and anchoring attention in the present moment, in order to respond to subtle changes in both infant cues and breast sensation. Gestalt breastfeeding relies on the concept of workability, also drawn from applied functional contextualism, to mitigate against the damaging effects of perfectionism.

Step 3: Switching on Your Baby’s Breastfeeding Reflexes

Gestalt breastfeeding teaches parents five strategies that switch on an infant’s breastfeeding reflexes (Colson et al., 2008; Schafer & Watson Genna, 2015; Smillie, 2016). These are most reliably achieved across diverse anatomic configurations in a cradle hold in the semireclined position:

The infant’s chest and abdomen lie flat against the woman’s body and breasts, facilitated by the semireclined position (see Figure 3).

The infant’s bare hands move freely in order to pat the breast and embrace the woman’s body and are never trapped between her and the infant’s body.

Firm pressure of the infant’s chin and lower lip on the breast stimulates mouth-opening and sucking reflexes (Cantrill, Creedy, Cooke, & Dykes, 2014). This occurs when the infant is positioned so that her or his face lies on the breast and the infant is able to orient herself or himself by moving the head with rooting or bobbing movements. It is not necessary to take the infant off the breast and reattach if the initial latch is shallow. Repeated attempts to achieve a wider gape or to bring the infant on with an “asymmetric latch” are often not successful, may worsen pain, and can cause a conditioned sympathetic nervous system hyperarousal at the breast for some infants (Douglas & Hill, 2013; Thompson et al., 2016). Instead of focusing on how the infant comes on to the breast, the mother is encouraged to commence micro-movements as soon as the infant starts sucking so that she or he is quickly positioned for optimal intraoral breast tissue volume as the feed progresses, with elimination of conflicting vectors.

The infant’s cervical, thoracic, lumbar, and sacral spines are aligned, with gentle forward spinal flexion achieved as the infant wraps around the maternal body. The neck is moderately extended, without lateral flexion or rotation of the cervical spine (see Figure 4).

Gentle pressure between the infant’s shoulder blades supports her or his core stability, allowing strong independent movements of the infant’s head and neck, although force is never applied. In contrast, a hand pressing on the back of the infant’s head or neck both flexes the neck and risks interfering with the infant’s breastfeeding reflexes and should be avoided (Thompson et al., 2016).

Figure 3.

This woman presented at Day 3 with nipple pain. The infant was less able to tilt his head back when breastfeeding on the right at first, due to the delicate shape of her breast. His most workable fit and hold was vertically down her body in a reclined position.

Figure 4.

He also fed comfortably in a reclined cradle hold.

Step 4: Applying the Power of Micro-movements

Micro-movements are small experimental movements of the infant’s body relative to the woman’s breast and body, made by the woman as she supports the infant in her arms at the same time as gravity draws the infant into her body. Movements of 1 or 2 mm at a time are made in multiple directions and frequently throughout the feed. One kind of micro-movement occurs as the woman uses her forearm to change the angle of the infant’s facial contact with the breast; another kind of micro-movement occurs as she slides the whole of the infant’s body against hers. Experimentation with micro-movements, by observing the infant’s responses and mindfully attending to changing breast and nipple sensation, is key to effective pain-free milk transfer. Micro-movements ensure that the infant is relaxed and stable and that the woman is able to find a fit and hold in which she experiences a deep drawing sensation of her breast tissue, without pinching or pain.

The forearm is used as a lever to achieve face–breast symmetry, so that the lower half of the face is deeply buried into the breast, creating an interface line that is parallel to, or square with, the breast (see Figure 5). This is vitally important in the context of unpleasant nipple sensation or pain. Four points—the nose and buried upper lip (with the nose either apposed to the breast or just a millimeter or two above it), both cheeks, and the chin—are symmetrically buried into the breast (Thompson et al., 2016). The lips sit neutrally against the breast and are not visible. They do not need to flange, and if they are visible, intraoral breast tissue volume is compromised (Douglas & Geddes, 2017). Pulling the breast tissue back to visualize the infant’s lips, or using a finger to make the lips turn out, pulls breast tissue out of the intraoral cavity and should be avoided. Once a workable position has been found, the mother’s elbow typically requires the support of a firm cushion, so that her shoulder and arm can relax and musculoskeletal pain does not occur.

Figure 5.

In an effective face-bury, the lower half of the face is buried into the breast, with a parallel or square face–breast interface. The four points of the nose, cheeks, and chin are symmetrically buried. The lips are not visible.

After permission to touch the woman’s arms is obtained, the breastfeeding support professional may ask the mother to take deep breaths and consciously relax her shoulders and arms as she holds her infant against her body. Then, the breastfeeding support professional places hands gently on the woman’s forearms to assist with micro-movements, carefully optimizing the face–breast interface and asking the woman for feedback about breast sensations. Together, the woman and breastfeeding support professional watch and respond to the infant’s subtle cues. This hands-on work helps the mother to lay down new neurological pathways in the clinical consultation, so that she can retrieve somatic memories when experimenting for herself later.

Once the biomechanics of infant suck are properly explained, it becomes clear to parents that digital tongue massage, other orofacial muscle stretching and massage, and oral connective tissue stretching will not alter sucking dynamics in neurotypical infants with breastfeeding difficulty. This kind of manual therapy risks disempowering the mother–infant pair, by shifting the focus from the mother’s empowered capacity to achieve optimal milk transfer through bodily fit and hold to an externally applied, “fix the baby” intervention. Frequent digital intraoral maneuvers also risk oral aversion.

Step 5: Experimenting With “Around the Dial” Breastfeeding

Once women understand the biomechanics of breastfeeding and have experienced the benefits of strategies for ensuring optimal intraoral breast tissue volume, they may choose to experiment with gestalt breastfeeding in a range of positions “around the dial” of the breast. All positions around the dial require the same attention to the details of positional instability, face–breast symmetry, and intraoral breast tissue volume.

Lying down breastfeeds may be addressed in the first consultation, because of night management benefits. Maternal hips and knees should not be flexed, firm pillow support behind the mother’s spine is required, and the infant lies on her or his side, pressed flat against the mother’s body. The mother’s arm is not under the infant’s head.

Other positions around the dial are usually only explored later. The koala position often creates conflicting vectors and, in our experience, works for a minority of women, depending on lap length and other anatomic configurations. We almost never use the football hold, due to the high incidence of conflicting vectors observed in this position. In time, women learn to replicate the bodily sensations of gestalt breastfeeding in situations of minimal postural recline.

Conclusion

Maternal nipple pain and infant behaviors such as back-arching during breastfeeds, crying and fussing with breastfeeds, or difficulty fitting onto or staying on the breast are often signs of positional instability. Current fit and hold interventions, including hands-off mammalian approaches, do not improve breastfeeding outcomes, including in randomized controlled trials. Given the limitations of existing fit and hold interventions, it is not surprising, then, that signs of positional instability are often inappropriately medicalized by breastfeeding support professionals who hope to offer solutions. For example, in the absence of classic tongue-tie, many mother–infant pairs with positional instability problems are referred for laser frenotomies of the lingual and maxillary labial frenula (Joseph et al., 2016; Walsh, Links, Boss, & Tunkel, 2017), despite lack of evidence of efficacy and risk of side effects (O’Shea et al., 2017). There is an urgent need for an effective, reproducible (yet flexible and woman centered) fit and hold intervention.

The authors of a recent systematic review, which found that breastfeeding mothers had difficulty transferring what they gained from existing interventions into real-life breastfeeding practices, called for theory-based breastfeeding interventions focused on modifiable causes of breastfeeding cessation and for intervention fidelity (Wood et al., 2016). Gestalt breastfeeding responds to this call by directly addressing the two most common reasons that parents give for commencing infant formula: nipple pain and unsettled infant behavior (Brown, Dodds, Legge, Bryanton, & Semenic, 2014; Odom et al., 2013; Redsell et al., 2010; Wasser et al., 2011). Gestalt breastfeeding integrates four theoretical frames: first, complexity science; second, physiologic breastfeeding initiation; third, findings of ultrasound studies investigating the biomechanics of infant suck; and fourth, applied functional contextualism, a modern form of cognitive behavioral therapy. Building on these strong theoretical foundations, a novel intervention has been developed (see Table 4).

Table 4

What Is New About Gestalt Breastfeeding?

Innovation	Implication	Reference
Theoretical frames
New model of biomechanics of infant suck	Intraoral vacuum not tongue action drives milk transfer	Douglas & Geddes, 2017; Geddes & Sakalidis, 2016
	Positional instability results in conflicting vectors, which compromise intraoral breast tissue volume, impairing milk transfer and damaging nipples
	Positional instability causes unsettled infant behavior
	Don’t need to try to bring infant on with wide gape
Neurobiological model of unsettled infant behavior	Positional instability from suboptimal fit and hold results in difficulty latching on or staying on the breast, back-arching, crying and fussing at the breast, and in some, conditioned sympathetic nervous system hyperarousal	Douglas & Hill, 2013
Psychological strategies from Acceptance and Commitment Therapy	Workability not perfection	Whittingham & Douglas, 2016
	Deep breathing
	Conscious muscle relaxation
	Cognitive defusion
	Mindful focus on breast sensations and infant cues
Avoid “breast is best” and concepts of a natural, instinctive, or right brain approach	Pressures and disempowers women who feel that they have failed if their body doesn’t appear to “work”	Burns, Schmied, Fenwick, & Sheehan, 2012
Intervention delivery
Consenting hands-on support (placed on mother’s forearms)	Forearm micro-movements
The power of micro-movements	“Snuggle and slide” micro-movements
Use of knitted breast	Illustrates concepts of landing pad, breast tissue drag, and optimal intraoral breast tissue volume, which protects nipple
Use of technology
Short videos	Illustrate healthy sucking; lying down breastfeeding	https://www.youtube.com/watch?v=CrysrsFzBWY
Parent’s cell phone	Photo from above infant’s forehead to illustrate symmetrical face–breast interface
	Photo from front to illustrate infant spinal alignment in cradle hold
	Photo from mother’s view above to illustrate face–bury

Gestalt breastfeeding aims to optimize positional stability and intraoral breast tissue volume, so that nipple pain is prevented or repaired and milk transfer optimized across a wide variety of maternal and infant anatomic diversities. Gestalt breastfeeding promotes the empowerment and resilience of the complex adaptive system of the breastfeeding pair, by supporting women to experiment with breast sensation and observation of and response to infant cues. Gestalt breastfeeding can be taught to breastfeeding support professionals and reproduced for research purposes, including in comparison studies with oral surgery. This new approach to clinical breastfeeding support has the potential to improve breastfeeding outcomes and is currently undergoing evaluation.

Footnotes

Acknowledgements

Gestalt breastfeeding builds on the work of many clinical breastfeeding support pioneers. In particular, the authors acknowledge the work of Anne-Marie Widström, Rebecca Glover, Jack Newman, Tina Smillie, Nancy Mohrbacher, Susan Colsen, and Cathy Watson Genna, all of whom will recognize elements of their contributions in gestalt breastfeeding. The authors recently discovered Robyn Thompson’s method, which has a similar focus on face–breast symmetry, and have used her four points of contact model in this article as another way of describing symmetrical face–breast bury. The Gestalt Breastfeeding Online Program, including videos of application in various cases, photographs, and greater detail of the strategies used in gestalt breastfeeding, is available online at . Accreditation of health professionals in the application of gestalt breastfeeding is available at education@possumsonline.com. All proceeds return to the authors’ charitable organization, Possums for Mothers and Babies Ltd., for the development of research and education materials.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Pamela Douglas is the medical director of a charitable organization, The Possums Clinic (Possums for Mothers and Babies Ltd.). Ms Renee Keogh is a Lactation Consultant at The Possums Clinic. This organization sells two online products, the Gestalt Breastfeeding Online Package and the Possums Sleep Film (). All revenue goes toward further development of evidence-based education programs for parents and health professionals.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Berens

Eglash

Malloy

Steube

A. M.

(2016). Persistent pain with breastfeeding: ABM clinical protocol #26. Breastfeeding Medicine, 11(2), 46-56.

Brodribb

Kruske

Miller

Y. D.

(2013). Baby-Friendly Hospital accreditation, in-hospital care practices, and breastfeeding. Pediatrics, 131(4), 685-692.

Brown

C. R.

Dodds

Legge

Bryanton

Semenic

(2014). Factors influencing the reasons why mothers stop breastfeeding. Canadian Journal of Public Health, 105(3), e179-e185.

Burns

Schmied

Fenwick

Sheehan

(2012). Liquid gold from the milk bar: Constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science and Medicine, 75(10), 1737-1745.

Cantrill

R. M.

Creedy

D. K.

Cooke

Dykes

(2014). Effective suckling in relation to naked maternal-infant body contact in the first hour of life: An observation study. BMC Pregnancy Childbirth, 14, 20.

Colson

S. D.

Meek

J. H.

Hawdon

J. M.

(2008). Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449.

Dennis

Jackson

Watson

(2014). Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews, (12), CD007366. doi:10.1002/14651858.CD007366.pub2

de Oliveira

L. D.

Giugliani

E.R.J.

do Espirito Santo

L. C

. (2006). Effect of intervention to improve breastfeeding technique on the frequency of exclusive breastfeeding and lactation-related problems. Journal of Human Lactation, 22(3), 315-321.

Dias

C. C.

Figueiredo

(2015). Breastfeeding and depression: A systematic review of the literature. Journal of Affective Disorders, 171, 142-154.

10.

Douglas

P. S.

(2013). Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry a lot in the first few months overlooks feeding problems. Journal of Paediatrics and Child Health, 49(4), e252-e256.

11.

Douglas

P. S.

(2016). Tongues tied about tongue-tie. Griffith Review Online. Retrieved from https://griffithreview.com/articles/tongues-tied-about-tongue-tie/

12.

Douglas

P. S.

Geddes

D. B.

(2017). Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Manuscript under review.

13.

Douglas

Hill

(2011). Managing infants who cry excessively in the first few months of life. BMJ (Clinical Research Ed.), 343, d7772.

14.

Douglas

P. S.

Hill

P. S.

(2013). A neurobiological model for cry-fuss problems in the first three to four months of life. Medical Hypotheses, 81(5), 816-822.

15.

Douglas

P. S.

Hill

P. S.

Brodribb

(2011). The unsettled baby: How complexity science helps. Archives of Disease in Childhood, 96(9), 793-797.

16.

Forster

McLachlan

Lumley

Beanland

Waldenstrom

Amir

(2004). Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: A randomized controlled trial. Birth, 31(3), 176-182.

17.

Geddes

D. T.

Sakalidis

V. S.

(2016). Ultrasound imaging of breastfeeding—a window to the inside: Methodology, normal appearances, and application. Journal of Human Lactation, 32(2), 340-349. doi:10.1177/0890334415626152

18.

Henderson

Stamp

Pincombe

(2001). Postpartum positioning and attachment education for increasing breastfeeding: A randomized trial. Birth, 28(4), 236-242.

19.

Joseph

K. S.

Kinniburg

Metcalfe

Raza

Sabr

Lisonkova

(2016). Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: A population-based study. CMAJ Open, 4(1), e33-e40.

20.

Kronborg

Maimburg

R. D.

Vaeth

(2012). Antenatal training to improve breast feeding: A randomised trial. Midwifery, 28(6), 784-790.

21.

Kronborg

Vaeth

(2009). How are effective breastfeeding technique and pacifier use related to breastfeeding problems and breastfeeding duration? Birth, 36(1), 34-42.

22.

Labarere

Bellin

Fourny

Gagnaire

J.-C.

Francois

Pons

J.-C.

(2003). Assessment of a structured in-hospital educational intervention addressing breastfeeding: A prospective randomised open trial. BJOG: An International Journal of Obstetrics and Gynaecology, 110(9), 847-852.

23.

McFadden

Gavine

Renfrew

M. J.

Wade

Buchanan

Taylor

J. L.

. . . MacGillivray

(2017). Support for healthy breastfeeding mothers with healthy term babies (Review). Cochrane Database of Systematic Reviews, (2), CD0011141.

24.

Moore

E. R.

Berman

Anderson

G. C.

Medley

(2016). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (11), CD003519. doi:10.1002/14651858.CD14003519.pub14651854

25.

Odom

Scanlon

Perrine

Grummer-Strawn

(2013). Reasons for earlier than desired cessation of breastfeeding. Pediatrics, 131(3), e726-e732.

26.

O’Shea

J. E.

Foster

J. P.

O’Donnell

C.P.F.

Breathnach

Jacobs

S. E.

Todd

D. A.

Davis

P. G.

(2017). Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews, (3), CD011065.

27.

Redsell

Atkinson

Nathan

Siriwardena

Swift

Glazebrooke

(2010). Parents’ beliefs about appropriate infant size, growth and feeding behaviour: Implications for the prevention of childhood obesity. BMC Public Health, 10, 711.

28.

Schafer

Watson Genna

(2015). Physiologic breastfeeding: A contemporary approach to breastfeeding initiation. Journal of Midwifery and Women’s Health, 60(5), 546-553.

29.

Smillie

C. M.

(2016). How infants learn to feed: A neurobehavioral model. In Watson

C. G.

(Ed.), Supporting sucking skills in breastfeeding infants (pp. 89-111). New York, NY: Jones & Bartlett Learning.

30.

Svensson

K. E.

Velandia

Matthiesen

A.-S. T.

Welles-Nystrom

B. L.

Widstrom

A.-M. E.

(2013). Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: A randomized trial. International Breastfeeding Journal, 8, 1.

31.

Thompson

R. E.

Kruske

Barclay

Linden

Gao

Kildea

S. V.

(2016). Potential predictors of nipple trauma from an in-home breastfeeding programme: A cross-sectional study. Women and Birth, 29(4), 336-344.

32.

Wallace

L. M.

Dunn

O. M.

Alder

E. M.

Inch

Hills

R. K.

Law

S. M.

(2006). A randomised-controlled trial in England of a postnatal midwifery intervention on breast-feeding duration. Midwifery, 22(3), 262-273.

33.

Walsh

Links

Boss

Tunkel

(2017). Ankyloglossia and lingual frenotomy: National trends in inpatient diagnosis and management in the United States, 1997-2012. Otolaryngology—Head and Neck Surgery, 156(4), 735-740. doi:10.1177/0194599817690135

34.

Wasser

Bentley

Borja

Goldman

B. D.

Thompson

Slining

Adair

(2011). Infants perceived as “fussy” are more likely to receive complementary foods before 4 months. Pediatrics, 127(2), 229-237.

35.

Whittingham

Douglas

P. S.

(2016). “Possums”: Building contextual behavioural science into an innovative evidence-based approach to parenting support in early life. In Kirkaldy

(Ed.), Psychotherapy in parenthood and beyond (pp. 43-56). Turin, Italy: Edizioni Minerva Medica.

36.

Widstrom

Lilja

Aaltomaa-Michalias

Dahlof

Lintula

Nissen

(2011). Newborn behaviour to locate the breast when skin-to-skin: A possible method for enabling early self-regulation. Acta Paediatrica, 100(1), 79-85.

37.

Wood

N. K.

Woods

N. F.

Blackburn

S. T.

Sanders

E. A.

(2016). Interventions that enhance breastfeeding initiation, duration, and exclusivity: A systematic review. MCN: The American Journal of Maternal Child Nursing, 41(5), 299-307.