Breastfeeding went much better for Mariana and her five-week-old baby when she stopped using a supply line (or supplementer)

Mariana came in to see me with her five-week-old baby Diego. Right from the beginning he'd fussed a lot at the breast and had difficulty coming on. Mariana told me his older brother had had latching problems, too.

When a woman tells me that the problems she has with this baby are similar to those she had when she was breastfeeding an older child, I am immediately alert to the possibility that she may have particular anatomic challenges which affect fit and hold (regardless of each individual baby's unique orofacial anatomy).

Mariana said she was using a supply line because Diegao "hasn’t got sucking down properly". An International Board Certified Lactation Consultant (IBCLC) started her on the supplemental nursing system when Diego was ten days old, and his weight gains have been great ever since. She pumps her breast milk about five or six times a day, and puts some expressed breast milk in the supplementer each breastfeed.

Mariana also told me rather proudly that she had quite a lot of expressed breast milk stored in the freezer! I was astonished.

"You're amazing!" I said, genuinely. "Honestly, what women do for their babies!" Mariana smiled warmly.

"Even though it still hurts, at least he keeps drinking with the supply line on," Mariana explained. Otherwise, he'd only drink when the breast was full and there was a good letdown. After that he fell asleep. The lactation consultant had told her Diego was sucking his own tongue at the back of his mouth, with overactive gag reflex and a tight temperomandibular joint. Mariana could see his lips when breastfeeding, and was worried that the lower lip often folded in.

However, Mariana had come in because her nipple was wedged with a white line after feeds, with painful vasospasms. It hurt so much that sometimes she even wondered if she could keep on breastfeeding. After she fed (using the supplementer), she said the face of her nipple turned a bright white. When she tried without the supplementer, he'd feed well for a while but then quickly start fussing and pulling off, and she worried he wasn't getting what he needed.

When I examined her, I could see that each nipple had a calloused, keratinised appearance on the outer part of the face of nipple, and also on the walls of the nipple on that same side. This was hyperkeratosis (or thickening of the skin) due to repeated rubbing against the plastic tubing.

I also saw that Diego had a prominent sucking blister in the middle of his upper lip due to the supplementer's tubing. Mariana brought Diego on by squeezing her breast, tilting her nipple towards his nose, pressing her nipple against his upper lip, and waiting for a wide gape before bringing him with her nipple pointing towards his nose. She used a breastfeeding pillow in her lap as she sat upright to feed. I could see the blanching of vasospasm when she took him off her breast.

Mariana had a fabulous breast milk supply. I could see when I performed an oromotor assessment and watched the feed that this baby had normal oromotor function. Mariana's nipples had a diameter of about two centimetres at the base. But when I looked at her breast fall, I could see that Mariana's tummy encroached upon her breast's landing pad. Her breast-belly contour did not allow for landing pad exposure in this position, resulting in substantial nipple and breast tissue drag when Diego was breastfeeding. He managed this for a time, but whenever he relaxed, his little nose buried into her breast and he was unable to breathe. Then he'd back arch and pull off. The problems were mechanical.

• You can find out about breast-belly contour here.

• You can find out about the directions nipples look here.

Together, we worked on fit and hold using the gestalt method. Mariana never used the supplementer again. The nipple pain disappeared, the baby was settled and stable at the breast, she offered him frequent flexible breastfeeds in the midst of days filled lots of sensory motor nourishment, and she, her older boy and her baby got on with a much easier, more enjoyable life.