Verity prepares to use the gestalt method with 25-day-old Riku (conditioned dialling up, positional instability): steps 1 & 2

Disclaimer: the case below is an amalgam of multiple cases that have presented to me, and is not derived from any specific or identifiable mother-baby pair who have seen me as patients. Needless to say, all names are fictional.

Verity and her newborn prepare to experiment with the gestalt method

Riku has had difficulty coming on to the breast from birth due to positional instability, and has now developed a conditioned dialling up at the breast, too.

• You can find the story of the first four days of Riku's life and how difficult it was for Verity to bring him on to the breast here.

• You can find what has happened with breastfeeding for Verity and her newborn in the three weeks after they came home from hospital here.

In this article, I share with you what Verity, 25-day-old baby Riku and I did in our first consultation together after I'd properly assessed their situation and worked out what was going on. We talked about how to use the gestalt method first, step by step, since Riku was very sensitive at the breast and I wanted Verity to be ready before we tried bringing him on.

Step 1: understanding the biomechanics of infant suck

A deep and symmetrical face-breast bury

You can see in the photo above that the baby has a lovely deep face-breast bury, little nose touching the breast but still breathing freely.

I go to my computer and pull up a short video of a baby’s face and mother’s breast as the baby breastfed, with easy, pain-free milk transfer. I use an example of a baby at a more generous breast. We watch the screen together. You can find an animation showing how babies breastfeed here.

"See how deeply the baby’s face is buried into the breast?" I say in a while. "We can’t see those little lips at all!"

"But I was told Riku needed to have flanged lips," Verity says, confused.

"If you can see his lips flanged," I explain, "he won’t be drawing as much of the breast tissue into his mouth as he needs to. See the baby in this video? We can’t see his lips at all."

"But how can that baby breathe?" she asks. "His nose is buried!"

"It’s true," I explain, "that we don’t want the little nostrils so buried in that he can’t breathe easily. He’ll pull off if he can’t breathe, that’s for sure. And you’ll hear it anyway if his nostrils are partly blocked." I demonstrate the heavy sound of a baby breathing when the nostrils are partly occluded against the mother’s flesh by holding the back of my hand against my own nose and inhaling in through my nose.

"You’ll hear it, and then you’ll know to release the face-breast bury a fraction, or to draw the baby back towards his toes a little. Also, your paddle-hand with firm pressure between the shoulder blades helps release the nostrils." Verity nods a little.

I continue. "But see in the video – his little nose is touching the breast tissue, and because of the way a baby’s nostrils are shaped, little air channels form against the breast. He is breathing really easily."

I take my old knitted breast from the cupboard, the one with the purple ‘breast’ and orange ‘nipple and areolar complex’, and hold it with the nipple pointing horizontally.

Baby's jaw drops to create a vacuum in her mouth

"The baby’s jaw drops reflexly when the baby comes on, creating a vacuum in the baby’s mouth." I demonstrate by holding my four fingers together on top of the nipple and areola, and then dropping the thumb down away from the fingers underneath the nipple and areola.

"It’s this vacuum that incrementally draws breast tissue up into the baby’s mouth, bit by bit through the first few sucks…" I use my fingers to draw up the nipple and areola and an increasingly exaggerated amount of adjacent knitted ‘breast tissue’ deeper and deeper towards the palm of my hand.

The vacuum in the baby’s mouth fills up with breast tissue

"… until the breast tissue is drawn in as deeply as possible, with the nipple sitting just a few millimetres away from where the hard palate joins the soft palate. Then the little mouth is as open as it can be, held open by all that breast tissue. This is what we want for Riku."

Verity is standing by my side studying the video, which I have playing on a loop.

Hiromi has given up rocking Riku and is holding him over his arm on his tummy so that he can see out.

"He seems to love that position over your forearm!" I say to Hiromi as an aside.

"Yes", Hiromi says, "this has become my ‘go to’ if he isn’t sleeping!"

"He can see out when you hold him like that. Which means, in the way I think of it, that his hunger for rich and changing sensory input is met," I observe. You can find out about this and other ways of carrying your baby, here.

We’re all standing in the consulting room now, me at my standing desk, Hiromi with the baby who is quietly watching us, draped over his father’s forearm and tucked in firmly against his father’s body, and Verity. Hiromi comes up to watch we’re doing, and the baby gazes at his mother and me, rapt.

"Babies usually come on superficially," I explain, illustrating again with my fingers grasping the orange wool nipple. "That’s normal."

"But the LC said to take him off if he didn’t come on with a deep latch. That the whole problem is he has a shallow latch."

You can see in the photo above a deep and symmetrical face-breast bury from the side. Baby’s hands are bare and embracing breast; there is a gap between baby’s forehead and mother’s upper arm; the mother is applying some gentle pressure between shoulder blades.

The problem of breast tissue drag

"If we keep taking the baby off, we accidentally dial him up and we can worsen any nipple damage too," I explain. "It’s not how he comes on that matters. Shallow is normal when they first come on. The problem is breast tissue drag. If there is breast tissue drag pulling away from the direction of the vacuum when Riku comes on, then Riku can’t draw up breast tissue as he needs. He comes on but will either stay shallow or won’t be able to stay on because there is a drag in a direction different to the direction of his suck."

I illustrate the concept of breast tissue drag with the knitted breast.

"The breast wants to fall here …… and Riku is dragging it here." I drag the nipple and areolar and top of the knitted breast up, and then down.

"Or the breast wants to fall here ….. and the baby is dragging it here." I illustrate dragging the breast tissue off to each side.

"Too high and too far off to the side are the two most common directions of breast tissue drag," I explain. "But the breast tissue might also be dragged too much to the midline, or too low, relative to where the breast wants to fall."

"If there is breast tissue drag, the baby’s mouth can’t open wide. This is not because the baby lacks the capacity to open her mouth. It’s because there is some breast tissue dragging and pulling away and interfering with her capacity to fill her mouth up with breast tissue. When all goes well, the vacuum incrementally draws up as much breast tissue as possible, until the mouth is as wide open as possible, completely filled up. …. Though you won’t be able to see that, because of the lovely deep face-breast bury."

This is where women typically completely get it. That’s what has been happening, they say.

And Verity, too, suddenly says: "That’s it! That’s what’s been happening. There has been a serious problem of breast tissue drag each time Riku manages to get my nipple into his mouth."

Exposing the landing pad

I nod. "So, if we want to eliminate breast tissue drag, firstly we need to have an exposed landing pad."

Again, I use the knitted breast to illustrate. "If we want the lower half of his little face to be completely buried in the breast," I explain, pressing my open palm over the knitted breast’s nipple and areolar and landing pad to illustrate, "we need about a ten centrimetre diameter ‘landing pad’ exposed."

Both Verity and Hiromi are nodding. The baby watches on, enthralled by the events unfolding around him.

Step 2: Preparing your body

Make sure your breast's landing pad is completely exposed

In the photo above, the mother’s garment is encroaching on the landing pad. This can interfere with the baby's face-breast bury or cause the baby to fuss at the breast.

"The three things that typically get in the way of the landing pad are, one, clothing and bras." I illustrate with my fingers, to show how bras and garments can come over and also distort the landing pad, making the symmetrical face-breast bury impossible.

"Babies will fuss and pull off if there is clothing in the way of the landing pad." But this hasn’t been the case for Verity.

"Two. Your upper arm impacts on the baby’s forehead." I illustrate with my own upper arm held up close to the side of the knitted breast, showing how this interferes with the landing pad and the baby’s capacity to bury deeply into the breast.

"And three. This is a very common. Our tummies can interfere with the landing pad." I use my hand under the knitted breast to illustrate how our tummies can sit up under the breast and interfere.

"This," I explain to Verity, "is what I can see is happening for Riku. The landing pad is not properly exposed. But the good news is that there are some simple strategies we can use to help expose that landing pad and get him stable at the breast."

"Ok, so my breasts are too big," Verity announces, finally.

"Goodness! No breast is too generous for breastfeeding," I explain. "We just need some strategies for getting rid of that breast tissue drag and exposing the landing pad. Similar problems can arise with very delicate breasts."

"Alright," she says, doubtfully. Hiromi and Riku listen quietly.

"You can see that I worry about shaping the breast with your hand, because as soon as you let go, the breast falls and Riku will experience breast tissue drag. I think that explains why a large study showed that shaping the breast is associated with a fourfold increase in nipple pain, too."

Verity raises her eyebrows. "Really?"

I nod. "Which isn’t to say that some women don’t continue to shape the breast to bring the baby on. Sometimes they just find it works best that way. But you need to know the risk, which is that as soon as you let go, there might be breast tissue drag. So you would lift the breast just as little away from where it naturally wants to fall as possible, and be ready to do the micromovements as soon as you let go, to eliminate any breast tissue drag. We’ll talk more about micromovements in a minute."

Verity is nodding slowly.

The baby in the photo above has a good-enough face-breast bury with only mild asymmetry. The mother is semi-reclined with the baby’s head on her forearm.

Semi-reclined in a deck-chair position

In the photo above, the baby is wrapped up under the mother’s other breast in a rib-cage wrap. You can see that the mother has a paddle hand applying gentle pressure between the baby’s shoulder blades. the baby has reasonable spinal alignment in a nice rib-cage wrap, though the baby is almost becoming too long for a horizontal wrap and will be increasingly diagonal across her mother's body. There is firm pillow support under her elbow at the level that works for her and her baby.

"We want you lying back semi-reclined, because that will open up the landing pad immediately." Again, I illustrate with my palm lengthwise and flat under the knitted breast, as if the base of my palm is hinged at the base of the breast, and I show how leaning back opens up the lap so that the landing pad is exposed.

"That’s why I’ll give you the footstool, which helps keep your spine aligned, and we’ll get you semi-reclined in the chair. What sort of chair do you use at home?" I ask.

Hiromi answers. "We bought a breastfeeding chair that has big comfy arms, and that reclines back," he says.

I respond carefully. "Ok. Well, you can see that I use a two-seater lounge, which doesn’t have arms and particularly not solid arms up close to Verity and Riku. Unfortunately, our breastfeeding armchairs or rocking chairs can really interfere with breastfeeding, because the chair arms tend to push the baby too far ‘around the corner.' Riku will tend to push off the chair arms with his legs. No matter what size a woman’s body, breastfeeding chairs can seriously interfere with fit and hold. I hate to say it, but right at the moment we're best not using it. Look for a lounge chair in the house that has plenty of space on either side of Verity and Riku. There’ll be lots of use for that lovely new recliner later."

Verity looks at Hiromi. "The double seater in the TV room will work," she says.

"We could even re-arrange things and bring it into the bedroom if you wanted," Hiromi suggests.

I settle Verity into a deckchair position on my two-seater couch, with a very soft pillow tucked into the small of her back and her feet on my low footstool. We notice together just where her breasts want to fall when she is semi-reclined, at about 45 degrees, and where her nipples want to look. Verity’s nipples project one or two millimetres above the surface of her areola at rest like this. We make sure the landing pad is properly exposed using a tightly rolled up face-cloth .

I continue my educational spiel, eager to fit as much into our hour together as possible.

But firstly I explain how wonderful Verity's interactions with Riku are. "A dialed-up baby will have more difficulty getting organized and he needs your snuggling up and soothing, your kisses and caresses. He is so lucky to have this!"

“We’ll need to remove all excess cloth from the landing pad,” I explain. This includes the baby’s bib, the baby’s bunny-rug, and the nappy or cloth that some women like to tuck into the bra under their breast to catch any leaking milk. All of this excess material can interfere with a simple, unencumbered face-breast bury and rib-cage wrap.

"You’ll also need to pay attention to your bra, when you’ve got one on, to make sure it doesn’t encroach on the landing pad, but for now we’ll try breastfeeding without one, if that suits you.”

“Usually I’ve been trying to feed without a bra,” Verity explains. Sometimes, if a woman only ever feeds with a bra, we work together with the bra on.

“Riku’s mouth will need to come on at the level that your breasts and nipples naturally fall. Then we don't want him pulling the nipple too high, but just directly up into the mouth.”

This is what is relevant to Verity, but I also regularly see women for whom the breast sits much higher relative to their elbow, and baby comes on dragging breast tissue downwards.

Recommended resources

• You can find a video of me working with the gestalt method in a consultation with a mother and her baby here, and in demonstration with a mother and her baby here.

• You can find the story of the first four days of Riku's life and how difficult it was for Verity to bring him on to the breast here.

• You can find what has happened with breastfeeding for Verity and her newborn in the three weeks after they came home from hospital here.

• You can find out how I talked about steps 3 & 4 of the gestalt method with Verity and Hiromi here.

• You can find out how Verity experiments with the gestalt method, so that Riku is breastfeeding well at follow-ups here.