Why are breastfeeding women and their babies often unnecessarily pathologised?

"When we demonise the absence of breastfeeding per se, we insinuate that anyone who does not breastfeed is a “bad” mother. When we demonise the choice of non-breastfeeding per se, we eliminate the practice of breastfeeding 'as a right and a true choice for all women'. Moreover, we remove the responsibility from those who are there to provide care, social policies and lactation education in our healthcare system." p. 9 Groff & Steger 2023

Problems caused by breast tissue drag are often misdiagnosed as medical conditions or oral connective tissue restriction

Women who have been told by their breastfeeding support professionals that their baby's fit and hold is fine still often have classic signs and symptoms of positional instability or breast tissue drag: persistent nipple pain, or a baby who dials at the breast a lot, back arching and pulling off.

Guidelines on the wide range of difficulties faced by breastfeeding women, from nipple pain and damage to mastitis to low supply, refer constantly to the important role of fit and hold, both in causing these problems and also in treating them.

But to date none of the research which explores the management of breastfeeding problems clarifies which particular approach to fit and hold is being applied. It's wrongly assumed that any approach used by a mother or breastfeeding support professional is as good as another. Some lactation consultants might even believe that you need to work fit and hold out for yourself and that there is no reason to offer systematic help for fit and hold when you run into problems.

These problems are then often wrongly attributed to medical conditions or functional abnormalities. You can find the list of pathologies which are often inappropriately applied to the problem of breast tissue drag and positional instability here.

An inaccurate diagnosis is disempowering because you haven't been given the tools to deal with the real underlying problem

The problem with being told it's a medical condition or due to the baby's inadequate anatomy or capacity to function (e.g. capacity to suck) is that you then feel you have no choice but to pay for and apply external fixes, like exercises, or surgery, or medications. You might feel you have to use a range of breastfeeding aids.

• But external fixes always come with some kind of risk to you and your baby, even if the risk is low.

• Worse, inaccurate diagnoses are disempowering. They lead you to believe that you don't have control over the nipple pain or the baby's fussiness in the feeds, which is often not true.

Possums Breastfeeding & Lactation aims to give you back control, the kind of control that comes from working with your own and your baby's biology, not against it. Possums Breastfeeding & Lactation aims to make your days easy and enjoyable, instead of burdening you with more tasks and exercises which you have to perform on your baby, and instead of putting you and your baby at risk of side-effects from unnecessary interventions.

Why are signs of positional instability at the breast often inappropriately pathologised?

Today, our health systems' understanding of how to help breastfeeding women has a troublesome blind spot. Breastfeeding support professionals have often not been trained to see that the way a baby fits into his mother's breast and body is fundamentally important for breastfeeding ease.

• We might look at an ultrasound or MRI image of the baby's tongue during breastfeeding, and still not see how the tongue's contour and movement is determined by the amount of breast tissue in the mouth.

• We might look at a pursed upper lip, and still not see how the appearance of lip tightness results from the way the baby is positioned while breastfeeding.

• We might look at what people call a shallow latch, and still not see that the baby can't draw up more breast tissue because of the way she is fitted into her mother's body.

When we don't see the critical importance of breast tissue drag, we don't see how breast tissue drag impacts on how much breast tissue can be drawn up as the baby reflexly drops his jaw, which results in a 'shallow latch', which then causes the mother pain or the baby to fuss, which then affects the shape and mobility of the tongue and what we can see of the lips. We don't see that tongue shape and movement are contextual.

Instead, we imagine that there must be something wrong with the baby's tongue or upper lip or the baby's capacity to open up his mouth. We then pathologise the baby's anatomy or motor function or fascia, we apply diagnoses. And then try fix them. Women are left disempowered, unable to make things better themselves, dependent on the traditional bodyworker or the health professional's exercise, aid, medication or surgical intervention.

A well-meaning groupthink takes hold when there is an absence of robust theoretical frames to guide research and practice

Humans are highly social creatures. Our capacity to make collective decisions about how best to care for each other is a tremendous Homo sapiens strength, ensuring our survival over millenia. Consensus thinking operates as a protective mechanism amongst health professionals, too, and is how clinical guidelines are typically created. But a groupthink is something different again. It requires actively rejecting and ejecting dissenting perspectives. Groupthink diminishes the group, but cancelling diverse perspectives and narrowing options for group decision-making.

Today, our breastfeeding support professionals invest great effort, whole international conferences year after year, into parsing out abnormalities which, according to the current groupthink, are causing nipple and breast pain and fussy baby behaviour. Anatomic variables which are not viewed as pathological in any other part of medical practice are confidently diagnosed in the world of breastfeeding support as abnormal.

Many doctors, afraid of being labelled as unfriendly to breastfeeding, knowing our profession's inglorious history when it comes to breastfeeding support, try to fit in quietly.

All the while, the little infant tongue and oral fascia are simply responding to the amount of breast tissue that is available in the baby's mouth (in the context of diverse chin sizes and palate heights and tongue lengths and frenula shapes, in the context of diverse breast elasticity and shape and maternal arm lengths and abdominal contours).

The amount of nipple and breast tissue that can be drawn up into the baby's mouth changes depending on how the little one fits into his mother's breast and body. This fit has been described by my colleague Renee Keogh as an interlocking puzzle between the many anatomic variables in each. For some women and their babies, the fit is easy, with a great deal of give. For others, the fit needs to be very precise, and millimetres matter, particularly in the early days.

This claim is so elementally simple, and physical, and un-technical, that some breastfeeding support professionals think of it as breathtakingly ignorant and dangerous! But knowing about fit and hold empowers women to find their way through many of the breastfeeding problems that can arise, when so much else fails to help.

About the photo at the top of this page

If the mother in the photo at the top of this page had any breastfeeding problems at all, we'd suggest that she drew the baby in closer to her body and breast, so that the little nose was just touching her breast skin (but breathing freely), and so that her upper lip wasn't visible. Of course, to do this successfully, the woman will need to use micromovements so that by drawing the baby in, she isn't also creating breast tissue drag.

Selected references

Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.

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;58:145-155.

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):509-518.

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:DOI: 10.1177/17455065211031480.

Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2022;18:DOI: 10.1177/17455057221087865.

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/s12884-12021-04363-12887.

Groff E, Steger F. The ethics of ancient lactation and the cult of the perfect breastfeeding mother. Healthcare. 2023;11(2941):https://doi.org/10.3390/healthcare11222941.

Kolodziej M, Bieruszczak-Biatek D, Piescik-Lech M. Overuse continues despite no new evidence on the efficacy of proton pump inhibitors for crying and irritability in infants. Acta Paediatrica. 2021;111(3):682-683.

LeForte Y, Evans A, Livingstone V, Douglas PS, Dahlquist N, Donnelly B, et al. Academy of Breastfeeding Medicine Position Statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine. 2021;16(4):278-281.

Svensson KE, Velandia M, Matthiesen A-ST, Welles-Nystrom BL, Widstrom A-ME. 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.

Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.

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.