Part 2. Watching Muhammad breastfeed, applying the gestalt method, encouraging Angelika to rest her nipples, and a few words about scabs, slough and antibiotics

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.

Angelika is determined to have me watch a breastfeed despite her nipple damage and pain

Angelika is absolutely determined to use this time with me for helping with breastfeeding. She stands, rocking her baby. As he dials up more, I suggest we may be best letting her nipples heal for a week. But Angelika is already seated and lifting her blouse, pulling down the bra flap. I pass the nipple shield under running tap water. For a moment, she places her finger in Muhammad's mouth and he sucks on it quietly.

“Water helps the shield stay on. Some women use milk too, but moistening it with clean water is enough. If there's no water handy, you can just put it on dry. You don’t have to invert it to place it on, either – that’s too much bother, and doesn't do anything to help. You could give the shield a slight stretch as you place it on directly over the nipple, but frankly, as long as it’s placed with the nipple nicely centred, that’s all we need to worry about. Babies constantly knock shields off as you’re bringing them on, and we want to make everything as simple as we can.”

When there is this much damage I try to do some preliminary work preparing a woman for what we're about to do together with the gestalt method. We need to work closely together to immediately minimise any breast tissue drag in Muhammad’s mouth once he comes on, so that we don't perpetuate damage. But little Muhammad starts to seriously cry, bobbing and searching with his mouth against her.

Angelika places one hand on the back of the baby’s neck and head, and uses the other hand to lift the breast and secure the shield at the same time. She brings Muhammad on, and in a little while she lets go of her breast, holding him in the crook of her arm.

I don’t need more than a few seconds to see the breast tissue drag that is occurring, even as she uses the nipple shield. I also see landing pad encroachment. Angelica sits upright, shoulders tight and high as she winces and catches her breath through the terrible pain, bouncing her feet and trying to suppress small sounds of distress.

Muhammad is held higher than where her breast wants to fall, and too far towards her upper arm on the same side from which she feeds. Her upper arm affects his capacity to symmetrically bury into the landing pad of her breast. His lips are visible, and his chest and tummy are a little rolled out from her body. But the baby is swallowing enthusiastically, bless him, and appears to be enjoying the feed.

After barely five seconds, I suggest we take him off. “Already, I can see why your nipples are so damaged,” I explain, “and we don’t want to continue causing damage and pain.”

“The pain is shocking!” she says, her voice catching as she inserts a practiced finger into the corner of his mouth, quickly breaking the seal by going in towards the gum, to take him off.

“How would you rate the pain on a scale of 0-10 if 10 is the worst pain you can think of?” I ask.

Angelika says the pain is worse than giving birth

“Eight,” she says. “Eight at least. It’s worse than giving birth. And look,” she says, lifting her breast a little. “It’s always like this. The nipples come out wedged. Isn’t it his tongue?”

“Ah! Let me explain!”

I work quickly because the baby is keen to keep feeding and Angelika is trying to pat and settle him. I explain about the normal biomechanics of sucking, and the problem of breast tissue drag.

“This is what’s been happening to you,” I say, demonstrating breast tissue drag on the knitted breast. “This is what’s caused the damage.”

“That’s it,” she says, amazed. “That’s exactly what’s been happening!”

We look together for a moment at where her breasts fall, and the way her nipples look in somewhat different directions. “This will alter how the baby is positioned between sides, you see.”

“Usually we turn on the baby’s breastfeeding reflexes, by burying that little face into your breast, well above the nipple and areola, and then the baby bobs down and you use your forearm to help the little one on and in with a nice deep face-breast bury.

“But we can’t do that when we’re using a shield. So just bring the baby on in whatever way you can. You’ll probably keep the shield in place with the hand on the same side as your breast, and support Muhammad under the head and in the armpit with your other hand and fingers. What’s important is that you don’t drag the breast away from where it wants to fall. So as soon as the baby is on, you change to support his head with your forearm, and begin micromovements. The micromovements are critical to getting rid of breast tissue drag.”

Angelika and I work together using the gestalt method

After quickly running through the basics of the gestalt method, we give it a go. Angelika brings the baby on with a cross-cradle hold while I help her by holding the nipple shield on lightly. Then she moves into the gestalt fit and hold and I work closely with her as I support her forearm, inviting her to let me take the weight, constantly checking in as we perform micromovements together, millimetre by millimetre.

Angelika’s arm and shoulder naturally want to tighten, and I quietly remind her: “Just let the arm go floppy. Let me take the weight. I know it's easy for me to say and quite hard to actually do ...”

"Try taking a deep breath in, then as you breathe out, consciously let your shoulders drop as relaxed down as you can ...." I continue.

“Always, whenever you have the baby at the breast,” I explain to Angelika, “you are aiming for zero pain or discomfort. Right throughout the feed with the micromovements: is this better, is this worse. Horizontal micromovements – to the toes or to the nose; vertical micromovements – higher or lower relative to the breast; and then control of the angle.”

“There will come a day, if all goes to plan, when you'll just pop Muhammad on without thinking and it will all be relaxed and you won’t worry about breast tissue drag, but right now, we’ve got to keep applying the micromovements right throughout every feed, looking for zero, so that we heal you up.”

She shoots me a disbelieving glance, her breath still ragged sometimes with pain, and I hasten to add: "Right now, we won't get anywhere near zero because you've got so much damage. But we keep on aiming for the least pain we can possibly find with micromovements right throughout the feed, anyway."

"One day you might think you’ve got it pain-free, on zero, then the baby will move, or you’ll move – something changes – and there is discomfort or pain again, and we need to keep going with the micromovements, back to zero again.”

I remember a case where the breastfeeding woman required a large movement to relieve breast tissue drag, not just micromovements

Once, I saw a woman with awful nipple pain who said, as we worked with the micromovements, that it hurt so much she couldn’t feel any difference. This was a serious situation, so with her permission I experimented more boldly. Often there are cues which hint the direction that might be most useful. I might notice that the surface of the breast is visibly tugging as the baby sucks, and suggest micromovements to eliminate that. I might notice if the nipple swings in or out or drops down when she takes the baby off, which tells me the direction of breast tissue drag. But in this case I was guessing too. We simply experimented.

And although usually just millimetre by millimetre is necessary with the micromovements, with this lady's consent, I put my hand on that baby’s bottom and moved him a couple of centimetres towards me, much more towards the side she was feeding from and – ah! She immediately experienced relief. There had been so much breast tissue drag towards the midline that only the bigger movement helped. From there, we worked with micromovements and we were able to get the pain down from a seven to one on the pain scale.

This woman told me later that she was going so far towards the midline because the lactation consultant had told her to place baby's chin on the inner breast, aiming for nipple to nose. She'd also been told to take baby off and start again when it was hurting.

"You don't need to worry about nipple to nose - that doesn't help with the biomechanics," I explained to that woman. "And taking baby off when it hurts can actually make everything worse, unless you decide to stop breastfeeding at that time altogether. When it hurts, you're best immediately experiment with micromovements."

In Angelika's case a complete rest of the nipples to let them heal may be the best way to protect breastfeeding overall

In a while, I suggest that Angelika takes Muhammad off again. I'm reluctant to let the feed go on for too long, given the extent of Angelika's nipple damage. I want to review how we're doing.

“While we are healing you up, take him off when he doesn’t seem to be transferring much milk. Just use your judgement. This will mean thinking creatively about sensory nourishment but we don’t want him on the breast for longer than he needs to be right now. As you heal up, though, you’ll be able to be very relaxed and use the breast for your own convenience, just to keep him dialled down and the days as easy as possible.”

I look carefully at Angelika.

“I know you’ve stopped offering the breast completely in the past but the wounds came back, and you’re not going to be keen on this. But it could be that you're best not using the breast for a number of days, to get on top of the healing. Those are pretty bad wounds that you have. The downside to pumping is that the pumping too often perpetuates the damage. The vacuum of the pump even on the lowest settings can continue to open up the healing skin of the nipple.”

I want Angelika to understand all options, so she can choose her own way through, experimenting.

“Some women who are desperate to heal stop breastfeeding, and only hand express as required to keep the breast safe and not engorged over a period of five to seven days. We try to make sure the nipples really are well healed before starting again. In this case, women use what expressed breast milk they have, and then formula. It’s a short-term strategy to heal up properly, before starting again with new and effective methods for eliminating breast tissue drag.

"It's true that this will cause your supply to drop off. But it might be quickest way to come out the other side. This time I'll be helping you get rid of all that nipple and breast tissue drag that's been doing the damage ...

“If you do use the pump, which helps protect your supply, you’ll need to keep the vacuum setting on low, and again, only pump for as much as you really feel you need to. Or use the pump for short periods of time, even if you do it more frequently.

“Would you like to bring the pump in next time? We need to make sure that the nipple is moving freely in the flange and that very little areola is being drawn up. Too much areola drawn into the flange worsens pain and damage. A small amount of oil in the flange will protect against any rubbing.

I rarely prescribe a management plan. My task is to share with a woman all the information she needs to find her own way through. Only that unique woman, in her own unique and dynamic situation, will know how quickly she is healing, how well the gestalt method is coming together, how much damage is being done by pumping. She's the only one who knows, really, how to find the balance that works for her in her own life. She makes judgements each day according to what she knows of her own body and her own baby.

Often it takes two consultations for a woman to feel confident with the gestalt approach to fit and hold. I suggest to Angelika that we meet again in two or three days. That will give her time to try out these new ideas, but also allows us to work together soon, if it doesn’t seem to be coming together.

What about the scabs, slough, and antibiotics?

“Do I need antibiotics?” she asks.

“No, you don’t need oral antibiotics or even antibiotic ointment, actually.” I explain how the slough and exudate are her nipple's healing process. It doesn't hurt baby to swallow a little bit of slough or exudate so she doesn't need to try to remove it before putting on the shield and feeding.

"But if there's so much slough or scab that it seems too much for the little baby's mouth, or it's going to clog up a nipple shield, then a woman is, in my view, best not trying to breastfeed any longer. Nipple rest and healing is required," I explain.

I talk about nipple care. Angelika could continue to use the hydrogel pads – but women with nipple damage easily develop overhydration (or what's called moisture-associated skin damage) from the moist applications they are using, which worsens pain and discomfort and makes the nipples even more prone to wounds. I advise alternating between placing a large glob of lansinoh in her breast pads, where the nipple will contact, and the hydrogel, when she needs to wear a bra. The more chemicals and balms we apply, the more we risk irritating already sensitive nipples and areolas, so these are the only two I recommend.

Women often think that lansinoh will heal the damage, but that is not the case. Lansinoh doesn’t improve nipple healing – but it does prevent damaged skin sticking to breast pads, which is important.

“As much as possible,” I suggest, “leave your nipples to dry in the air. We do want to get you and Muhammad out of the house as much as possible though, so again, use your judgement. Air exposure or leaving nipples free under a very loose soft garment for as much time as is practical helps during the day, but in particular leaving the nipples exposed to the air at night will help them heal.”

"But I leak everywhere! I am soaked at night if I don’t wear a bra to bed!"

“You could try placing a towel under you or under the sheets at night to soak up the leaking?" It is important to have her painful, cracked or ulcered nipples exposed to the air for as much as possible.

Angelika doesn't want to leave the house during the day while she has such difficulty with breastfeeding

“I’s going to be hard to leave the house to feed – partly because it hurts so much, partly because I feel it’s really obvious using a shield, so much fiddle it’s just not possible to do in pubic!”

“Just make it easy,” I suggest. “Tuck the shield in your bra, don’t turn it inside out to put on, shake a little water on it from your water bottle or just put it on without moistening. It’s about workability!”

“Do you recommend breast shells?” she asks.

“Sometimes women experiment with them. They might become one thing you use, in a range of strategies. But when a breast shell is held in place inside a bra, pressure is applied onto the ducts inside your breast which risks mastitis. Also, breast shells tend to become a hot moist environment, which causes overhydration of the skin and makes the nipples more prone to damage when baby feeds again.”

“I’ve been using nurofen at night when I can’t sleep for the pain. Can I keep doing that?”

“Yes, that’s a good idea. But some ladies take nurofen before they breastfeed, and I don’t recommend that. We need you to be able to tune in to what you’re feeling and use the micromovements. We don’t want your sensations to be blunted at all. If the pain is so bad that you need to take painkillers before breastfeeding, it's much better to stop using the breast for a time to let the nipples heal.”

"Silverettes?"

"Well, you could experiment," I reply, carefully. "But the silverettes also place pressure over the milk ducts, which could cause mastitis, and again keep the nipple moist, which can make the nipple more prone to damage. I think it's just being aware of the risks, then experimenting as you wish between different aids, to see what helps when you have to wear a bra."

“Ok. Also, my sister said to ask you if laser treatment on the nipple might help it heal.”

“Low level light therapy has been shown to accelerate healing, although we don’t really know if that’s true with nipple damage. But firstly we’ve got to remove the underlying cause. I suggest we focus on the fit and hold today, then decide whether or not to add in laser later on if the pain is still ongoing once you’ve been experimenting with this new approach. Usually, using the gestalt method, things heal up surprisingly quickly, in my experience.”

Within three weeks Angelika is back to exclusive breastfeeding and is mostly painfree

Angelika stops performing the exercises the chiropractor had prescribed for Muhammad. In the end she takes a five-day break from breastfeeding, which I thought would be the quickest way to completely recover, and she uses the pump sparingly in that time. She feeds Muhammad a mix of expressed breast milk she’s already stored in the freezer and also some formula. Her supply does take a temporary hit. But within three weeks from first seeing me she is back to exclusive breastfeeding, mostly pain free, still using the shields, and Muhammad continues to gain weight nicely.

Now, when pain returns, it reminds Angelika that she needs to pay attention to the fit and hold, and she is able to quickly resolve it before it gets any worse.

She has worried that maybe she should stop using the shield. I explain that she'd had such a difficult start that it's probably best to go for quite a long period of time just stabilising her breastfeeding relationship, before she tries to breastfeed Muhammad without them.

"Many women have long and successful breastfeeding relationships with their little ones and use shields the whole time," I explain. "But when you're ready, you could try slipping it off sometimes, or even, at nights perhaps when he is sleepy and dialled down, you might even see if he'll take the breast without it."

"Right now, what you've done has been amazing. To my mind, you might just want to enjoy easy breastfeeding for a time, without feeling you've got to stop the shield."

A couple of months later, when Angelika comes back in to see me for something quite unrelated, she tells me she stopped using the shield a month ago - and all has gone well. There's been no pain, and she's exclusively breastfeeding.