"'It's the oldest rule in the book,' said the King. 'Then it ought to be Number One,' said Alice. The King turned pale, and shut his notebook hastily." Alice in Wonderland

What is nipple and breast tissue drag?

Often, a woman's nipple and breast pull (or drag) away inside the baby's mouth in a direction that is different to the pull (or mechanical pressure) created by the vacuum of sucking. In the gestalt method, we call this 'nipple and breast tissue drag' or 'breast tissue drag' for short. This refers to drag on the skin (of the nipple, areola, and of the breast beyond your areola), on the underlying tissue in the core of your nipple, and also on your breast's glandular tissue, all of which are drawn up into your baby's mouth while suckling.

Breast tissue drag commonly results in two main problems, sometimes both together but often just one or the other.

• Nipple pain (inflammation, or cracks or ulcers in the skin) for you

• Fussing at the breast (difficulty coming on, back arching, pulling off a lot) for your baby.

If you have nipple pain or damage, or a baby who fusses a lot at the breast, you may still be told that your fit and hold - often referred to as 'latch and positioning' - is fine. (You’ll notice that I don’t use the words latch and positioning, but refer to ‘fit and hold’ instead. I find fit and hold a less technical, more friendly, phrase. You can read more about why I personally don’t like the word latch here.)

Or maybe your lactation consultant had some suggestions to make about fit and hold at first, but then in later checkups told you all was good.

But if you're still experiencing nipple pain and damage, or if your baby still fusses or dials up with breastfeeds, there may well be ongoing fit and hold challenges even after you've been told this is no longer a problem. This is no individual's fault - it is because we have a health system blind spot.

Why is the way your baby fits into your body to breastfeed so important?

Two-thirds of your milk glands are located in just a three centimeter radius around the base of your nipple, irrespective of the size of your areola. You can find out about the normal anatomy and function of the lactating breast and nipple here and here.

Your baby doesn't just need your nipple for breastfeeding, though it is normal for babies to take the nipple quite superficially at the beginning of a feed. As suckling gets underway, your little one needs to draw up as much of this glandular breast tissue, which lies packaged up under the skin, as deeply into his little mouth as possible. This is needed so that

• The milk ducts, which run from the milk glands to the top surface of your nipple, can open up just as much as possible

• The mechanical pressure of the sucking vacuum is spread evenly over as a big a surface area of your nipple, areola, and breast skin as possible, to protect you from having intense pressure stretching on just a small part of your nipple, which causes pain.

The amount of tissue that your baby can draw up into her mouth depends before else on how she fits into your body. There are some other things that matter too, but the way baby fits into your body is by far the most important. It's still not widely understood that this is the case.

So fit and hold is the first thing we need to explore together if you've run into problems, beginning here.

A note about the photo on the top of this article

If this breastfeeding woman has no problems at all (good baby weight gain, no fussing of baby at the breast, no discomfort or pain for her) then ... "if it ain't broke, don't fix it"! But if she had pain, or if her baby fretted and pulled off a lot, I'd be saying that's not a surprise to me. We can see the little one's upper lip, for instance, which means the baby isn't drawing up as much nipple and breast tissue into the mouth as he could, which is likely to result in high stretching forces applied to a small surface area, and also possibly difficulty feeling stable in his positioning. Baby's lips are quite neutral in successful breastfeeding (not flanged out or everted), but they also shouldn't be visible due to a deep face-breast bury.

Recommended resources

Change things up straight away if you have nipple discomfort, pain, or damage

Start here if your baby fusses a lot when coming onto the breast, or whilst breastfeeding, or after breastfeeds

What causes nipple pain when you're breastfeeding or lactating and there's no visible break in the skin (though there may be redness and swelling)?

What causes visible nipple damage (cracks, ulcers, bruising, or other wounds) when you're breastfeeding or lactating?

Selected references

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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. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.

Douglas PS. Special Edition: Tongue-tie Expert Roundtable. Clinical Lactation. 2017;8(3):87-131.

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, 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.

Geddes DT, Sakalidis VS. Ultrasound imaging of breastfeeding - a window to the inside: methodology, normal appearances, and application. Journal of Human Lactation. 2016;32(2):340-349.

Milinco J, Travan L, Cattaneo A, Knowles A, Sola VM, Causin E, et al. Effectiveness of biological nurturing on early breastfeeding problems: a randomized controlled trial. International Breastfeeding Journal. 2020;15(1):21.

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 R, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home bresatfeeding programme: a cross-sectional study. 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.

Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.