A 2004 newsletter, ultrasound studies, and the turbulence of paradigm shift: working out how babies suck in breastfeeding

In 2004 a newsletter for paediatricians started an international tongue-tie epidemic

For much of my professional life, our model of infant suck in breastfeeding was based on what was known from either bottle-feeding, sucking on a finger, or from the dairy industry. Throughout those years, it was believed that a wave-like or peristaltic motion of the baby's tongue squeezed milk out from the nipple, helped by the milk ejection reflex.

This erroneous belief about the role of the baby's tongue, and also a lack of knowledge about normal infant oral anatomy, gave rise to the frenotomy epidemic from the mid-2000s, which still has us in its grip, though the focus has shifted to include traditional bodywork techniques for the diagnoses of restricted oral connective tissues and fascia, as well as frenotomy.

The tongue-tie epidemic began with a small article in the American Association of Pediatrics newsletter in 2004, which proposed that breastfeeding problems arose from a difficult-to-see form of tongue tie, initially labelled a submucosal tie but soon referred to as a posterior tongue-tie.

• You can find out about posterior tongue-tie here.

• You can find a video which gives a short history of the diagnosis of posterior tongue-tie here.

Ultrasound studies demonstrated the biomechanics of infant suck in breastfeeding, corroborated by Magnetic Resonance Imaging (MRI)

By 2016, the ultrasound and vacuum studies coming out of the Geddes Hartmann Human Lactation Research Group had decisively re-written international understandings of how babies suckle at the breast. It seemed to me that Professor Donna Geddes and her teams' work could help stem the great tide of overtreatment of babies with frenotomies, and I made contact with them.

Professor Geddes warmly welcomed my visit. That first time, I took a six-hour night flight over the vast red Simpson and Great Victoria Deserts to spend a single day in her laboratory in Perth. I walked in through the art deco entrance to the King Edward Memorial Hospital and found the laboratory tucked away at the end of an upstairs corridor. Her lab was just two tidy, sun-spilled rooms with high sash windows and old-fashioned lino floors, a modest little space crammed with large machines and big ideas.

I'd had concerns before I visited that the ultrasound probe was interfering with fit and hold in the studies coming out of this lab, impacting on what could be visualised as babies suckled. But Professor Geddes was a sonographer before she became an academic, and her exceptional skill with the long narrow plastic gynaecology ultrasound probe, applied under the baby's chin was immediately apparent.

I watched Professor Geddes place the probe in the midline under the baby's jaw to visualise inside the mouth, deftly manoeuvring the probe to keep it in position despite movements of the mother's and baby's bodies. I could see that sensitive little infants with a conditioned dialling up wouldn't tolerate the probe, and our bony little newborns might also have problems. But the worst of my concerns about the potential for the probe to disrupt fit and hold were allayed.

I also wanted to see how these two-dimensional ultrasound of babies breastfeeding, and how the findings might be interpreted for the three-dimensional, real-world of mothers and babies. The paper I went on to publish with Professor Geddes analyses her team's many pioneering ultrasound and vacuum studies, as well as David Elad's 2014 ultrasound study, to propose a revised biomechanical model of infant suck during breastfeeding, called the gestalt model. This biomechanical model translates into the gestalt clinical method of fit and hold.

To my mind, the new gestalt model of infant suck in breastfeeding is proven, corroborated by Dr Nikki Mills's groundbreaking MRI study or breastfeeding mothers and babies. You can find out more about Dr Mills's research here.

We're still stuck in the turbulent phase of paradigm shift

If you track their blogs and articles over the years, you'll see that advocates for frenotomy in the absence of classic tongue-tie have been morphing their biomechanical models of baby suck in breastfeeding as new evidence comes to light, without letting go of the basic belief that tongue movement drives milk transfer and that fascial restriction is the dominant course of breastfeeding problems.

Tracking alongside this, there's been a shift from immediate referral for frenotomy to referral for traditional infant bodywork first.

• You can find out about frenotomy here.

• You can find out about traditional bodywork here, and the Possums programs' evolutionary bodywork here.

Because all these other biomechanical models of infant suck are interpretations of data, I needed to give a name to the alternative biomechanical model of infant suck in breastfeeding which I was offering, to distinguish it from others.

I also wanted to emphasise the holistic nature of the gestalt biomechanical model, given the narrow focus out there on fascial restrictions as the explanation for changes in tongue shape and mobility. That's why I used 'gestalt', a German word that has come to mean, at least in English, 'a whole that is more than the sum of its parts.'

The figure below illustrates a phenomenon that often occurs with paradigm shift. There is usually an interim stage of confusion and conflict, or turbulence, before the final tipping point into a new way of making sense of something is reached. This phase of turbulence, which we are still in when it comes to clinical breastfeeding support, can last for many years.

Selected references

Ardran G, Kemp F, Lind JN. A cineradiographic study of breast feeding. British Journal of Radiology. 1958;31:156-162.

Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.

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

Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation. 2017;33(3):519–523.

Douglas PS. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):180-181.

Douglas PS. Untangling the tongue-tie epidemic. Medical Republic. 2017;1 September:http://medicalrepublic.com.au/untangling-tongue-tie-epidemic/10813.

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

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, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(1):94. DOI: 10.1186/s12884-12021-04363-12887.

Geddes DT, Gridneva Z, Perrella SL, Mitoulas LR, Kent JC, Stinson LF, et al. 25 years of research in human lactation: from discovery to translation. Nutrients. 2021;13:1307.

Mills N, Lydon A-M, Davies-Payne D, Keesing M, Mirjalili SA, Geddes DT. Imaging the breastfeeding swallow: pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology. 2020;5:572-579.