Dr Pam Douglas's Gestalt breasfeeding: how to avoid cracked nipples and breastfeeding pain
- Elise Armoiry My Baby Moon
- Jan 15
- 5 min read
Many mothers I meet during consultations thought that breastfeeding would be "natural and easy" and are surprised by the difficulties they encounter. Breastfeeding can be very complicated at the beginning: it is an art that has been lost over generations fed with artificial milk bottles. One of the most frequent difficulties is the nipple crack: this small, very painful wound on the nipple, encouraged by suboptimal positioning.
The primary reasons for consultation in my practice as an IBCLC lactation consultant are cracks and nipple pain
Mechanism of crack formation
Breastfeeding is learned by watching others do it, by being in contact with breastfeeding mothers, or by getting informed. Therefore, I often advise getting informed as early as pregnancy in order to prepare for breastfeeding in advance and to have all the information needed to react in case of difficulty.
The Gestalt Breastfeeding Approach for Cracked nipples and Nipple or breast Pain
Cracks (nipple wounds) appear in most cases due to positioning problems at the breast (or fit and hold issues as Dr Pam might say!), and notably due to traction and stretching forces on the nipple. (For more information on managing cracked nipples, see this article).
If you have pain during feedings: nipple pain, breast pain, cracked nipples, or pain after the feeding, you can contact me.
Nipple Cracks Sometimes there are other causes:
Size: small mouth / large nipple.
Baby's retrognathia: recessed chin.
Tongue-tie.
Infectious context: thrush/yeast infection.
Dermatological context: eczema.
Ineffective Advice in Case of Cracks and Nipple Pain
Very often, mothers who consult me have received the following advice:
To vary positions. New mothers are generally a bit clumsy when handling baby, even when it's their second child (we forget quickly!). This means that with each new position, the mother rediscovers the posture, finds her bearings, hesitates, and is in pain.
To do the "natural position" (laid-back/biological nurturing). Even if it is very effective at the very beginning of breastfeeding, this position does not suit all anatomies and many mothers have persistent pain.
In general, despite the fact that several professionals have qualified the position as "good," the pain persists; very often this pain is between 6 and 8/10 and many mothers cry with pain during feedings.
To see an osteopath or a chiropractor. Despite one or more sessions, the pain persists. (Note: there is no high-level evidence study reporting the effectiveness of osteopathy for breastfeeding pain, and these practices are questioned by the French Academy of Medicine and the French Society of Pediatrics).
The "Gestalt Breastfeeding" Approach, part of the Possums or NDC approach
Gestalt Breastfeeding was developed by Dr. Pamela Douglas, an Australian physician, lactation consultant, and researcher. Its goal is to reduce all traction and stretching on the breast tissue, in all directions.
This approach has been the subject of several scientific publications, notably on the biomechanics of sucking and the importance of breast tissue traction and opposing force vectors in the appearance of cracked nipples and nipple pain. There is notably a case study demonstrating the improvement of the nipple's position in the baby's mouth.
The Gestalt approach consists of a step-by-step process explained to the mother with photos and a demonstration with a doll, so that she can modify the positions and reduce pain. While we often talk about helping the mother find an "instinctive position," in practice, after a month of intense pain, mothers need very concrete answers.
I offer this approach in cases of pain during breastfeeding, cracked or bruised nipples, or for a baby who gets frustrated or is ineffective at the breast, has slow weight gain despite a latch that "looks perfect." This technique also allows for optimal breast drainage.
Principles of the Position
These are the main points; the explanation is more detailed during the consultation and adapted to the anatomy of the mother and baby.
To achieve effective and comfortable breastfeeding, we will try to:
Find the most comfortable position for mom:
In a semi-reclined position (slumped on the sofa, at a 45° angle), the mother relaxes her shoulders and creates a support so that baby's body is stable and they can use all their reflexes to feed. The weight of the baby rests on the mother’s body (= we try to free ourselves from gravity).
Baby is tummy-to-tummy, arms on either side of the breast, hands free to help them search for the breast.
Try to create a "landing strip" for baby's face on the breast, all around the nipple.
We are tummy-to-tummy with baby and we ensure ear-shoulder-hip alignment.
We aim to have the face buried in the breast symmetrically, where the breast naturally points.
We can then perform "micro-movements" to adjust the position.
Baby’s Agitation During the Feeding, fussy baby
Positioning that hinders the latch (e.g., baby’s arm between mother and baby) can pull on the nipple and generate pain or milk blisters, poor breast drainage (slow weight gain, mastitis), or baby's frustration (who cannot find the nipple or fusses during the feeding).
Very often, this baby agitation during feeding, a sign of positional instability, is attributed to reflux (GERD), a cow's milk protein allergy , or hyperlactation. Very often, pain radiating into the breast is attributed to breast thrush.
Conclusion
This approach has been the subject of several publications. In my clinical experience, this position has been very effective on many occasions for:
Reducing pain and localized cracks on the nipples.
Reducing pain radiating into the breast (often wrongly attributed to thrush, see this article).
Reducing itching on the breast.
Reducing nipple blisters (see this article).
Improving breast drainage (shorter or more spaced-out feedings) and reducing recurring mastitis.
Disclaimer: This article is intended to provide general information and is by no means a substitute for medical advice. It is essential to consult a healthcare professional for any questions related to your personal situation.
References:
Douglas P, Keogh R. Gestalt Breastfeeding: Helping Mothers and Infants Optimize Positional Stability and Intraoral Breast Tissue Volume for Effective, Pain-Free Milk Transfer. Journal of Human Lactation. 2017;33(3):509-518. doi:10.1177/0890334417707958
Douglas, P.S., Perrella, S.L. & Geddes, D.T. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy Childbirth 22, 94 (2022). https://doi.org/10.1186/s12884-021-04363-7
Do not hesitate to contact me for advice or questions: "My Baby Moon" by Elise Armoiry, IBCLC lactation consultant & founder of My Baby Moon.
Over 2,000 families supported since 2014. Doctor of Pharmacy by training, specialized in breastfeeding and sleep.
Email: info@mybabymoonibclc.com Tel: 07.49.50.67.82 Website: https://www.mybabymoonibclc.com/
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