Breastfeeding Problems Due to Baby's Anatomy

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A baby's oral, head, and neck anatomy is where the whole process of feeding begins. Issues such as a recessed chin, or dimpled cheeks while the baby is feeding, can interfere with breastfeeding and may be caused by an anatomical problem. The function of this region of the baby's body can make or break the whole breastfeeding experience. The major players are:

  • Esophagus: This is yet another passageway, this time from the mouth and throat into the stomach.
  • Larynx: This passageway allows air to travel to the trachea while keeping food out.
  • Nasal cavity: This is the main passageway for air, where it is purified and moisturized before entering the lungs. In the front, this area is surrounded by the cartilaginous (a tough, elastic tissue) part of the nose. Underneath the nose, the hard palate provides a firm border between the nasal and oral cavities.
  • Oral cavity: Of course, the mouth has a significant role in the ingestion of food. This cavity is bordered by the lips, the cheeks, and the roof and floor of the mouth.
  • Pharynx: Its most important job is swallowing and keeping itself open, which is critical for respiration. During breastfeeding, babies have to coordinate sucking, swallowing, and breathing all at once.
  • Trachea: From the trachea, air passes into the lungs.

Potential Oral Abnormalities

Babies with these anatomical issues may have difficulty latching or sucking, or both. Some may be diagnosed at or before birth, while others take time to identify. In any case, you will need advice from a pediatrician or lactation consultant.

  • Cleft palate or lip: There are three different types of clefts—lip, palate, or palate and lip. The feeding issue stems from the baby not being able to form a sealed oral cavity to generate suction.
  • Micrognathia: This is a small or "pushed back" lower jaw. On the outside, the chin looks recessed. In the mouth, the tongue is positioned further back in relation to the oral cavity. It is often related to a wide U-shaped cleft palate and Pierre-Robin malformation sequence. With a small or recessed jaw, the baby's tongue may not be able to come forward sufficiently to be properly positioned below the nipple. In addition, the lower jaw may not be well-positioned to compress the areola for productive milk ejection. One technique that may help is gently pulling forward under the jaw.
  • Retracted jaw or tongue: If a baby's cheeks are dimpled or she makes a clicking sound when breastfeeding, she is not latched on well. To improve the latch, options include making sure that the baby's head and neck are properly aligned; doing exercises where you stroke and apply pressure to the baby's tongue from the tip to the back; and short-term use of a nipple shield, a flexible silicone nipple that is worn over the mother's nipple to feed.
  • Short frenulum: Also referred to as "tongue-tie" or a "short tongue." Some babies can breastfeed normally with a tongue-tie. Others may benefit from a frenotomy (a minor procedure to cut the frenulum, which is the tissue that attaches the baby's tongue to the bottom of his mouth).

Sucking Problems

Babies may have trouble sucking for many reasons, including anatomical and medical problems. Work with your baby's health care providers to make sure he is getting enough to eat and to improve his ability to breastfeed.

  • Biting, clamping or clenching: This often stems from overactive muscle tone. Make sure that the baby is very well supported. "Mouth play," or giving the baby a lot of oral experiences (feeding, touching) to increase awareness of what the mouth can do, can help, along with stimulation on the face.
  • Excessive jaw excursion: Some babies have disorganized sucking, where they keep losing suction and need to re-latch. Proper positioning, along with jaw and cheek support, can help.
  • Gagging: Sometimes gagging means the baby is having trouble coping with an overactive letdown or an oversupply of milk.
  • Inadequate mouth opening: There can be many reasons for this, but it typically relates to the baby's state of alertness or a clenching jaw. Some methods to try: adjusting the baby's state (helping them wake up); beginning the rooting reflex; helping to open the baby's mouth.
  • Lack of central grooving of the tongue: The best method of treatment is "proprioceptive input," or teaching the sensory receptors in the tongue to respond to a stimulus. This involves placing a downward pressure at the midline of the tongue and slightly stroking forward. A firm, straight nipple may also help, so a nipple shield may be recommended.
  • Low or high muscle tone: These babies are described as "hard to hold," or they arch away from the breast. A lactation consultant may be able to suggest feeding positions that can help.
  • Poor initiation of sucking: There can be many reasons for this—premature, jaundiced, or neurologically impaired babies may have difficulty. Quite often, a baby will display an excessive rooting reflex. You can manage this by firmly supporting the baby's body and head through proper positioning. It is also important to assist the baby with mouth closure by supporting the jaw. Regardless of the issue, it is critical to treat the underlying problem.
  • Tongue protrusion or thrusting: One treatment includes applying firm, downward pressure to the tongue to push it down and out. Another technique is to walk your fingers back on the tongue to achieve the same goal.
  • Tongue-tip elevation: The tip of the tongue is raised up against the hard palate, just behind the area of the mouth where the sockets of teeth should be. In this case, putting the breast in the mouth is problematic. You may need help from a lactation consultant and/or a swallow specialist.
  • Weak suck: Typically, if a baby is sucking too weakly, the breast continually comes out of his mouth, with even the slightest movement on the mother's part. Also, milk leaks out of the baby's mouth while he is nursing. Overall weakness can be a contributing factor, or the baby may have respiratory or endurance problems. Helping the baby to have a stronger suck and increasing the flow of milk are the keys to changing a weak suck. Ensure that the baby's latch and positioning are correct, and be sure to support his cheek and jaw support.

Premature Babies

If your baby is premature, you may notice that he has a combination of sucking issues. The most common are:

  • Disorganized or inefficient sucking patterns
  • Impaired tongue shaping or movement
  • Irritability
  • Low control of posture
  • Poor ability to awaken and to stay alert at the breast
  • Trouble synchronizing the suck and swallow with breathing
  • Weakened lip seal
  • Weakened stability of the inner cheek

One commonly seen complication in premature babies is Infant Respiratory Distress Syndrome (RDS). This can have a negative impact on feeding as well. Babies with RDS have difficulty synchronizing their sucking, swallowing, and breathing. They cannot withstand long feeds and tire easily. As a result, they do not have an adequate intake of nutrition and may need to be fed with a tube.

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  • Cherney LR. Clinical management of dysphagia in adults and children. 2nd edition. Gaithersburg, MD: Aspen. 1994.
  • Wolf L and Glass R. Feeding and swallowing disorders in infancy: Assessment and management. Tucson, AZ: Therapy Skill Builders. 1992.

By Melissa Kotlen
Melissa Kotlen is an International Board-Certified Lactation Consultant and Registered Lactation Consultant.