Message: Hi, I have enjoyed hearing both of you talk at conferences through the years, and feel I’ve learned so much from you both. I have a mom and baby I am working with that has me puzzled. Baby was only 5-11 at delivery, 37.5 weeks, and was on bottles for the first two weeks while mom pumped. Great milk supply. He does not have a tongue tie, but has issues extending his tongue. We tried a nipple shield, and without, he’ll do fine occasionally and then resort to biting again. Mom has discovered that she can get him on in the semi-reclining (nurturing?) position, but then he bites with the upper gum. He has a high palate, could this be the cause of him biting with the upper gum? The only thing I could think of. She does have ‘smallish’ nipples, which gives him less to get his tongue under. She is very determined and I want to help her succeed. Any suggestions??
Suzy Adams, RN, BSN, IBCLC
There are so many variables in a case such as this. The late preterm (34 to 37 weeks gestational age) infant has an elevated risk for feeding problems. They tend to be weak breastfeeders. They also struggle while bottle feeding and often cannot coordinate sucking, swallowing and breathing. Signs of this can be that they spill milk from the corners of their mouth and gasp/choke during bottle feeds. These struggles can cause them to do funny things with their tongues to defend their airways. They may pull back the tongue or hump the tongue to block a too-rapid milk flow. So this learned, protective behavior may explain why they don’t cup and extend the tongue. They may then transfer this behavior to the breast, where it hinders breastfeeding.
Another idea to consider is that this infant may have a stage 4 tongue-tie – the most serious form of ankyloglossia. In such cases there is not a visible frenulum under the tongue. The tongue is simply abnormally adhered to the floor of the mouth and can neither lift nor extend normally. Because the tongue shapes the palate during fetal development, the presence of tongue-tie may alter the shape of the palate, often creating a “bubble palate.” If you look at the attached photo, you will see a baby whose tongue is both short and unable to lift to the upper gum ridge. Note the deep concave shape of the palate. Compare this photo to the one of the baby with the normal tongue, which easily lifts to the upper palatal ridge. Remediation of stage 4 tongue-tie requires a more involved surgical intervention than does a simple release. Many physicians are still unclear on diagnosis and treatment of the condition, although research is beginning to offer more insights for practitioners.
I have not personally seen very small nipples be a problem for normal babies. The biting you report is probably a compensation of some kind that helps the baby hold onto the breast. In cases where tongue mobility,muscle tone, or palate shape are problematic, the baby often clenches with the jaws to keep the breast in the mouth.
A nipple shield is actually a smart temporary solution/intervention. It can give this baby more tissue to hold onto, helps to bridge the baby to the breast and away from the (by now familiar) bottle. Research suggests that shields decrease the work of feeding for weak or small babies. Over time, as the baby matures and gets bigger, the LC works to help the mom move away from the shield, but only as the baby can demonstrate improved sucking without it. If you use a shield, I would suggest taking test weights to make sure the baby transfers adequate amounts of milk from the breast with the shield in place. If needed, the mom should do “insurance pumping” to protect her milk supply. Using biological nurturing positions and lots of skin-to-skin holding will help protect “breast focus” and give the baby many opportunities to practice. The trick is to practice when baby is not too hungry so that there is no pressure. We want the mom and baby to just enjoy being close.
The final message to communicate to the mom is that this set of problems may resolve over time as the baby gets bigger, providing she maintains an adequate milk supply. Persistence on her part is key to overcoming the obstacles they are facing! If there is an ENT,pedodontist, or other HCP in your area who can assess for tongue-tie, this would be useful, even if just to rule out tongue-tie as the problem. If ankyloglossia is present, ideally the tongue can be released.
Barbara Wilson-Clay, BS, IBCLC, FILCA
Coryllos E, Genna CW, Salloum AC: Congential tongue-tie and its impact on breastfeeding. AAP Breastfeeding: Best for Baby and Mother 1-6, Summer 2004
Engle WA, Tomashek KM, Wallman C and the Committee on Fetus and Newborn: Late-Preterm infants: a population at risk. Pediatrics 2007; 120(6):1390-1401.
Hong P, Lago D, Seargeant J, et al. Defining ankyloglossia: A case series of anterior and posterior tongue ties. International Journal of Pediatric Otorhinolarhyngology 2010; doi:10.1016/j.ijport.2010.05.025.
Meier P, Brown L, Hurst N, et al. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. Journal of Human Lactation 2000; 16(2):106-114.