One possible explanation for why your baby is not getting enough milk at the breast that he is moving his mouth and tongue incorrectly while nursing. Potential problems include: a tongue that moves side to side or back to front instead of front to back, pulling the tongue back in the mouth or thrusting it forward, jaw clamping, weak suction, or repeated breaking of the suction. The clearest evidence for a sucking problem is a distorted nipple after the baby lets go of the breast so that it is not as round after feeding as it was before. On the other hand, a baby with a very weak suck can not draw out the mother’s nipple at all. There are many causes of suck dysfunction, ranging from injury caused by deep suctioning of the baby’s mouth and throat at birth, to anatomical malformations, to underlying health problems.(1) A detailed discussion of tongue-tie, one common cause of suck dysfunction, is included below.
Some babies develop disorganized sucking habits as a result of not getting enough milk out of the breast. These babies were born sucking well, but then their suckling ability deteriorated over time as they became weaker from lack of calories, or as they did not receive adequate reward (milk) for moving their tongues correctly. Babies are smart, and when one thing doesn’t work, they will try another. Once they are receiving enough milk, many babies’ sucks will improve spontaneously, without any other intervention, because they are then being rewarded with milk when the tongue moves correctly.
Other babies may have temporary problems with suckling due to the effects of medications mother received during labor. They may be sluggish in the first days after birth and have difficulty sensing and cuing upon mother’s soft nipple in their mouth; mothers of such babies report that it can take many days for their babies’ to react more alertly and their suck to become organized and efficient. In these cases patience, and support with feeding, if necessary, are important while baby’s still-maturing body eliminates the medications.
Accurately assessing and resolving sucking problems can be difficult and is a challenge even to lactation specialists. The first step is to ensure that the baby is latching as deeply as possible, and to make sure that he is being fed adequately while you work to solve the problem. Several “suck training” methods have been developed over the years to help infants who do not respond to techniques designed to encourage a deeper latch.(2), (3), (4) Special artificial nipples or at-breast supplementers are used by some lactation specialists to help resolve suck dysfunction.(5) Any baby that is not sucking correctly by the end of the first two weeks should be evaluated by a doctor who specializes in identifying and treating anatomical problems such as tongue-tie, including the forms of tongue-tie that are more subtle, but yet more problematic. When anatomical problems have been thoroughly assessed and ruled out some babies respond positively to physical therapy by speech pathologists and chiropractors who are specialized in infant motor function and trained in techniques to resolve certain types of suck dysfunction.(6), (7) Another option is Craniosacral therapy (CST), which has been observed by lactation specialists to be effective in improving some suck dysfunctions.(8) CST is a very gentle manipulation of the plates of the skull.
Click here for a list of frenotomy surgeons
A baby’s ability to milk the breast well is dependent upon his ability to move his tongue freely and effectively. A baby’s tongue plays three important roles in breastfeeding; it grasps the breast; it shapes the breast to stabilize it in the mouth; and it helps to create the vacuum that pulls the milk out of the breast. In order to grasp an adequate amount of his mother’s breast for latching deeply, a baby’s tongue needs to extend past his lower gum. In order to shape the breast to stabilize it in the mouth, the sides of the tongue need to be able lift so that it can cup the underside of the breast. In order to help create the vacuum to withdraw milk, the front of the tongue needs to lift and touch the breast so that the back of the tongue can drop. When the back of the tongue drops, a vacuum of negative pressure is created, which pulls milk from the breast.(9)
Infants with tongue-tie (also known as ankyloglossia) are not able to move their tongue freely in the ways they need to be able to breastfeed effectively because of the placement of the frenulum, the membrane that connects the base of the tongue to the floor of the mouth. The frenulum’s job is to help anchor the tongue to the floor of the mouth and to stabilize its motions. In tongue-tie, the frenulum is attached too tightly to the tongue, anywhere from the base of the tongue to the very tip. It may look like a thin, stretchy band that is almost transparent, or it may be thick. A restrictive frenulum may be attached to the floor of the mouth anywhere from mid-way to just behind the lower gum. When the frenulum extends close to the tip of the tongue, a small “notch” may be seen when baby tries to extend his tongue and the frenulum holds it back.
Tongue-ties come in many combinations, and the effect on baby’s sucking will depend on where the frenulum is attached to the tongue and the floor of the mouth. In the classic presentation, only the sides of the tongue can move, resulting in a heart shape when baby tries to extend his tongue. Other tongue-ties are not so obvious; clues may be a squared or thick tongue, a notch where the tip should be, or just the fact that baby never seems to lift or extend his tongue. According to Catherine Watson Genna, BS, IBCLC, more subtle tongue-ties cause more problems with feeding and damaged nipples than the classic tongue-tie that extends to the tip of the tongue.(10)
Tongue-tie can lead to low milk production problems, since the baby cannot effectively remove milk from the breast. But there will be earlier indications that a baby is tongue-tied: latch problems, chronic sore nipples, “clicking” or “popping” sounds while baby is breastfeeding, shortened feedings (baby quits early), or prolonged feedings because baby is not satisfied.
Tongue-tie is not a rare condition. In one study, 4.8 percent of newborns were identified as having some degree of tongue-tie, most on the mild side.(11) Of the babies who had tongue-tie, 24 percent had significant problems with breastfeeding that lasted six weeks or longer. In another study, approximately 3.2 percent of babies were found to have “significant” (problematic) impairment of the frenulum. Thirteen percent of the mothers in that study who sought help for breastfeedinghad problems related to tongue-tie.(12) Males are more likely to have tongue-tie than females, and this condition often runs in families.
Treatment for tongue-tie consists of “clipping” the membrane with surgical scissors or by laser to release the tongue. This procedure is called a frenotomy. Most frenula are very thin and have few blood vessels or nerves in them, so there is very little bleeding or discomfort. The procedure itself takes only seconds; more time is spent immobilizing baby’s head and body in preparation. The baby may be upset about being restrained. After the clipping, there may be a couple of drops of blood, rarely more. Baby will feel some stinging, but generally a frenotomy is no more traumatic than an immunization shot. The baby can usually be put to the breast within a minute or two, where he should be easily soothed. In rare cases, a more involved procedure called a frenuloplasty may be necessary.
Some health care providers will acknowledge the impact of tongue-tie on breastfeeding but suggest mothers “wait and see” if the frenulum will stretch or break on its own. According to Dr. Brian Palmer, a pediatric dentist who specializes in the relationship of breastfeeding to dentistry, it is very rare for frenulums to stretch or break. He cites many examples of 80 year old people who have intact restrictive frenula. A recent study compared the effectiveness of frenotomy for babies with tongue-tie against intensive work with a lactation consultant to help the baby breastfeed better. The researchers found that babies who had the frenotomies were immediately able to breastfeed much more easily and effectively, while the babies in the other group did not make much progress until the mothers were offered the option of frenotomy. The authors also concluded that frenotomy was safe.(13) Another very recent study examined frenotomy and also concluded it was safe, had no likely complications, and was highly effective.(14)
The “wait and see” approach can lead to more problems. If milk production is affected by the baby’s inability to nurse well, it will be necessary for the mother to pump after feedings to ensure thorough milk removal and give the baby supplements of pumped milk or commercial formula. In addition, the longer the baby sucks incorrectly because of his tight frenulum, the longer it may take him to learn how to breastfeed with his tongue fully extended. All this translates into more work for both mother and baby.
Although it is often advised due to sore nipples and/or poor infant weight gain, weaning may not solve the problem. Many mothers of babies with tongue-tie find that their babies also have difficulty feeding from a bottle. Dr. Palmer has also documented that restrictive frenulums may cause more harm beyond feeding difficulties. It has long been known that they cause speech impediments, but he has discovered further evidence that they also can contribute to dental malformations, indigestion, snoring, and sleep apnea, and even make swallowing pills and licking ice cream cones difficult.(15)
Forty or fifty years ago care providers were more aware that tongue-tie could cause problems with breastfeeding, but as more and more infants were exclusively bottle-fed this knowledge was lost. More recent generations of physicians have received little education on tongue-tie beyond its implications for speech in older children. But in the past five years, articles have been published in medical journals about tongue-tie’s effect on babies’ ability to breastfeed. (16), (17), (18) One particularly thorough article by Coryllos, Genna, and Salloum also appeared in the American Academy of Pediatrics Section on Breastfeeding Newsletter in the summer of 2004.(19) As a result, more health care providers are starting to take this condition seriously and refer babies to others for treatment if they do not perform frenotomies themselves. Your lactation specialist should be familiar with local health care providers who are able to to knowledgeably assess for and clip a tight frenulum. The list may include pediatricians, ear-nose-throat specialists, family practice doctors, dentists, or oral surgeons. Some midwives and nurse practitioners are also experienced in performing frenotomies.
While tongue-tie is the most well known type of frenulum restriction, there is another type that can also cause latch problems. Inside the center of the upper and lower lips is a small membrane between the lips and the gums that is called the labial frenulum or frenum. If it is noticeable and tight, it may prevent baby from flanging his lips widely as he latches onto the breast. He may purse them instead, resulting in a shallower latch. The overgrowth or overextension of upper labial frenulums are responsible for gaps between the two front teeth . Labial frenulum restrictions can occur alone or with tongue-tie and are also easily clipped when necessary.
Click here for a list of frenotomy surgeons
An excellent journal article about tongue ties
An excellent article by lactation consultant Catherine Watson Genna
Article by Catherine Watson Genna in an AAP Newletter
(1) Mohrbacher, N. The Breastfeeding Answer Book, 3rd rev ed. Schaumburg, IL: LLLI, 2003; 80.
(2) Marmet, C. and Shell, E. Lactation Forms: A Guide to Lactation Consultant Charting. Encino, CA: Lactation Institute Publications 1993; 4-11, 4-17 - 4-28.
(3) Marmet, C. and Shell, E. Training neonates to suck correctly. MCN 1984; 9:401-407.
(4) Bovey, A., Noble, R., Noble, M. Orofacial exercises for babies with breastfeeding problems? Breastfeed Rev 1999 Mar; 7(1):23-8.
(5) Noble, R. and Bovey, A. Therapeutic teat use for babies who breastfeed poorly. Breastfeed Rev 1997; 5(2):37-42.
(6) Bahr, D. Oral Motor Assessment and Treatment: Ages and Stages. Needham Heights, MA: Allyn and Bacon, 2001.
(7) Mohrbacher, N. and Stock , J. The Breastfeeding Answer Book, 3rd rev ed. Schaumburg, IL: LLLI, 2003; 80.
(9) Hazelbaker, A. The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation Consultant Private Practice. Master’s Thesis. Pacific Oaks College, 1993.
(10) Genna, C. Personal communication with Diana West. July 4, 2005.
(11) Messner, A., Lalakea, M., Aby, J. et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000 Jan; 126(1):36-9.
(12) Ballard, J., Auer, C., Khoury, J. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002 Nov; 110(5):e63.
(13) Hogan, M., Westcott, C., Griffiths, M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr: Child Health 2005; 41:246-50.
(14) Amir, L., James, J., Beatly, J. Review of tongue-tie release at a tertiary maternity hospital. J Paediatr: Child Health 2005; 41:243-45.
(15) Palmer, B. Breastfeeding and Frenulums. Presented at the 2006 Bay Area Lactation Associates Conference. Berkley, CA, USA. March, 4, 2006.
(16) Ballard, J., Auer, C., Khoury, J. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002 Nov; 110(5):e63.
(17) Livingstone, V., Willis, C., Abdel-Wareth, L. et al. Neonatal hypernatremic dehydration associated with breast-feeding malnutrition: a retrospective survey. CMAJ 2000 Mar 7; 162(5):647-52.
(18) Messner, A., Lalakea, M., Aby, J., et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000 Jan; 126(1):36-9.