Hidden Latch Problems

We love the "simple" breastfeeding latch problems that only require an adjustment in positioning to help a baby come on the breast comfortably. During lactation consults, we show moms how to support their baby's shoulders, turn the baby's body in towards them, and wait for the baby to open wide before hugging the baby "chin first" deeply onto the breast. There are all kinds of little tricks and tips like these that can transform a painful, inefficient latch into one that is both comfortable and effective at removing milk. (See these tips in action in these videos.) After making some positioning changes, most moms we work with notice instant improvement. But then there are those other times where the mom seems to be using ideal positioning but nothing she tries results in a "good" latch. We know its not a good latch because she feels discomfort, the nipple comes out of baby's mouth looking pinched, or baby is having a hard time removing the milk. Sometimes clicking sounds can be heard while baby suckles or feedings routinely take much longer than expected. What is the cause of these problems, when positioning adjustments don't "fix" latch difficulties? 

Lactation specialists are becoming increasingly aware of the role of tongue and lip ties - also known as tethered oral tissues and ankyloglossia - in breastfeeding problems. A tie occurs when the tissue under the tongue (or elsewhere in the mouth) called a frenulum restricts the movement of the tongue or the lips. The restriction may be happening because the frenulum is either too short or too tight to allow normal range of movement. A baby needs to be able to stick his tongue out past the lower lip, cup it around the breast tissue, and lift it in a wave-like motion in order to effectively remove milk from the breast and protect his airway in the back. Its a surprisingly complicated feat for a baby to suck, swallow and breathe effectively! When any direction of the tongue's normal range of movement is inhibited, this can create problems. In order to properly assess for tongue and lip ties, it is critical to assess not just the visual appearance of the tongue but actual, functional movement of the tongue. A quick glance in the mouth will only reveal a minority of ties that are present at the tip of the tongue. Many tongue-ties are hidden behind a thin wall of tissue, making them impossible to see. They can be "felt" (palpated) by a trained specialist doing an oral exam with a gloved finger, or can be detected based on symptoms and the limited range of motion. Likewise, lip ties need to be evaluated based on function. Almost all babies will have a frenulum connecting their upper lip to their gum, but this connective tissue should not make it difficult for the lip to lift up to touch the nose. This flexible lift enables baby to form a seal on the breast necessary for good suction (and prevents swallowing air). Thankfully, there is treatment for tongue and lip ties. The restricted frenulum is freed either by clipping it with scissors or cauterizing it with a laser (this is usually done by an ENT or dentist who has had additional specialized training). It can be difficult to find a provider who is skilled in evaluating and treating ties, so be sure to meet with your lactation consultant for a helpful referral. In the graphic below, tongue-ties are described by Type 1-4 which is based on the location, not the severity, of the tongue-tie. Type 1 tongue-ties are often caught earliest, whereas type 4 tongue-ties may not become apparent for several weeks after birth.

2. Malpositioning In-Utero & Birth 

Occasionally babies are positioned in unusual and awkward ways during pregnancy and/or delivery that puts uneven pressure on their head, neck and shoulders. This pressure can lead to tight muscles, tendons and misalignment. You can imagine if a baby presents in an asynclitic (crooked) or posterior ("sunny side up") position during labor, the pressure of contractions could easily lead baby to feel discomfort or experience tightness in the first few weeks after birth. This may result in baby having difficulty opening his mouth wide, feeling discomfort when breastfeeding, or favoring one side/breast. Sometimes a pediatric chiropractor is able to restore baby's alignment and help baby feel more comfortable. Other specialized "bodyworkers" may be able to help, including  craniosacral therapists, physical therapists, and infant massage therapists. Parents can also help with this at home by massaging baby's neck and shoulders and making sure baby alternates head positions during sleep. See the videos here for more tips.

Acynclitic presentation

3. Overuse of Swaddles & Containers 

Infants who spend significant amounts of time with their movement restricted by swaddles, certain sleep sacks, or containers (seats, bouncers, car seats, rock n plays etc) tend to have very tight muscles and fascia that can greatly affect their ability to latch well. To obtain a deep latch, an infant needs to comfortably coordinate movements towards the breast, including placing one hand on each side of mother's breast, tipping their head back into a semi-arched position and lifting their chin up towards the breast ("extension"). Signs that generalized tightness are impacting a baby's ability to latch may include baby's chin resting on their chest ("no neck"), arms tight against chest (can't comfortably lift arms up over head or out to side), hips/pelvis tight and can't easily twist and roll, and baby crying immediately in tummy time. To combat this, we recommend using swaddling only at night and only as needed if baby isn't sleeping 3 hour stretches. Discontinue all swaddling and restrictive sleep sacks by 2 months of age or when baby starts sleeping 3+ hour stretches. Instead of purchasing seats or swings, place baby on a flat surface when he/she is not being held such as a floor mat or dock a tot where baby will naturally have some extension (chin OFF chest!) and room to move. Floor play is essential as babies move past the first month. We recommend incorporating at least 10 minutes of tummy time after every nap after the first month. Although it might not seem related, the skills and movements babies practice when their movement is unrestricted makes a huge difference in how well they can latch, as well as their ability to reach developmental milestones.

4. Fit Issues 

Occasionally, mother and baby have "fit issues," meaning mother's breast/nipple shape and size don't seem to fit well inside baby's mouth. Although positioning tricks will help compensate for these differences, time is often the best medicine. As baby's mouth grows, fit issues typically resolve on their own by two months of age at the very latest. Meanwhile, sometimes it is necessary to use a nipple shield or pump as a supportive measure until breastfeeding is going well. A lactation consultant can help you come up with a plan.

5. Unusual Conditions 

There are many other less common reasons for latch difficulties. Sensory processing dysfunction, high or low muscle tone, and various genetic and neurological problems can all effect breastfeeding. Baby may not be diagnosed until he or she is older (sometimes years older) and other symptoms become apparent. If you are concerned about the possibility of an underlying condition, talk to your child's pediatrician and your county's early intervention agency.

Mamas in the north Charlotte and Lake Norman area, if you feel like you are experiencing latch problems, we encourage you to setup a home visit so we can help you address these issues.  We can evaluate the latch, help you adjust positioning and determine if a referral is needed to another healthcare provider. If you are out of our travel area, you can setup a virtual consult with us or google "lactation consultant near me" to find local help.