Hidden Latch Problems
I 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, I 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/pulling the baby in 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 I'm working 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?
Tongue or Lip Ties
Lactation specialists are becoming increasingly aware of the role of tongue and lip ties - also known as restricted frenulums or ankyloglossia - in breastfeeding problems. A tie occurs when a normal membrane, called a frenulum, restricts the movement of the tongue or the lips. The restriction may be happening because the membrane is either too short or too tight to allow normal range of movement. A baby needs to be able to stick his tongue out over the gumline, cup it around the breast tissue, and lift it in a wave-like motion in order to effectively remove milk from the breast. Its definitely more complicated than sucking on a straw! 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" (palpitated) 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 membrane connecting their upper lip to their gum, but this membrane 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 membrane 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 check with your local breastfeeding group or lactation consultant for a helpful referral.
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.
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. Or baby's mouth is an unusual size or shape (such as high palate) that causes fit issues. 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.
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.
In short, if you feel like you are experiencing latch problems, make an appointment with your local breastfeeding specialist. She can evaluate the latch, help you adjust positioning, and determine if a referral is needed to another healthcare provider.