Now that you’ve considered the factors under your control that can affect milk production, its time to explore those that affect baby’s ability to nurse effectively. If your milk production decreased because your baby has been unable to remove milk well, it can be a challenge to narrow the possible reasons down to an actual cause. You may need to work closely with your pediatrician and lactation consultant to find definite answers. The information in this blog will help by providing an overview of reasons babies may not be able to breastfeed effectively.
The Milk Supply Equation
Sufficient glandular tissue
+ Intact nerve pathways and ducts Adequate hormones and hormone receptors
+ Adequately frequent, effective milk removal and stimulation (baby’s side)
= GOOD MILK PRODUCTION
Effective sucking depends on the baby’s ability to coordinate the use of his tongue, cheeks, palate, jaw, facial muscles, and lips. Any significant variations or problems may affect his ability to remove milk efficiently.
The clearest evidence for a sucking problem is painful nursing and a nipple that comes out of baby’s mouth significantly misshapen, bruised, cracked, or bleeding. On the other hand, a baby with a weak suck isn’t able to draw out his mother’s nipple much at all. As mentioned in BLOG__5, the longer a mother receives pain medications during labor, the greater the chance they will affect baby’s sucking ability until his body has eliminated them. Suck problems can also occur as the result of anatomical malformations or underlying problems such as torticollis, a tightening of some of the neck muscles. Newborns can develop disorganized sucking habits as a result of not getting enough milk out of the breast: they were born sucking well, but then their sucking movements deteriorated as they desperately tried alternate ways to get milk from the breast. Babies are smart, and when one thing doesn’t work, they try another. Once they experience a little success at the breast and discover the movements that draw milk out most effectively, the suck often improves spontaneously without any other intervention.
Accurately identifying and resolving suck problems can be a challenge even for lactation consultants. The first steps are to ensure that baby is latching as deeply as possible, feed him adequately in a way that is supportive of breastfeeding while you work to solve the problem and pump as needed to maintain maximum milk production. When those bases are covered, some lactation consultants may refer you to another specialist for suck training exercises or special feeding methods that encourage baby to move his tongue more effectively. At-breast supplementers or special bottle nipples may also be used. If these techniques don’t work, the baby should be evaluated by a healthcare provider who specializes in identifying and treating suck dysfunction.
When anatomical problems have been thoroughly assessed and ruled out, therapies that treat nerve impingements or other subtle interferences are worth exploring. Some babies respond positively to infant oral motor function therapy by a speech or occupational therapist.1 Chiropractic treatment also can be effective in improving some suck problems.2 A third option is craniosacral therapy (CST), a very gentle manipulation of the plates of the skull to release subtle pressures on nerves affecting muscles and reflexes. CST has been effective in improving some suck problems.
A baby’s ability to draw milk from the breast depends on his ability to move his tongue freely. In order to grasp an adequate amount of breast for latching deeply, his tongue must comfortably extend past his lower lip. To stabilize the breast, the sides of the tongue need to be able cup it. Finally, the tip of the tongue needs to be able to lift higher than halfway when the mouth is open, while the back of the tongue needs to lift and then drop to create the vacuum that pulls out milk. Infants with tongue-tie, also known as ankyloglossia, lack the tongue mobility to breastfeed effectively because the membrane that connects the base of the tongue to the floor of the mouth, called the lingual frenulum or frenum, is too tight and restrictive. While a normal frenulum is hard to see in an infant, a tight frenulum attaches on the bottom side of the tongue anywhere from the base of the tongue to the tip and connects to the floor of the mouth anywhere from the base of the tongue to the top of baby’s gum ridge. It may look like a thin, stretchy web that is almost transparent, or it may be more like a thick rope or knot. A submucosal frenulum runs under the floor of the mouth, often pulling the floor up when the baby tries to lift his tongue, like a rope pulling up the center of a carpet. Any type of tight frenulum can lead to feeding fatigue, poor milk transfer, slow weight gain, and ultimately, low milk production if the baby cannot remove milk effectively from the breast.
Because tongue-ties occur in a number of variations, the effect on baby’s suck depends on where the frenulum connects. With an attachment close to or at the front of the tongue, only the sides of the tongue can rise when baby tries to lift it, sometimes forming a characteristic heart shape. A notch may be visible at the tip when he attempts to extend his tongue, or the tongue tip may even roll downward. When the frenulum is attached tightly at the base of the tongue, the tip is able to lift more but still not as much as it should, while the back cannot rise and drop enough to create a good vacuum. As a result, a frenulum attached too tightly to the base of the tongue can be even more problematic.
Clues that a baby is tongue-tied include latch trouble, sucking blisters on the lips, chronic sore nipples, “clicking” or “popping” sounds during breastfeeding, a persistently abraded nipple, or a flattened nipple when baby unlatches. A “bunching” of the back of the tongue may be felt as the baby tries unsuccessfully to maneuver, resulting in friction to the nipple. He may have difficulty opening his mouth widely enough to latch deeply because the tight frenulum is pulling on the hyoid bone in the neck that supports the root of the tongue, which in turn pulls the jaw muscles. Inadequate feedings are common as baby wears out from his efforts before his tummy is full, and tongue tremors may be visible as he tires. He may fall asleep quickly and awaken hungrily a little later, or feedings may feel more like marathons as he slowly keeps working to fill his belly.
The most common treatment, frenotomy, divides the membrane with surgical scissors or laser to release the tongue. In most cases, a frenulum connected to the front part of the tongue is very thin with little or no blood vessels or nerves in it, so there is very little bleeding or discomfort when it’s cut. A tight frenulum at the base of the tongue is thicker and so may bleed slightly more. The procedure itself takes only seconds; baby may feel some stinging, but generally a frenotomy is no more traumatic than an immunization shot, and in most cases baby can usually be put to the breast within a minute or so for soothing. Frenotomy is safe, rarely has complications, and is highly effective when performed correctly. After the procedure, your lactation consultant may suggest special exercises to help baby relearn effective tongue movements. Until the frenotomy can be done, or especially if it isn’t done for some reason, it may be necessary to pump after feedings to ensure thorough milk removal and provide any necessary supplement. Lactation consultants usually know local health care providers often ear, nose, and throat (ENT) specialists who are able to knowledgeably assess and treat a tight frenulum. Some less experienced providers will acknowledge the impact of tongue-tie on breastfeeding but suggest waiting to see if the frenulum will stretch or break on its own. This may not happen enough or at all, though, which is why there are older people who still have a tight frenulum. Rather, the mouth will enlarge as baby grows so that he is able to take in more breast tissue; it is hoped this would improve stabilization and milk transfer, but it does not always do so. Relying on this enlargement is likely to jeopardize your milk supply and decrease the likelihood of successful breastfeeding. If weaning is recommended, this eliminates only the breastfeeding issue. Babies with a tight frenulum can still have difficulty with bottle- feeding, speech impediments, reflux, dental malformations (eventually requiring orthodontic care), indigestion, snoring, and sleep apnea. Tight frenulums can even make swallowing pills and licking ice cream cones difficult.2 While tongue-tie is the most well-known type of frenulum restriction, another type that can also cause latch problems involves a similar membrane inside the center of the upper and lower lips, called the labial frenum or frenulum. When this membrane is tight, it may prevent baby from flanging his lips widely, and he may purse them instead, resulting in a shallower latch. If it extends into the upper gum, it can cause a gap between the front teeth that becomes more prominent in adulthood. Labial frenulum restrictions can occur alone or together with tongue-tie and are also easily treated during infancy In discussing the possibility of tongue-tie with your baby’s doctor, it may be helpful to refer him or her to Supporting Sucking Skills in Breastfeeding Infants by Catherine Watson Genna, B.S., IBCLC, for detailed tongue-tie diagnostic criteria and treatment information If your baby’s doctor is reluctant to treat the frenulum but you believe that treatment would benefit you and baby, don’t hesitate to ask your lactation consultant for a referral to another practitioner who is familiar with their diagnosis and treatment.
The Murphy Maneuver
If baby is having trouble breastfeeding and you aren’t sure if he is tongue-tied, San Diego pediatrician Dr. James Murphy suggests pushing your little finger to the base of the tongue on one side and sweeping it across to the other side to see what you can feel. If you feel little or no resistance more than a small “speed bump, then most likely there is no problem. Should you feel a large speed bump that you can get past with a little more effort, it is most likely a “tree trunk frenulum, a short, wide band of tissue buried in the floor of the mouth and attached to the base of the tongue. It usually, though not always, restricts tongue movements and causes latch problems even though it looks like there isn’t enough there to be a problem. When you can’t sweep your finger across without pulling it back to “jump over a fence,” the frenulum is a fibrous band attached closer to the front of the tongue. It may be buried underneath the floor of the mouth or visible as an external web. If you see a narrow white streak running down the middle of the floor of the mouth that feels like a wire, it usually extends to the front of the tongue like a string. Pushing your finger into this “piano wire frenulum will often cause the tip of the tongue to tilt downward and the center of the tongue to pull down and crease along the middle. “Tree trunk,” fence and “piano wire” frenulums are red flags for significant tongue function impairment.
Variations in the shape of the palate may affect baby’s ability to maintain the suction that helps keep the breast in his mouth and creates the vacuum to remove milk. You can feel your baby’s palate by offering him a clean finger to suck on, with the pad of your finger pointing up. A normal hard palate slopes gently upward from front to back until it becomes the soft palate in the back. The sides are wide, and the pad of your finger should rest comfortably in it, touching the top.
A high palate is shaped like a dome with steep sides, and the top is not as easily touched when the baby sucks on your finger (pad side up). Variations that feel like a fingerprint indentation are known as “bubble” palates. Babies who have high palates may not be comfortable drawing the breast in deeply and tend to gag easily. After initially latching deeply, they often pull back into a shallower position where suction breaks more easily, frequently causing characteristic clicking sounds.
While some unusual variations in palate shape can be genetic, most high palates are caused by problems with tongue mobility. As the baby grows in the womb, the tongue shapes and spreads the palate. When tongue movement is restricted, so is spreading. Bubble palates and tongue-tie are commonly found together.
A baby with a high palate needs to be encour- aged to accept the breast more deeply in his mouth. Lying on your back with baby on top of you, tummy to tummy, can help by naturally encouraging head extension and drawing the hyoid bone forward to increase baby’s tongue reach and grasp. Whatever position you nurse in, encourage him to open his mouth widely and keep him tucked close to the breast. CST and treatment for tongue-tie, if present, can be effec- tive in helping the palate to spread after birth. In the meantime, extra pumping may be needed to maintain your milk supply.
Probably the best-known palatal problem is a cleft of the hard palate, with or without cleft lip When there is an opening in the hard palate, it’s almost impossible for baby to create the vacuum necessary to hold the breast and draw out milk. Babies with only a cleft lip should be able to form a good seal if they are positioned in a way that allows the soft tissue of the breast to fill in the cleft. Those with a cleft of the hard palate, however, are rarely able to form an effective seal even with an obturator (a customized device that temporarily covers the cleft).
The baby with a cleft of the soft palate has similar problems and challenges. Because the hole is less visible, it may not be noticed in the early newborn exams and may be detected only when the baby has difficulty feeding.
A subtle, lesser-known variation is a submu- cosal cleft of the soft palate. The surface of the soft palate is intact, but there is an opening in the muscle underneath that may cause an inadequate closing of the soft palate muscle, known as the velopharyngeal sphincter, resulting in a condition called velopharyngeal insufficiency. This condition makes it difficult for the baby to maintain adequate suction. Submucosal clefts are hard to detect. There may be a slight V-shaped notch where the hard and soft palates meet, and the uvula, the hanging flap of tissue in the back of the mouth, may be split. A baby witlh a submucosal cleft will have difficulty staying attached to the breast and may slip off easily when you move. Clicking sounds from suction breaks frequently occur when he is nursing. On occasion, milk may come out of his nose as he feeds or spits up. Most tellingly, he may not gain weight well. Interventions for submucosal clefts of the soft palate are rare. Because they are tricky to identify, time may have elapsed and milk production may be diminished before the situation is discovered. If baby’s suck feels weak and neither you nor your lactation consultant can pinpoint the problem, ask your pediatrician to observe a feeding and examine baby’s moutłh more thoroughly to rule out anatomical problems. If the pediatrician can’t determine the source of the problem, ask for a referral to an ear, nose, and throat specialist, or otolaryngologist, for a more thorough evaluation.
Cleft lips are one form of facial abnormality. Others include non-symmetric facial features, which may become more noticeable as the baby grows, or small jaws, called micrognathia. When the chin and lower jaw are small in relation to the rest of the face, baby’s tongue is also small, making it difficult to extend it out far enough to breastfeed effectively. Some babies go on nursing strikes or eventually refuse to eat solids because it hurts to move the jaw. There may also be underlying facial nerve damage affecting suck. Special positioning and latch techniques may be required to help this baby breastfeed. In many cases, he just needs time to grow in order to breastfeed well. In the meantime, pumping will help to maintain good milk production.
A baby who cannot breathe easily will have difficulty coordinating sucking and swallowing with breathing, which makes it challenging to remove milk well enough to sustain good milk production. Sometimes the cause is as simple as secretions blocking the nostrils. These can be softened with your milk or sterile saline water and then gently suctioned out prior to feeding Chronic stuffy noses may be due to allergies, and removing the offending substances from the environment or your diet may help. Talk with baby’s health care provider for guidance about minimizing allergy symptoms, Narrow nasal passages or other structural blockages of the nose can also interfere with breathing when the baby is eating. Fortunately, as baby grows larger the passages usually enlarge as well. In rare cases, surgery may be required.
Laryngomalacia and tracheomalacia occur when parts of the larynx, pharynx, or trachea (windpipe) are “floppy” due to poor development, causing a high, squeaky, wheezy sound known as stridor when baby cries or feeds. The baby may struggle at the breast, feeding in very short sucking bursts (three to five sucks) with long breaks to recover. He also may hold his breath for several sucks and swallows or let go of the breast entirely in order to grasp and pant and catch his breath. He often ends the feeding before he is full simply because he is too tired to continue. As a result, he may not take in enough milk to gain weight well, and milk production may suffer over time. Severe cases are usually caught early and only rarely corrected with surgery. The more common mild to moderate cases often go unno- ticed unless they are causing a problem. These conditions usually resolve on their own by the end of the baby’s second year.
Maintaining as open an airway as possible is crucial if your baby has breathing issues. Position him at the breast with his neck extended back to open the airway further and make breathing easier for him. Keeping him in a more upright position is also helpful. Pacing the feedings by initiating periodic breaks before he falls behind is usually necessary, especially if baby routinely holds his breath for too long Milk production may need to be supported with pumping until feedings improve.
Babies who have heart problems breathe more rapidly to get enough oxygen into their bodies. They tire easily in normal activities and so may end feedings before they get all the milk they need. A feeding strategy that minimizes the effort they expend is important since their faster breathing and heart rates use more calories Breastfeeding is easier than bottle-feeding and provides higher and more stable oxygen levels. Massaging the breast before feeding and breast compression during feeding can help get more milk into the baby with less effort on his part. It may be necessary to pump after feedings in order to maintain an adequate supply, Many babies with cardiac difficulties do well with at-breast supplementation, but others may require supplementary bottles. The good news is that these babies usually breastfeed much better after the heart defect is corrected surgically.
Nervous System issues
Nerves send messages to the brain about sensations such as pressure, taste, or temperature and also allow the brain to direct the actions of muscles, including those used for sucking, swallowing, and breathing. Nervous system-related feeding issues can result from hereditary problems, prenatal drug exposure (recreational or prescription), trauma, cerebral palsy, Bell’s palsy, or certain other medical conditions, Some nervous system issues can be explained by developmental immaturity, while in other cases there is no good explanation at all. Whatever the cause it may take time for baby’s sucking to improve Some babies with nervous system issues need supplementary feedings, which may require you to pump in addition to breastfeeding to maintain your milk supply.
Low muscle tone, or hypotonia, is common in babies with Down syndrome but can also occur in other infants with neurological issues. Babies with low muscle tone have difficulty with all aspects of latching and sucking-getting a good seal on the breast, maintaining suction, and Using the tongue properly to remove milk. The suck may feel weak or “light.” There may be dimples in baby’s cheeks while feeding, and because he does not maintain suction well, he may fall off the breast easily. Babies with low muscle tone may tense key muscles around the lips in an attempt to stabilize their position at the breast and compensate for other muscles that are not doing their job. This can be tiring and stressful. The baby may nurse well at first, but as the muscles tire, it becomes more hypotonia babies tend to nurse better later in the day and into the night as they slowly gather tension in their bodies.
The Dancer hold is a special way of holding the breast while simultaneously supporting baby’s face to stabılize his jaw and cheeks so that he can put all his energy into sucking, When cradling baby in your arm, slide your opposite hand under your breast, palm up, and put your thumb on one side of baby’s lower jaw and your index finger on the opposite side, Curl vour third finger and place lightly under baby’s chin (you’ll have two fingers left underthe breast).
Babies with hypotonia also benefit from being flexed at the hips while nursing because it helps them organize their sucking better. Good flexioin keeps ear, shoulder, and hip in line but bends baby at the hip joint so that he “wraps” or “curls around your body.
Infants with hypertonia have very tight, tense muscles. Their bodies feel stiff, and they don’t flex, cuddle, or relax easily into a parent’s arms They tend to breastfeed fitfully and poorly, popping on and off the breast. It is not uncommon for them to clench their jaws while nursing or even clamp down on the breast with their gums. Because of the feeding difficulties, your nipples may be sore and your breasts may not get enough stimulation to sustain good milk production
Hypertonic infants tend to nurse best in the night and morning hours, before the day’ tensions increase their muscle tone still more. Prior to breastfeeding, try placing baby in a blanket with the four corners gathered and then swing gently in a head-to-toe direction to help him relax. Rocking or walking around with baby snuggled closely, even skin to skin, may help. Swaddling baby into a moderately flexed position is another technique that may calm him and help him to focus. Positioning baby by your side with his feet pointing behind you, commonly called the “football” or “clutch” hold, to feed can help maintain this flexed position, as will holding baby in the traditional position with his chest against your abdomen and his hips flexed to wrap around your side. Conversely, some hypertonic babies breastfeed better when allowed to stretch out on a pillow. Experiment with different approaches to find what works best for your baby.
Sensory Processing Disorders
Sensory processing disorders, also known as sensory integration dysfunction, are not easily diagnosed in an infant. Sensations that are usually interesting or pleasant, such as the brush of a hand or a soft touch, can be aggravating and even intolerable to these infants. They are often irritable, adapt poorly to changes in their environment, and may seem terrified of movement. They find it hard to tolerate noise and the touching involved in baths or diaper changes. Or they may seem to crave movement, needing to be carried much of the time. Some have difficulty interpreting sensations and actively try to avoid those that bother them. These sensitive infants may not breastfeed well because they are overwhelmed by sensory input and will arch away from the breast, cry, latch poorly, and release the breast frequently, which can be mistaken for high or low supply. Milk production can suffer over time if the baby does not breastfeed effectively due to his heightened sensitivity. Sensory defensive infants often respond better to firm touch with deep pressure; smooth, soft fabrics without irritating zippers, tas, or rough seams; swaddling; swinging head to toe before breastfeeding; breastfeeding in a sling: and low light and noise levels during feeding.
Some sensory defensive infants may feel calmer with direct skin-to-skin contact rather than being clothed or swaddled. Others breastfeed better with minimal touching, sometimes preferring to rest on a pillow on your lap rather than being held in your arms. Babies who do not sense the breast well while latching may re- spond best when the nipple is aimed downward toward their tongue rather than toward the palate. They also may be more willing to latch on to a nipple shield because of the firm sensation it provides.
If you suspect that your baby’s latch or sucking problems may be due to sensory issues discuss your observations with your pediatrician and request a referral to an occupational therapist or early intervention program for a formal assessment. These experts are trained to help infants with sensory processing disorders and can provide helpful guidance. A skilled lactation consultant may also have ideas to help your baby nurse better and can work with the occupational therapist.
In the meantime, you may need to do supportive pumping until the baby is able to handle the job adequately himself.
The Large, Small, or Early Baby
Gestational age and overall development at birth can affect a newborn’s ability to thrive at the breast and maintain adequate milk production. Premature babies have less stamina and can fatigue quickly: they may also have poorer muscle tone that interferes with effective suckling (See _blog_14). Borderline early babies (thirty- five to thirty-seven weeks) can look deceptively normal yet not be mature enough to nurse well. Infants who are small or large for gestational age have been affected by something in the uterine environment that may also affect their ability to breast-feed. In all of these situations, “insurance pumping” after feedings is wise until the baby is breastfeeding well enough to maintain a good milk supply.
In some cases of poor infant growth, an underlying infection, such as a urinary tract infection, may be the culprit. Energy requirements may be higher and growth can slow down when the body is fighting an infection. If the baby is suddenly not feeding well or his weight gain has slowed down, it is important to ask your doctor if underlying infections or other health conditions could be the cause.
Gastroesophageal Reflux Disease
All babies spit up some, and some babies spit up a lot. Most of the time it is largely a laundry problem. But there are babies who have such signifi cant problems with milk coming back up (reflux) that eating becomes painful and unpleasant. Their condition may be obvious because they regurgitate large amounts after and in between feedings, or they may have a “silent” version of reflux in which partially digested milk comes just far enough up the esophagus to cause burn- ing sensations and sometimes interfere with breathing, making the baby cry and choke. This is usually diagnosed as gastroesophageal reflux dis- ease (GERD). Infants with GERD may begin to associate feeding with negative consequences (“I eat, then I hurt”) and then put off feedings, eat ing only when they absolutely have to, resulting in slow weight gain. This, of course, can affect milk production as well.
GERD often is simply a problem of immaturity, but it also may be triggered by sensitivity to a protein, often dairy in your diet, that passes into the milk. Sometimes it can even be a mechanical issue such as misalignment of the spine or cranial plates, or a side effect of tongue-tie. Regardless of the cause, all babies with GERD benefit from smaller, more frequent meals; having their heads higher than their bottoms during feedings; being kept upright for twenty minutes after eating; and being laid down to rest with the head of the bed elevated. Medication may be prescribed, and sometimes tests are necessary to determine exactly what is happening. If your production is low because the baby doesn’t seem to like breastfeeding and exhibits some of these behaviors, it may be helpful to discuss the possibility of GERD with his doctor. In the meantime, if necessary, you know what to do to maintain your milk production-pump! That will buy you time until breastfeeding improves.