As the understanding of tongue tie and lip ties improves with respect to breastfeeding, so does the understanding of the long-term implications of untreated intraoral restrictions. Many of the compensations that a baby uses to make up for inadequate breastfeeding efficiency are evident when examining a baby’s latch. Some of those effects on the infant’s mouth can also be seen later as the child grows. This post will explain situations where a baby can overcome restrictions by making particular compensations, how those compensations are used, and why they can be problematic later in life.

There are numerous situations where a baby who has an oral restriction can seemingly do "well" with breastfeeding. The most common example involves focusing just on infant weight gain. How can a baby with a tongue/lip tie successfully gain weight?

This baby underwent a procedure at 5 months of age. Notice the plateau in weight gain between 4-6 months of age followed by recovery of weight after that.

Early in life, a baby can successfully gain weight by being very tenacious. These are babies who have relatively high muscle tone and can cause significant pain to mom while breastfeeding. They often have enough muscle tone to not fatigue at the breast, but because their oral restrictions make them inefficient feeders, they can feed for very long periods of time. It’s important to recognize that weight gain is not the only marker of successful breastfeeding and if mom is on the verge of quitting because pain is unbearable, the early successful weight gain becomes irrelevant.
Mom can have an overactive letdown (OALD) or oversupply. I have seen numerous situations where the baby has gained tremendous amounts of weight and mom has no pain, but the latch is completely pathologic. Why would we want to intervene in these instances? When a baby is passively receiving milk and not actually actively emptying the breast, it can predict future issues: plugged ducts, mastitis for mom from inadequate breast drainage or a sudden drop in milk supply once the signal for lactogenesis switches from hormonal control to latch quality, typically at weeks 10-16. A plateau in weight gain can follow (insert weight curve) and it can be very difficult to recover the supply once this occurs.
Supplementation with bottles may mask the issues that would have been apparent with exclusive breastfeeding. While the normal weight gain may make the primary care provider satisfied, the loss of exclusive breastfeeding is associated with shorter durations of breastfeeding. Additionally, bottle feeding can cause changes to palate architecture that have downstream effects.

Often, I see doctors, lactation consultants and parents focusing on a baby’s compensations and trying to change that behavior instead of trying to determine why the compensation is occurring in the first place. The most common compensation I see is that the baby uses pursed lips to hold on to the end of the breast. Technically, the baby is latched on. But we know from previous studies that the suction that keeps a baby on the breast should come from the tongue’s movements in the mouth (specifically from the mid-portion of the tongue). If the tongue cannot generate a seal, the baby responds by using the lips to hold on. The focus should NOT be how to flip the lips out - the focus should be on the reason the baby is using the lips in the first place.

Similarly, a tongue/lip tied baby will try to latch on the breast with a “small mouth”. They don’t open widely, and that narrow opening allows only a very small amount of breast tissue to enter the oral cavity. What results is a shallow latch that can predispose the mom to significant amounts of pain and nursing inefficiency. All too often, I hear lactation consultants say “What you need to do is to get the baby’s mouth open wider”, as if the baby is simply choosing to not open widely. Again, we must investigate why the baby has a small mouth opening when trying to latch - when oral restrictions are present, a wide latch causes the baby discomfort and tension. The baby responds by closing the mouth until the tension dissipates, which forces the shallow latch. It’s also important to realize that a baby cannot simultaneously use the lips to hold on and have a wide latch on the breast. That’s analogous to using a really wide straw instead of a narrow one when trying to drink.

Finally, I want to address why the compensations that the baby employs can cause problems in the long-term. Before that can be addressed, however, I want to explain how normal breastfeeding promotes optimal craniofacial growth. Completely normal breastfeeding is nature’s palate expander. The malleable breast is carried up by the tongue and molds the palate into a broad shelf by putting pressure on the inside of the gums. This, in turn, allows the teeth to eventually come in with adequate spacing. Many of the orthodontic problems that we see are a result of a high palate and crowded teeth (maxillary constriction). There is good evidence that breastfeeding promotes better dental occlusion (Peres, et al). The nasal septum sits on the palate (anatomically, the roof of the mouth is the floor of the nose). When the palate arches up instead of staying broad, the nasal cavity is narrowed. Furthermore, the septum has to buckle if the floor it sits on comes up - this results in a deviated septum. Both of these consequences predispose the baby to mouth breathing. While the deviated septum happens over years, the high palate can be noticed immediately after birth (some babies are very snorty while nursing). Because babies are obligate nasal breathers, the nasal obstruction can even further complicate the latch.

The palate is the hub of facial growth as a child gets older. If the palate is low and broad, the child can breathe out of the nose and there is less chance of sleep disordered breathing and sleep apnea. Breastfeeding for as long as possible (even when it’s not primarily for calories as a child enters toddlerhood) is critical for optimizing palate formation. We are starting to see more evidence for the benefits of breastfeeding for reasons previously undescribed. Guilleminault from Stanford shows the correlation between tongue tie and sleep apnea (2015), which has many downstream consequences (fatigue, difficulty concentrating, teeth grinding, bedwetting, behavioral issues and even symptoms mimicking ADHD).

Medical professionals who care for infants can learn to identify common tongue/lip tie compensations and instead see them as actual symptoms of tongue/lip tie. If we focus on keeping a child on the growth curve without examining *how* the baby gets to where they are on the growth curve when compensations are present, then we can set them up for early cessation of breastfeeding, issues with dental malocclusion, and sleep disordered breathing later in life. Our goal as medical professionals should be a thriving human. If we don’t change our practices, we are setting our patients up for consequences that are preventable.

References

Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions: a systemic review and meta-analysis. Acta Paediatrica. 2015; 104: 54-61.

Huang YS, Quo S, Berkowski JA, Guilleminault C. Short Lingual Frenulum and Obstructive Sleep Apnea in Children. International Journal of Pediatric Research. 2015 1:1.