There are many books dedicated to the subject of nursing positions, including Supporting Sucking Skills in Breastfeeding Infants, 2nd editions (Genna 2012). Chapter 1 describes the most direct and efficient way to nurse a baby with the perfect latch—prone, with skin-to-skin contact with the mother’s breast, and with the mother supporting the weight of the breast. This position can also be diagnostic and therapeutic. However, if the baby has a wide gape and fits easily onto his mother’s breast, almost any position can be utilized. Lactation consultants are trained in these positions and situations where one position may be more helpful than another.

A study done by Blair et al. (2003) found that no single set of attributes in nursing position was more related to level of pain experienced by the mother than another. Therefore, no single aspect of positioning is more crucial than another. However, this study did not control for the latch and gape. What they did show is that, without an appropriate latch, positioning alone cannot compensate.

There is one notable exception when discussing nursing position: when mothers have oversupply. If a mother with an oversupply of milk uses the cradle hold, the let down may be too much for her infant, even with a good latch. A better position in these cases is for the mother to lie on her back, with the baby prone on top of the breast. This position allows the baby to suck the milk they can handle without the extra pull of gravity.

In the last decade, the application of osteopathy for infant health, specifically for correcting nursing problems, has grown. Osteopathy is a form of medicine based on the concept that structure determines function. Through manual contact with the patient, structural imbalances in the body can be corrected, ultimately allowing the body to self-heal. Treatment should be done by a trained Doctor of Osteopathy who has knowledge and experience specific to cranial osteopathy in infants. Their techniques are modified and adapted for infant anatomy. Ideally, infants are seen shortly after birth and can be treated by a single visit or a series of four to eight treatments.

The first step is an evaluation of the newborn’s general condition, asymmetries, and defects in posture. Then the assessment is performed using TART (Tissue alteration, Asymmetry, Range of motion, and Tenderness) criteria, a standard osteopathic technique (Ward 2002). Testing requires only passive participation from the infant.

Osteopathic manipulative treatment (OMT) techniques are used to treat the body’s framework. The movements are gentle and repositioning. In infants, indirect techniques are used, where the dysfunctional body part is moved away from the body part that has restricted motion, allowing equal tissue tension in all directions. Cranial osteopathy has a demonstrated history of success in treating infants. In one study (Cerritelli et al. 2014), researchers evaluated and treated 100 preterm newborns over 8 months. Treatment was associated with a decrease in length of stay and hospital cost, and because of the adapted techniques, there were no infant injuries as a result of the treatment.

Specific osteopathic treatment has been recommended for preterm infants and babies with suck disorder. In newborns, the cranial base, mandible, and hyoid influence the position and movement of the tongue. Additionally, the 22 bones in the skull are mobile. Due to forces during birth (travel through the birth canal, forceps, vacuum) cranial nerves 9, 10, 11, and 12 may be compressed at the cranio-cervical junction. One aim of this type of treatment is to release the hypoglossal nerve where it exits the skull base the between the basilar and condylar parts of the infant occiput. Additionally, restrictions of ligamentous, fascial and vascular connections can be released to allow free movement of head and neck structures (Lund et al. 2011; Wescott 2004).

Since cranial osteopathy is safe in experienced hands, every infant can benefit from at least one treatment. In many cases, this gentle repositioning results in enough of an increase in gape that the infant can latch on successfully. However, since timing is important, I recommend that if, after a few sessions improvement is not being made, referral to a specialist be made for further intervention.

Additionally, some babies undergo surgical release of inhibitory tissues but still cannot gape widely enough to nurse. Cranial osteopathy is an excellent adjunct in these cases.

A nipple shield (NS) is a thin silicone device placed over the mother’s nipple and areola prior to nursing. There are openings in the nipple cover to allow the baby to nurse. Variations of a NS have been used for centuries. They have been made from materials concurrent with the time, such as silver, pewter, animal skins, rubber, latex and finally thin silicone.

NS’s are routinely given to mothers when babies are preterm, or if they have trouble latching the baby on and nursing. The research regarding the efficacy of NS’s is contradictory, but mostly incomplete. Concerns with use of NS’s are:

In summary, research suggests:

When babies are not able to nurse on the breast efficiently, various alternative forms of feeding are often recommended, such as syringe, cup, and finger feeding. These systems provide ways to feed the baby that are thought to avoid nipple confusion because they are not bottles. But studies, including two large review studies, have shown no improvement in breastfeeding rates using cup feeding or finger feeding with nasogastric tubes. (Flint et al. 2007; Collins et al. 2008). As stated above, this is probably because nothing else feels like the breast. A baby can become conditioned to whatever feeds him.

A supplemental nursing system (SNS) is a very thin, soft silicone feeding tube attached to a bottle that contains either breast milk or formula. The tube is taped to the breast so that the opening is at the level of the nipple. The bottle is elevated above the opening of the tube to allow gravitational drainage of milk or formula. The baby is then latched onto the breast and is able to transfer milk from the breast simultaneously with supplemental milk or formula from the tube. It is a cumbersome, imperfect system.

As with the nipple shield or any other device to aid in nursing, the baby’s latch must first be corrected before assuming that using an SNS is going to fix the problem. If the mother is experiencing pain and the baby cannot transfer milk from the breast, using a supplemental feeder will not help the situation. But many mothers are given the erroneous advice to nurse on the breast, pump, and then feed the baby again on the breast with the SNS. This is thought to reduce the risk of “nipple confusion.” But if the breasts still need to be pumped after nursing, it is clear that the baby is not able to transfer milk. Using the SNS in these types of cases is not only a waste of time, but the pain and nipple damage experienced by the mother (due to an improper latch) can hinder her milk supply.

I make the following recommendations for the use of an SNS:

Frenulectomy, frenulotomy, frenotomy are all different words that refer to the removal or division of the frenulum—more specifically, the lingual frenulum. The lingual frenulum is the band tissue that covers the floor of the mouth and ventral surface of the tongue. Although there is obvious indication for its division when it limits mobility of the tongue in speech, an accepted or standard degree of “tongue tie” requiring division to prevent speech issues has not been established. Crude measurements—such the as the ability to extend the tongue past the vermillion border (Jorgenson et al. 1982)—have been used by physicians for many years, but they confer no real prognostic power. Genna and Coryllos (2009) developed a classification for the lingual frenulum based on visual inspection, with Type 1 being tied anteriorly to the tip, and Type 4 merely a band of tissue across the ventral surface of the tongue with no appreciable visible frenulum on tongue extrusion.

In my practice, I release any anterior lingual frenulum that attaches to at least 75 % of the ventral surface of the tongue, or if there is a heart-shaped tongue tip, regardless of whether or not the infant is nursing. About 4–10 % of the general population has congenital anterior tongue tie that is significant enough for treatment (Segal et al. 2007).

Releasing the frenulum at birth as soon as tongue tie has been identified is helpful for many reasons. The tongue is a muscle. If it is tethered at birth, it can never fully develop into the appropriate shape and size. It cannot lift up to the palate or fully extrude. Without early release, the frenulum never stretches adequately. Tongue movement is hindered, resulting in adjustments of the head and mouth shape as the infant develops. It leads to many other consequences in the future that are not easily corrected, such as a high palate, narrowed nasal cavity, and crowded lower teeth and malocclusion (Srinivasan and Chitharanjan 2013). Tongue tie is often also accompanied by a high palate because the tongue could not flatten the palate during fetal development. In my clinical experience, the longer one waits to divide the frenulum, the lower the success rate, and the higher the regrowth and failure rate.

Releasing an obvious anterior frenulum was also found to aid in breastfeeding. Centuries ago, midwives lysed the frenulum with a long fingernail or metal object at birth. Over the years—as birthing babies moved into hospitals, formula was developed, and women went to work—the art of breastfeeding was lost and along with it, the art of the quick release of the frenulum at birth. Recently, there has been a resurgence in releasing the frenulum and several case studies followed, attesting to the benefits of the procedure (Ballard et al. 2002; Notestine 1990). Randomized controlled studies have been done in the last decade that provide significant evidence in support of the procedure (Berry et al. 2012; Buryk et al. 2011; Dollberg et al. 2014; Emond et al. 2014; Hogan et al. 2005).

Geddes et al. (2008) showed improvement in milk intake, milk-transfer rate, LATCH score, and maternal pain scores after frenulectomy. LATCH is a breastfeeding charting system that assigns a numerical score to five key components of nursing: L—latch, A—audible swallowing, T—type of maternal nipple, C—comfort level of mother, H—help needed by mother to hold the infant to the breast (Jensen et al. 1994).

Edmunds et al. (2013) studied the experiences of ten mothers with babies who had tongue tie and found devastating results in breastfeeding experience when tongue tie was not discovered and treated quickly. Mothers suffered through knowing something was wrong, seeking help, but encountering health professionals who were unable to provide appropriate advice or diagnosis. Were it not for the mothers’ own perseverance in looking for answers and treatment, breastfeeding would have failed completely.

There should be no debate in regards to the merits of performing an early frenulum release when one is noted at birth. There is simply no reason to not intervene.

However, there are still many areas of contention. There is no accepted protocol for how the procedure should be done or who should be doing it. There is no training for it—practitioners gain experience by trial and error in the office. Even surgical subspecialists are not trained in the anatomy of a nursing infant and appropriate incisions beneficial for nursing. And many practitioners perform the procedure with little understanding of proper surgical technique and anatomy and no preparation for adverse outcomes. The risks associated with any procedure are directly related to the experience of the surgeon. Without a thorough understanding of the anatomy and the ability to correct for risks, babies can be harmed, sometimes terribly (Opara et al. 2012). Also, if too much or not enough tissue is released, breastfeeding outcomes can actually worsen. Scarring and thermal injury from improper use of lasers in the neonate can cause an increase in tethering. There are right and wrong ways to perform this procedure.

In addition, simply releasing the tissue does not confer success in breastfeeding. Most mothers need to be shown how to latch their baby onto their breast. The procedure is only the first step. The goal is successful breastfeeding outcomes (Douglas 2013).

Although appropriately releasing the frenulum undeniably helps nursing outcomes (O’Callahan et al. 2013), no one has yet identified why it is helpful. My clinical observation is that it improves nursing because it allows the baby to gape wider by releasing the tongue from the floor of the mouth. When nursing, the tongue and jaw must move independently. When they are attached by a frenulum, they move together. This observation is mimicked in babies who present with no obvious tongue tie, but have a limited gape and cannot fit around their mother’s breast shape. These babies present the same way as tongue tied babies, but without obvious tongue tie. They have been referred to as having a “posterior tongue tie” because they have the same problems as tongue tied babies, but there is no visible culprit. The focus on the tongue alone confuses the real issue. Various descriptions of posterior tongue tie have been attempted, but there are no defining characteristics of a posterior frenulum that are clinically useful. The term is confusing for mothers and practitioners. Also, simply releasing the lingual frenulum in these cases is not very helpful—in my practice, I had less than 50 % improvement. It is much lower in untrained hands. Some lactation consultants, exuberant about releasing the tongue, pushed to cut deeper into the tongue muscle or raphe. But there is no evidence to show that deeper cuts are beneficial, and they risk injury to surrounding structures and excessive pain and bleeding for the infant.

One scenario I often see is a baby with a greater degree of retrognathia than normal and a high, arched palate. These babies present with a tongue that, at rest, points upward so that the ventral surface is mostly visible. Their frenulum is a band of tissue with no anterior involvement. In these cases, the tongue is positioned posteriorly in the throat relative to the jaw so it cannot lift up and move backwards to compress the breast against the palate. Since the palate is high, the tongue has even farther to go. When these babies gape, their upper lip is pulled down by their retrognathic jaw. Their upper lip doesn’t flange out as it should. In these babies, the tongue, jaw, and palate move together not independently. In tongue tied babies, the problem is more visibly obvious, but the outcome is the same: the structures are not able to move independent of one another.

Because of the low success rate of lingual frenulectomy alone when there is no obvious anteriorly based lingual frenlum, I began also cutting the labial frenulum to release the maxilla (palate) from the jaw. These babies instantly are able to gape widely and latch deeply onto their mothers’ breasts. In babies with obvious anterior tongue tie who also have retrognathia and/or a high palate, releasing the lingual frenulum widens their gape, as well. [For additional reading, a study by Todd (2014) discussed the diagnostic and treatment dilemmas regarding the often confusing diagnosis of tongue tie.]

Tongue tie reflects the importance of the gape. If the gape is small and tethered, it will lead to a shallow latch and poor milk transfer. This tethered gape is due to the inability of the palate, jaw, and tongue to move independent of one another. Sometimes babies have something visible, like tongue tie. Sometimes they have retrognathia and a high palate. Sometimes there is no discernable pattern to their anatomy, but they obviously can’t open wide enough to take in enough of their mother’s breast. It may be due to their mother’s breast shape and a different breast shape works better. And there are babies who have an obvious anterior tongue tie, but they can still gape widely enough that they can fit their mother’s breast shape (Ballard et al. 2002; Chu and Bloom 2009; Coryllos et al. 2004; Kupietzky and Botzer 2005; Messner et al. 2000; Ricke et al. 2005; Segal et al. 2007).

If, after establishing that the breast provides low return for his work, the baby is rewarded with a feeding source that offers him food more easily, he will quickly adapt to that source. It doesn’t matter if it is cup, bottle, or syringe (Flint et al. 2007). The converse has also been shown: If a baby is breastfeeding successfully, introduction of a nonnutrititive pacifier does not create an aversion to breastfeeding. A Cochrane review (Jaafar et al. 2011) examined the effects of pacifier use on full-term, effectively breastfeeding babies. In almost 1300 newborns in two trials, pacifier use had no significant effect on partial or exclusive nursers.

In babies who cannot breastfeed successfully, I submit that pacifier use will not encourage aversion to the breast, because the pacifier is not a food source. One study went a step further and showed that restricting pacifier use at birth decreased exclusive breastfeeding and increased supplemental and exclusive formula feeding. (Kair et al. 2013)

Pacifier and bottle use is recommended against by the WHO “Ten Steps” protocol, as if the exposure alone causes nipple confusion. Education is important, but if the baby is unable to latch onto the breast and transfer milk successfully, all of this education and policy change is for naught. No one is going to promote starving the baby to avoid nipple aversion (Venancio et al. 2012; Buccini et al. 2014).