Figure 4 and 5:  Lip blisters and a sucking blister from overcompensation of the facial muscles to maintain a latch at the breast.

Figure 2 and 3:  The white coating on the tongue is caused by the poor elevation of the tongue and inability to contact the high palate.

My baby has a very strong suck, but breastfeeding is painful and the infant is not gaining well?

Some babies will have a very strong suck when a finger is placed within the mouth to examine the tongue function and palate shape.  The tongue may elevate enough and the mouth may partially close to form a vacuum.  These infants may be overcompensating by using facial muscles to suck and form a vacuum.  The suck or negative pressure they produce is like sucking through a straw and will ineffectively transfer milk from the mother, but feel like a strong vacuum or suck.  The tongue is essential in completely and effectively draining milk from the breast and if the tongues function is compromised, so will efficient and effective transfer.  The baby still may “transfer” milk, but this may occur more due to the mother’s oversupply, milk ejection reflux and overactive letdown.  If a mother has an oversupply or overactive letdown, the baby just needs to subtly stimulate and swallow as the milk goes into the mouth.  These mothers will rarely feel empty when they are finished nursing because the thicker, higher fat content milk requires more effort to empty from the breast.  In certain cases, the thicker milk, or hindmilk, that is not removed from the breast will cause the milk ducts to clog.  If these clogged ducts are not cleared in a timely manner, they can progress into mastitis, which can be very painful and in cases require antibiotic treatment or surgical drainage.  This will obviously cause problems with the milk supply and feeding of the infant.  Should this imbalance in milk occur between fore and hind milk, the stools of the infants may appear greenish, frothy and not the typical yellow-seedy appearance.  Variations in stools can occur for other reasons as well like maternal dietary intake, food sensitivities and formula. 

What should breastfeeding be like for the infant?

You will learn to understand your infants hunger cues and behaviors in the first weeks of life.  The infant will typically eat on a very set schedule and nursing sessions should be efficient and not take excessive amounts of time.  Longer nursing sessions can burn valuable calories and cause irritation to the mother’s breasts.  The latching of the infant may take a few tries to establish a proper latch, but once established should only require subtle adjustments.  The mouth should open wide and accept the nipple and areola with a wide gape or opening.  The tongue will grasp, stabilize and draw the nipple into the mouth and create a vacuum, which will elongated the nipple to the back of the infant’s mouth.  Once the milk starts to flow, the tongue will continue the wave-like motion to maintain the vacuum and depth of latch.  The infant will make a suck or two and then an audible swallow should be heard as the milk is swallowed.  The sounds of “gulping” and “clicking” can signify a poor vacuum is in place and the child is swallowing more air then milk.  The infant’s hands should be open and relax and eye contact maintained with the mother.  Frustration, fatigue and quickly falling asleep at the breast are behaviors that are not common with an efficient and effective nursing infant.  After feeds, the baby should be fairly easy to burp and be satiated and happy.  Other common problems and concerns regarding the newborn are outlined below and talked about in more depth.  The baby must have the ability to have a properly functioning tongue and oral motor coordination to efficiently breastfeed.  Once a lactation consultant has properly assessed you and your baby and a suspected functional issue exists, you should consider looking further into a tongue and/or lip tie issue.  

Why does my child make a clicking or gulping sound when nursing?

The tongue is needed to make a primary seal and the lips help make a secondary seal when nursing.  The inability of the tongue to groove and elevate around the nipple and the upper lip to properly flange out does not allow for the baby to make a good seal at the breast.  When the upper lip is curled in and remains curled in, this can allow for milk to leak out of the sides of the mouth or for air to be ingested and swallowed by the baby.  You may notice small, darker triangles in the corners of the mouth if the lip is not fully flanged.  The parent will need to typically flange and adjust the upper lip manually to properly position the upper lip.  Even after a revision, the upper lip still may need to manually displaced until prior compensatory habits are unlearned and the facial muscular works less at the breast.

The tongue also plays a part in the maintenance of a seal because it pulls the nipple into the mouth and enables the baby to latch.  The tongue needs to extend, groove and cup around the nipple to pull it into the mouth.  If a tongue has limited ability to extend and elevate or cup around a nipple, or the finger when examined, this may also contribute to milk leakage and excessive air intake.

The clicking sound that is heard when the infant nurses can be a result of poor elevation of the tongue or a stronger letdown.  As the tongue elevates to draw the nipple into the mouth and form a vacuum, the baby needs to maintain a wide open mouth and allow for the tongue to elevate.  If the tongue is unable to maintain the elevation, each suck will make a click sound and this occurs as the tongue drops and breaks the vacuum.  The infant will gulp air and swallow this when the system is not closed.  This clicking and gulping can lead to ingested air and if not properly managed, lead to gassiness, excessive burping and even symptoms of reflux.  This is referred to as Aerophagia Induced Reflux (A.I.R.).

The best way to think about it is the mouth has to make a tube, or closed system to effectively draw milk from the breast or bottle.  The roof of the mouth or hard palate forms the top half of the tube and the cupped and grooved tongue forms the bottom half of the tube.  These two halves must come together or the tube is not formed and no seal is produced. 

Figure 1.  Ideal position of the nipple in relation to the tongue when nursing.  The tongue must elevate and compress the nipple against the roof of the mouth. (Picture: Brain Palmer DDS)

Why is my baby having excessive gas, hiccups, fussiness or reflux?

Mild degrees of reflux, hiccups, gas and spit up are all normal for a newborn or infant, but the cause can be for a host of reasons and should be explored.  These issues may be due to gastrointestinal issues, normal variations in muscle development and tone of the GI system, food sensitivities associated with the mother’s diet or from excess air intake during bottle and/or breastfeeding.  If excess air is ingested, it must exit the body either as gas or burping.  If the air is burped up, it can bring up stomach acid and cause discomfort and mimic reflux.  The excess air can also distend the stomach and cause fussiness and irritation with the child, too.  The child’s stomach may be distended or appear fuller when filled with excessive air after a feeding and mimic colic-like symptoms.  We refer to this phenomenon of reflux that is caused by excessive air intake during nursing or bottle feeding as Aerophagia Induced Reflux (A.I.R.).

An excessive amount of or very frequent hiccups can be the result of excess air intake while feeding, too.  The air intake will distend the stomach and it pushes on the diaphragm, which is the muscle used to fill and empty the lungs.  When the stomach places pressure on the diaphragm, its rhythmic cycle can be broken and lead to hiccups, especially after feeding.

What is the white coating on the center of my baby’s tongue?

The white coating on the center of the tongue is most likely residual milk left on the tongue and in rare cases, it could be thrush.  The “milk tongue” is typically only found on the center portion of the tongue and not the perimeter of the tongue.  This can occur because the tongue cannot fully elevate against the roof of the mouth and “self-cleanse” against the higher palate.  The perimeter, or outer border of the tongue, will be the normal pinkish color, because the upper and lower jaws make contact with the tongue perimeter.  The presence of a milk tongue is one reason to suspect or further investigate a potential tongue tie, which is not allowing for ideal movement and elevation of the tongue.

In cases of thrush, the white coating typically can be wiped off and the tissue under the coating is very red and sore.  White patches in other areas of the mouth, typically the cheeks, can be another sign of thrush.  Thrush can affect the mother and child, and if properly diagnosed, both individuals should be treated with appropriate anti-fungal medicines.  Mother’s may experience a burning sensation after nursing and can be confused with thrush, but may actually be vasospasms.  These vasospasms are a result of trauma to the nipple’s blood and nerve supply because the infant is causing damage to the nipple end.  With improvement in the depth of the latch and function, the vasospasms should subside soon after revision.  When the tip of the nipple is able to be drawn to the back of the infant’s mouth, the pain and discomfort will typically subside.  

Infant Nursing Challenges and Concerns