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Beyond tongue-tie: How to manage breastfeeding issues when baby does not have ankyloglossia

February 1, 2025

A 2024 AAP clinical report offers comprehensive, evidence-based guidance on managing breastfeeding difficulties in newborns with ankyloglossia.

It is important, however, for pediatricians to recognize that not all breastfeeding challenges stem from ankyloglossia and to consider other potential issues when evaluating a baby without tongue-tie.

Below are some causes of breastfeeding difficulty that are not related to ankyloglossia.

Infant factors

Oral anatomy

Beyond tongue-tie, other anatomical variations such as high-arched palates, cleft lip or palate, and micrognathia can affect breastfeeding.

Suck-swallow-breathe pattern

Premature infants or those with neurological conditions may struggle with the coordination of sucking, swallowing and breathing.

Some infants may have difficulty with the rhythm of suckling, leading to inefficient feeding and fatigue.

Maternal factors

Anatomy

Variations in nipple shape or size can impact latch and milk transfer. Flat or inverted nipples may require specific techniques or aids to facilitate breastfeeding.

Additionally, certain breast surgeries, such as reductions or augmentations, may impact milk production and breastfeeding success.

Breastfeeding technique

The mother’s and infant’s positioning and latch technique are critical. Inadequate latch can lead to poor milk transfer, nipple pain and damage.

Milk supply

Both oversupply and undersupply of milk can cause challenges. Hormonal imbalances, previous breast surgeries or insufficient glandular tissue may contribute to these issues.

Low milk supply may result in poor infant weight gain and overly frequent feeding, while oversupply can lead to breast engorgement, fast let-down and infant discomfort during feeding.

The most common cause of low milk supply is infrequent or ineffective breastfeeding. Milk production works on a supply-and-demand basis; if the breasts are not emptied regularly, milk production will decrease. Infrequent or short feeding sessions can impact milk production and infant weight gain.

Health issues

Postpartum depression or anxiety can interfere with breastfeeding. Conditions such as polycystic ovary syndrome, thyroid disorders and retained placental fragments can interfere with the hormonal signals required for milk synthesis.

Pain and discomfort

Nipple pain or breast infections like mastitis can discourage breastfeeding and require prompt attention.

Medications

While most medications are compatible with breastfeeding, some can interfere with milk production or may be contraindicated during breastfeeding. It is essential to review maternal medications when assessing breastfeeding difficulties.

How pediatricians can help

Although the list of potential breastfeeding issues may seem daunting, pediatricians can be proactive in addressing breastfeeding challenges or concerns and offer continuous encouragement and support, including the following.

  • Provide resources about breastfeeding techniques, the importance of skin-to-skin contact and the normal course of breastfeeding.
  • Monitor breastfeeding parents and babies regularly to identify and address breastfeeding issues promptly.
  • Schedule follow-up visits to evaluate the baby’s weight gain, feeding frequency and duration to ensure adequate nutrition and growth.
  • Recommend consultations with lactation specialists who can provide personalized support and address specific breastfeeding challenges.
  • Encourage parents to join breastfeeding support groups where they can share experiences and gain encouragement from other breastfeeding families.

Dr. Thomas is a member of the AAP Section on Breastfeeding. Dr. Hannon is a member of the section’s executive committee.

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