Infant Feeding

  • Difficulty in Breastfeeding

    Many new mothers will automatically search themselves for the reason their baby does not feed properly from the breast. Common factors looked at first are milk supply and inverted nipples. However, there are alternate causes that are the source or contribute to the problem. The baby could have difficulties breastfeeding due to an improperly or undeveloped mouth structures. These can be related to thin or non-existing sucking pads, tether-oral tissues (tongue or lip ties) and/or jaw weakness.

  • It could also be a combination of mother and baby due to a softened lifestyle. Mother having a sedentary lifestyle, breathing issues, and/or lack of sleep can translate into baby’s ability to successfully breastfeed and receive nutritional content.  

  • Breastfeeding and Bottle-Feeding Differences

  • While bottle feeding and breastfeeding will ultimately achieve the same desired goal, a happy and fed baby, they do differ in the way oral muscles are used. Alterations in the way a baby uses his/her muscles, can adversely affect the development of orofacial bones as well as breathing patterns, feeding/swallowing, and speech skills. Most full-term (40 weeks gestation) and close-to-term (37 to 39 weeks gestation) babies are born with the potential for breastfeeding, and many premature babies can be aided in the development of oral skills required for breastfeeding.

    Here are some differences to notice when feeding a baby with breast versus bottle:

  • Properly Breastfeeding Babies
  • Properly Bottle Feeding Babies
    • Root to locate the mother's nipple
    • Open mouth fully for a wide, sustained latch on breast
    • Draw mother's nipple and breast deeply into the mouth (helps maintain "U" shaped roof of the mouth)
    • Hold and cup the breast with the front of the tongue while lips seal against the breast
    • Lower jaw and front of the tongue together with little effort or cheek motion
    • Use the mentalis (everts or turns out the lower lip for latch) and masseter (raises the jaw against gravity) muscles more than bottle-fed infants
    • Have more sucking movements with more and longer pauses than bottle-fed babies
    • Move back of the tongue in a wavelike manner essential for swallowing
    • Have a stable mouth with tongue and lower jaw acting as lower stabilizer, the sucking/fat pads (if present) acting as side stabilizers, and the relatively flat roof of the mouth acting as top stabilizer
    • Have adequate pressure in mouth, so fluid can move safely and efficiently through the mouth for swallowing
    • Have a good feeding rhythm
    • Root if paced (baby led) bottle feeding is used
    • Open the jaw only enough for the particular bottle nipple
    • Extend the tongue over the lower gum
    • Use the lips and cheeks as a unit to latch onto the bottle
    • Cup the tongue if a rounded bottle nipple is used
    • Have more cheek and lip movement comparing to breastfed babies
    • Use the mentalis and masseter muscles less than breastfed infants
    • Have fewer sucking movements with fewer and shorter pauses than breastfed babies
    • Move the back of tongue downward to create a vacuum
    • Have a stable mouth with the tongue and lower jaw acting as the lower stabilizer, the sucking/fat pads (if present) acting as side stabilizers, and the relatively flat roof of the mouth acting as the top stabilizer
    • Have adequate pressure in the mouth, so fluid can move safely and efficiently through the mouth for swallowing
    • Have a good feeding rhythm
  • The shape of a breast versus the shape of a bottle nipple can cause differences in the development of mouth and airway of a growing baby. While a breastfeeding baby will develop forward, wide mouth, and open airway, a bottle can cause backward development with a crowded mouth and compressed airway, leading to health issues.

  • Tongue, Lip, and Buccal Restrictions

    Ideally, all babies should be screened for tongue, lips, and buccal ties at birth. Unfortunately, this is not commonly done. While everyone has tongue and/or lip frenums, many children are born with restricted frenums (ties or tethered oral tissues, TOTs). TOTs can limit the range of motion (ROM) of oral structures. Restrictions, tension, and/or limited ROM of the tongue, lips, jaw, and/or cheeks can negatively impact breast/bottle feeding and further contribute to improper jaw development as well as poor development of feeding, speaking, and other functional skills.

    Tongue, lip, and buccal (cheek) ties are developed when baby is still in utero from type 1 collagen (non-strechable) tissues that have not been absorbed in to the body during apoptosis (process of normal death of cells).

  • These ties can cause multiple issues for baby and mom. Mom will often find she has nipple problems such as pain during breastfeeding, plugged milk ducts, and/or misshapen, sore or cracked nipples.  Babies with TOTs have difficulty latching as well as struggle with coordinating suck, swallow, breathe pattern while breast or bottle feeding.  amongst other potentially dangerous symptoms. Many babies will also experience gastrointestinal issues such as colic, gassiness, and frequent spit-ups, etc, all of which have been linked in research studies to these babies ingesting too much air due to the difficulty with coordinating proper tongue movements for swallowing.

  • A tongue tie can also cause an improper mouth positioning, resulting in a narrow mouth development. This will cause the baby to have open mouth and mouth breathing, which is not normal, and can cause health problems for baby now and in the future. Mouth breathing has been linked to issues such as: allergies, respiratory illness, improper dental structure, and heart problems. 

    Ties are generally resolved through a surgical intervention. While it is preferred the tie is resolved as soon as possible, it can be done at any time during development. There is a laser or a scalpel option, however, decision on which one to use should be made with a licensed dentist, oral surgeon, otolaryngologist, pediatrician, or other appropriate physician.

  • Conditions Commonly Associated with TOTs
    • Poor Weight Gain
    • GERD/Reflux
    • Aerophagia
    • Colic/Gas
    • Torticollis
    • Laryngomalacia
    • Cranial Nerve Dysfunction
  • Importance of Therapy

    Proper evaluation of baby’s oral structures and feeding functions is essential, and other medical conditions need to be ruled out before tongue/lip-tie release is recommended. Therapy with a TOTs trained provider (Speech Pathologist, IBCLC, or OT) has proven to be crucial part of treatment for babies, both pre and post ties release.

    In an ideal world, every well-trained provider (pediatric dentist or ENT) would not release a tie without pre-op care. However, it is not always possible due to insurance, weight issues in babies, and/or availability of  the therapists. Typically before a procedure, a speech language pathologist evaluates the FUNCTION of oral structures which helps determine if a release is needed. Baselines of skills are also recorded so that parents, release provider, and therapist(s) can assess progress or lack there of after the release. In addition, therapy prior to the surgery helps release fascia tension in order to optimize the release of the restricted frenulum. Furthermore, caregivers need to be taught would management and post-op exercises, which it much easier for both the parent and child when the child is calm and not in discomfort/pain.  Acclimating the child to the intraoral stimuli (i.e. from parent/clinician’s fingers or special therapy tools) prior to the release is a huge piece of this complex puzzle. Post operatively, the child will require rehabilitation, and it helps to work with a therapist that he/she is familiar with. The rehabilitative care will consist on teaching baby how to move tongue, jaw, lips, and cheeks in a typical manner for eating, drinking, and speaking.

    This type of pre and post surgery care should be sought for by parents from well trained professionals to help guide the appropriate care and healing for the baby. This also helps to create a team of people who work together with the baby’s best interest in mind. This team should consist of the surgeon, parents, a qualified pediatric body worker (someone who works with baby’s whole body), and an oral sensor motor therapist (someone who works with feeding and mouth function).


  • Team Approach
  • IBCLCs, feeding therapists, and orofacial myofunctional therapists work with mouth function. Feeding therapists are speech-language pathologists or occupational therapists who have extensive experience with feeding. Orofacial myofunctional therapists are speech-language pathologists or dental professionals who are trained specifically in correcting the resting tongue position, a mature oral phase swallowing patter and other related processes. 

  •            Professionals who Commonly Work with TOTs

    • SLP
    • IBCLCs
    • OT
    • Physical Therapists/Body Worker/Massage Therapists
    • Cranial Osteopaths
    • Oral Sensory-Motor Therapist
    • Dental Professionals
    • Oral Surgeon/ENT
  • Professional Resources

      • Dr. Rajeev Agarwal, Pediatrician                                                                                                     
      • Dr. Bobak (Bobby) Ghaheri, Otolaryngologist                                                                                         
      • Dr. Marjan Jones, Integrative Dentist                                                                                    
      • Dr. Lawrence (Larry) Kotlow, Pediatric Dentist                                                                                      
      • Dr. Shahrzad (Sherry) Sami, Pediatric Dentist and Orthodontist                                  
      • Dr. Soroush Zaghi Sleep Surgeon Sanda Valcu-Pinkerton, Myofunctional Therapist                         
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    Source: Diane Bahr, MS, CCC-SLP, Book: “Feed Your Baby & Toddler Right” 2018