J Clinical Chiropractic Pediatrics 2016 (Dec); 15 (3): 1301 ~ FULL TEXT
Sharon Vallone, DC, FICCP
KIDSPACE Adaptive Play and Wellness,
South Windsor, Connecticut, USA
Increasingly, parents are presenting to the chiropractic office with the chief complaint of breastfeeding dysfunction. Early and consistent breastfeeding support is paramount to the dyad’s ability to establish a functional breastfeeding relationship. It is critical that chiropractors treating this population recognize feeding dysfunction and understand the mechanics of breastfeeding, what might alter those mechanics, and the importance of the role of the International Board Certified Lactation Consultant (IBCLC) in supporting the restoration of functional breastfeeding after the chiropractic adjustments have reduced the NMSK dysfunction. This paper outlines some of the mechanical dysfunctions that might interfere with the normal transfer of milk for a neonate.
Key Words: Chiropractic, breastfeeding, breastfeeding difficulties, biomechanics, pediatric, neonate
From the Full-Text Article:
Increasingly parents are presenting to the chiropractic office
with the chief complaint of breastfeeding dysfunction.
Through the efforts of organizations like La Leche League
International [1, 2] and the International Association of Tongue
Tie Professionals (IATP), 
books [4, 5] and professional publications, [6–15]
and a boom in activity on social media of both
professionals and concerned parents, [16, 17] The International
Board Certified Lactation Consultants (IBCLC) and other
healthcare providers (such as midwives, nurses in the hospital,
pediatric office and homecare settings, and pediatricians)
who support the nursing dyad are becoming more
familiar with and adept at recognizing neuromusculoskeletal
(NMSK) dysfunction that might interfere with breastfeeding.
As has been previously described,  it is important that early
and consistent breastfeeding support be implemented to
assist the dyad’s ability to establish a functional breastfeeding
relationship. Therefore, chiropractors working with this
population should understand the mechanics of breastfeeding,
what might alter those mechanics, and recognize the
importance of the IBCLC in supporting the restoration of
functional breastfeeding after the chiropractic adjustments
have reduced the NMSK dysfunction. [6, 10] The purpose of
this paper is to outline some of the mechanical dysfunctions
that might interfere with the normal transfer of milk for a neonate.
The Craniocervical Junction
The anatomy of the craniocervical junction (C01) is an important
consideration in the neonate who is not feeding
functionally at the breast or on the bottle. The skull develops from viscerocranium and neurocranium, which develop
into the facial bones and the portion of the skull that
protects the brain. The neurocranium consists of the chondrocranium
and dermatocranium which give rise to the
skull base from endochondral ossification and the calvarial
vault from membranous ossification respectively. The rapid
growth of the neurocranium is stimulated by expansion of
the size of the brain over the first 7 years of life with fontanels
closing (at different times) over the first two years of
The occiput, not yet fused at birth, is in 4 segments [19, 20] which
can be displaced (or misaligned) by the normal compression
of the cranium during the birth process. They, like other
plates of the cranium, may misalign or overlap and remain
so, when subjected to inordinate or prolonged forces.
The lateral components of the occiput each possess a condyle
that articulates with the first cervical vertebra (atlas or
C1) at the superior articular surface of the lateral mass. The
normal movements between the occiput and the atlas (C01)
are: flexion and extension (nodding the chin to chest and
back at the cranial base allowing an infant to lift their head
when lying supine or tip their head back to adore their parent
when resting on their shoulder, or the motion required
to shake the head “yes”), rotation (shaking the head “no”)
and lateral flexion (ear to shoulder) along with the possibility
of an anterior, posterior or lateral translation of the
full cranium on the atlas. Although subtle, identification
of restricted movement in one of these planes helps determine
the site of subluxation. Restricted movement can be
due to inflammatory changes, misalignment of the articular
structures, ligamentous injury, muscle spasm, tension in the
fascial planes or asymmetry in development. It can also occur
as a result of compensatory mechanisms put in place by
the infant due to other physiologic, neurologic or structural
obstructions to the normal mechanics of feeding. 
Any misalignment of the condyles can interfere with function
in a direct and obstructive way, functionally acting like
a rubber wedge carefully placed under a door to prevent
it from closing. Indirectly, if the misalignment results in
nociceptive input (caused by a myriad of alterations ranging
from fascial tension to an alteration in the patency of
one of the foramen through which cranial nerves pass), it
could also lead to a decrease or increase in muscle tone,
the latter perceived as muscle tension or spasm. Change in
muscle length or activity can adversely influence a functional
joint. But when this involves muscles that have been
demonstrated to bridge to the dura, via the fascia (like the
rectus capitis posterior minor or the rectus capitis posterior
major), nociception may be an even more critical factor in
the ongoing dysfunction. Torsion or strain at the myodural
bridge has been associated with cervicogenic headaches in
adults and could potentially cause the same type of neurogenic
pain for a neonate, as well as perpetuating the pain
spasm cycle. [22, 23] If the condylar displacement affects foraminal
patency for the cranial nerves, other systemic symptoms
may ensue (for example, compression or traction of the fascial
sleeve of the vagus nerve (CN X), can result in an alteration
in vagal “tone” or autonomic dysregulation which
could affect heart rate and blood pressure, respiratory rate,
colic-like symptoms, swallowing – and the suck-swallow-breath
synchrony – and cause an alteration in gut motility
and excretion). 
If movement is altered at the level of the occiput and atlas,
the brain will quickly initiate compensatory action of accessory
muscles to attempt to accomplish important functions
like breathing and eating. Breathing under stress or physical
exertion will be quickly assisted by engaging the secondary
muscles of respiration in the cervical spine. Feeding
(particularly to secure the mouth around the nipple) will be
supported by these same muscles as well as the submandibular
muscles, the muscles of mastication and the muscles of
the lips (primarily the orbicularis oris). The recruitment of
these secondary muscles can result in functional “postural”
changes (rounding of the shoulders, posterior translation of
the cranium on the atlas, flexing the head on the chest, tilting
of the head if unilaterally recruited, etc.).
Next let us consider how two examples how alteration in
function of musculature can influence the mobility at C01.
The styloglossus, the shortest and smallest of the three styloid
muscles, arises from the anterior and lateral surfaces
of the styloid process near its apex, and from the stylomandibular
ligament. The styloglossus is innervated by the hypoglossal
nerve (CN XII), it functions to draw up the sides
of the tongue to create a trough for swallowing and retract
the tongue. 
The stylohyoid muscle arises from the posterolateral surface
of the styloid process of the temporal bone, near the
base. It is a slender muscle, lying anterior and superior of
the posterior belly of the digastric muscle and inserts onto
the body of the hyoid bone at its junction with the greater
cornu. A branch from the extracranial path of the facial
nerve (CN VII) innervates the stylohyoid and the muscle
functions to retract the hyoid and elevate the tongue. 
If C01 is subluxated (fixed or immobile in any or all planes
of motion), when either of these muscles contracts, the action
of the muscle will be altered by the restricted mobility
of its proximal attachment (the styloid process). This will
result in increased movement of the distal attachment as
demonstrated by retraction of the tongue or elevation and
retraction of the hyoid bone. Likewise, if the tongue is tethered
to the floor of the mouth or the movement of the hyoid
is restricted by muscle activity or fascial tension, the proximal
attachment (the styloid process) will be pulled towards
the distal fixed attachment and affect the alignment of the
cranium on C1 (permitted by the mobility allowed at C01 at
Visible postural alterations and associated compensations
due to dysfunction of the craniocervical junction can range
from the subtle: slight head tilt, preferential rotation, chin
to chest posture or the presence of a wry smile (as the mandible
deviates) to more obvious distortion like torticollis or
plagiocephaly as a result of repetitive or sustained asymmetric
contraction over time. If unaddressed in infancy, postural
changes can manifest in toddlerhood as toe walking,
wide-based stance or gait, and increased AP curves of the
spine as the continued compensatory recruitment disrupts
the development of proprioceptive systems that determine
position and balance for the toddler.
It is this author’s hypothesis that biomechanical restriction
beginning with constraint or compensatory development
of asymmetry in the womb could potentially be significant
enough to negatively impact the normal egress of the fetus
during labor resulting in potential compromised situations
like an asynclitic presentation or shoulder dystocia because
of the lack of full range of motion during the spiral decent.
Other potentially far-reaching physiologic effects of altered
biomechanics in infants and children can include failure to
attain developmental milestones (due to decreased range of
motion, for example), irritability, mouth-breathing, snoring,
sleep apnea and disordered sleep, [25–27] feeding challenges
at breast or by bottle [4, 6] and potential alterations in cranial
nerve function which could result in dysregulation of respiratory,
cardiac and or digestive function. 
Assessment of the cranial nerves is critical, as altered cranial
nerve function may be the only indicator of articular
dysfunction at C01. For example, vagal irritation (due to
its proximity to the occipital condyle as it exits the skull
through the jugular foramen) could potentially result in
gastrointestinal distress or affect the function of cranial
nerves V, VII, IX, X and XII and result in failure to root,
suckle and swallow.
Manual Technique to Correct Dysfunctional Vertebral Segments
Chiropractic evaluation specifically identifies the areas of
dysfunction and the chiropractic adjustment addresses it
by restoring articular integrity, whether at the craniocervical
junction or associated articulations. Both evaluative and
adjusting techniques should be modified based on developmental
anatomy, dictated by the neonate’s gestational
age and concomitant conditions. Todd et al, published
a review of the literature describing the level of force applied
in a chiropractic adjustment or spinal manipulative
therapy (SMT) for a pediatric patient based on age. A set of
guidelines for different age groups has been developed by
Marchand, “drawing on findings from an extensive study
of tensile strength and osteoligamentous failure rates in pediatric
spines as well as a report of transient bradycardia
and apnea events that occurred with thrusts of 50 N to 70
N in infants younger than 3 months. Marchand has recommended
that SMT be applied at a maximum cervical loading
of 20 N for neonates.” [29–31]
A chiropractic evaluation should be multidimensional and
should include a clear image in the chiropractor’s mind of
the anatomy of the pediatric patient along with his or her
active and passive assessment of range of motion and visual
assessment of posture and attitude coupled with listening
for altered or strained breath sounds, clicking of the tongue,
swallowing or sucking in of air, the sound (and sometimes
smell) of the burp, hiccup or flatulence (or stooling) are just
a few of the sensory impressions that a chiropractor will
integrate with the infant’s history to differentially diagnosis
and plan a therapeutic approach.
Evaluation of the infant should begin with a soft tissue evaluation
appreciating the connective tissue components that
can interfere with joint mobility and function. Manual techniques
employed are too varied to cover in this paper. Many
current chiropractic techniques include soft tissue release to
facilitate mobilization. Extensive study of fascia “based on
functional relevance of myofascial chains” is recommended
by Wilke,et al.(2016) in his systematic review.  An appreciation
of the anterior and posterior superficial lines and
anterior deep lines as outlined by Myers  and applied to
the infant with breastfeeding dysfunction might prove to
facilitate shorter, more effective courses of treatment.
Manual assessment of each of the individual cranial bones
would be a part of the comprehensive assessment of the infant
with breastfeeding difficulty. For the purposes of this
paper, we will limit our discussion to the occipital bone, but
a comprehensive assessment is holistic and will assist the
practitioner in evaluating the intimate balance of mobile articulations
and the soft tissue that both moves and supports them.
Palpation of the occiput will include the evaluation of all
the aforementioned ranges of motion and the motion of the
occiput as it articulates with the sphenoid at the sphenobasilar
junction. This junction normally flexes and extends
with respiration, but may be fixed in flexion, extension, lateral
flexion or torsion. Palpation should also include evaluation of the individual segments of the occiput (anterior,
posterior and lateral condylar segments) to assess medial
and lateral translation or internal and external rotation, as
well as anterior and posterior translations of the individual
segments. (Figure 3).
As stated earlier, all chiropractic techniques taught in the
academic setting are modifiable for gestational age and
anatomy. For example, methods of choice for this author
are cranial adjusting (for example, as taught by DeJarnette [34, 35]
and Upledger ), low velocity, low amplitude
(low force) (manually (digitally) or with a pediatric drop
head piece), percussive instrumentation (like the Activator
Technique)  delivering a measurable, short range, reproducible
force, or non-force techniques maintaining steady
digital contact (“press and hold”) as a fulcrum about which
a neonate moves until they release the restriction at their
own pace. In the press and hold technique, the emphasis
is on acting as a stationary fulcrum and letting the neonate
“lead” the myofascial release which ultimately restores vertebral
motion. This avoids force or excessive range-induced
trauma and reduces the risk of tissue injury and activation
of the sympathetic response which can lead to autonomic
dysregulation if the trauma exceeds the neonate’s adaptive
threshold. The author refers the reader to the Marchand article
that reviews quite a number of chiropractic techniques
and age-appropriate modifications beyond the scope of this
Gently supporting the head with fingertip contact along the
occiput using two fingers to assess the “spread” and position
of the condyle or using all fingers to encourage anterior
translation or extension at C01 will gently accomplish mobilization,
often without distressing the neonate. At times,
they will express intermittent distress as they “unwind” the
fascia (connective tissue components that may have been
injured during the birth process or from misuse) or if a trigger
point in a suboccipital muscle is compressed. Patience
and a consistently firm but gentle digital contact usually allows
them to work through the discomfort until they are
relaxed and at ease, often falling asleep as the parasympathetic
system becomes more dominant than the sympathetic
system that had been engaged when all systems were not
Developing a discerning touch involves understanding the
neonatal anatomy. For example, that the occiput has four
individual pieces with each segment’s position and mobility
influenced by its own fascial envelope (or as mentioned
earlier, from a distal restriction along one of the associated
myofascial trains). The misalignment of one segment may
subtly change or be completely released by effectively releasing
the soft tissue or another subluxated segment.
Consider releasing the taut fascial envelope and use good
clinical judgment and develop precise manual skills before
applying any direct force (no matter how modified) to a
motion segment. In most cases, inducing nociceptive input
is more likely to cause more restriction than less.
Highly developed observation and palpation skills; familiarity
with anatomy and function; discernment; clinical
experience; appreciation of the role of myofascial components
in dysfunction; and a skilled, specific adjustment are
the tools that will allow the chiropractor to facilitate normal
motion and neurologic regulation for the neonate demonstrating
breastfeeding difficulties, interference with the
suck-swallow-breath synchrony or potentially other physiologic
Although only one articulation was specifically, and not
necessarily exhaustively discussed in this paper, the implication
that multiple articulations and myofascial components
may be compromised is implicit in this discussion.
Therefore, it is important that the neonate experiencing any
feeding (or breathing) challenges should also be evaluated
for NMSK dysfunction and be sent for evaluation by a qualified International
Board Certified Lactation Consultant (IBCLC).
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