J Clinical Chiropractic Pediatrics 2016 (May); 15 (2): 1230 ~ FULL TEXT
Sharon Vallone, DC, FICCP and Faraneh Carnegie-Hargreaves, DC
The World Health Organization recommends exclusive breastfeeding for the first 6 months of an infant’s life, followed by the introduction of complementary foods while breastfeeding for 2 years and beyond. Early and consistent breastfeeding support can often make the difference in a dyad’s ability to establish a functional breastfeeding relationship. While challenged dyads can sometimes accomplish competent breastfeeding given appropriate support, necessary interventions, and an opportunity to learn; timing is critical when a neonate has not been transferring adequate milk volume or is managing feeding in a passive or compensatory manner. Chiropractors should be most familiar with the diagnosis and treatment of musculoskeletal dysfunctions that could result in an inability to feed. They should also recognize and treat the compensatory changes that will develop in a healthy, neurotypical neonate who is challenged by an inability to feed efficiently in order to prevent the evolution of long term physiologic and postural ramifications.
Key words: breastfeeding, dysfunctional feeding, chiropractic, International Board Certified Lactation Consultant, tethered oral tissue, tongue tie, lip tie, neonate, pediatric.
From the FULL TEXT Article:
The World Health Organization recommends exclusive
breastfeeding for the first 6 months of an infant’s life, followed
by the introduction of complementary foods while
breastfeeding for 2 years and beyond.1
According to the 2014 breastfeeding report card produced
by the CDC, breastfeeding rates continue to rise in the
United States. In 2011, 79% of newborn infants started to
breastfeed, 49% were breastfeeding at 6 months, and 27% at
12 months. (However, it is important to note that this does
not represent exclusivity, as another CDC report states that
exclusivity rates did not rise between 2002 and 2012). 
the number of IBCLCs (International Board Certified
Lactation Consultants), and others trained to support
breastfeeding in various clinical and community settings
has also increased. [3, 4] Short-term risks of artificial-feeding
have been well-documented across the literature and include
increased obesity and incidence of infection — including
acute otitis media, respiratory tract and gastrointestinal
infection. In the long term, failure to breastfeed is likely a
factor in the development of inflammatory bowel disease,
celiac disease, and diabetes. Artificial-feeding has also been
associated with increased blood pressure and cholesterol
levels in adulthood. 
Early and consistent breastfeeding support can often make
the difference in a dyad’s ability to establish a functional
breastfeeding relationship. 
Despite the fact that challenged
dyads can still accomplish successful breastfeeding given
time-appropriate support and interventions, timing is critical
when a neonate has not been transferring milk. If released
from the hospital without appropriate assessment
of latch and transfer, symptoms may not appear until the
dyad has gone home and the neonate’s status can rapidly
decline. Neifert (2001) makes a compelling argument for
the importance of recognizing and resolving breastfeeding
dysfunction as it affects neonatal health: “Clinicians must
overcome the tendency to view the complications of mismanaged
breastfeeding as an indictment of the “process”.
Instead, pediatric practitioners are obligated to confront the
reality of breastfeeding failure, identify associated risk factors
and implement intervention strategies to prevent infant
Once at home, an infant who cannot transfer milk may
quickly become a lethargic infant but may be perceived
as a well-behaved baby. Even if parents express concern,
they are often advised not to wake a sleeping baby by well-intentioned
but ill-informed family, friends, or healthcare
providers. Without daily weights to observe weight loss (or
gain), or taking note of the requisite number of wet diapers
or stools produced, this failure to feed may go unnoticed
until the situation has become tenuous, or worse, untenable.
When the infant is unable to transfer a sufficient amount of
milk to sustain normal activity, they will often fall asleep
at the breast waking shortly afterward and crying inconsolably
until put to breast again. Other signs of inadequate
milk transfer include feeding for short intervals very frequently
or the infant who never gets off the breast yet fails
to gain weight and meet developmental milestones. 
these babies may gain adequately in the shortterm
if the mother has a robust milk supply and is willing
to nurse very frequently, however milk supply is dependent
upon milk removal, not only time at breast. 
New parents often receive input from a variety of sources
including family members, friends, and daycare providers
as well as parent support groups and local service organizations
like La Leche League  or Breastfeeding USA. 
But with all these different sources of information, there is
risk of parents being overwhelmed by confusing or conflicting
information, as well as myth and bias. Parents need
educated support to help them evaluate the available information
and resources so they can make informed decisions.
Tow and Vallone (2009) assert that this role should ideally
fall to the appropriately trained healthcare provider, the International
Board Certified Lactation Consultant or IBCLC.
Despite the IBCLC being the most suitable portal of entry
for breastfeeding education and support, a mother can potentially
receive guidance at a variety of junctures: while
still in the hospital by nursing or lactation support staff,
incidentally at a routine well-baby follow up with nursing
staff, well baby clinic or pediatrician check up due to
failure to gain weight, in consultation with another provider
because of past experience with a sibling or based
on their reputation (taking their newborn to a chiropractor
for breastfeeding difficulty), or due to an emergent condition
requiring a trip to urgent care (a somnolent infant who
cannot be roused). Although some of these professional interactions
are with healthcare providers who have sought
additional education or have experience in this arena, these
interactions are often fraught with conflicting or misinformation
which can lead to frustration and failure without
seeking the support of an IBCLC.
Chiropractors should be most familiar with the diagnosis
and treatment of musculoskeletal dysfunctions that could
result in an inability to feed. The delicate balance required
to nurse and transfer breast milk successfully is influenced
by the functionality of the associated joints, soft tissue, and
nerves of the cranium and cervical spine. Full, normal function
may be negatively influenced by the neonate’s innate
ability to compensate for any “roadblocks” it might encounter
(ranging from neurologic and musculoskeletal implications
of birth trauma to the presence of a tongue or lip
tie). The chiropractor also needs to recognize and treat the
compensatory changes that will develop in a healthy, neurotypical
neonate when challenged by an inability to feed
efficiently to prevent the evolution of long term physiologic
and postural ramifications. [12-14]
A chiropractor may not be the first individual who will be
positioned to support the breastfeeding dyad when challenges
arise. Frequently, our role will be collaborative.
Yet, with the increasing number of parents seeking early
assessment by a chiropractor for their newborns [15-18] it
behooves us to educate ourselves as to the differential diagnoses
related to breastfeeding. This means the ability to
identify the infant who cannot feed efficiently (or at all), is
failing to thrive, or feeding in a compensatory pattern; and
make referrals as appropriate. 
Other healthcare providers the chiropractor can expect to
collaborate with when working with an infant who cannot
feed include: IBCLCs, midwives, naturopaths, nurses, pediatricians,
dentists, oral surgeons, pediatric surgeons, ear/nose/throat (ENT) surgeons or otolaryngologists, speech
and language pathologists (SLP), occupational therapists
(OT), oromyofunctional therapists (OMT), or other feeding
or airway specialists who may play various roles in the care
of the infant. Unfortunately, the parents may also be receiving
conflicting information from these providers. When this
happens, they are in even greater need for an advocate to
help them create a plan of care for their infant to reduce the
risk of premature cessation of breastfeeding.
When any one of these healthcare providers recognizes that
the dyad is having breastfeeding challenges, an assessment
should be performed including a system survey. The musculoskeletal
examination (at which the chiropractor should
be proficient) may reveal biomechanical dysfunction. For
example, decreased range of motion of the joints of the cranium
(like the temporomandibular joint) can interfere with
a neonate’s ability to gape comfortably and competently
latch and transfer milk. Restricted cervical range of motion
can result in discomfort or inability to latch with resultant
behaviors like arching at the breast, crying in frustration, or
pulling off the breast repeatedly. [20-29]
The collaborative protocol might include components of
natural alternatives and/or holistic interventions based on
the presenting diagnosis. Interventions may be straightforward
and limited to chiropractic adjustments to restore
normal joint function and neurologic competency or may be
fraught with comorbidities and expand to include surgery
(most often to release tethered oral tissues), [30, 31] supplementation
to provide calories, rehabilitative exercises, pharmaceuticals,
homeopathy and nutritional supplements to support
gastrointestinal health and wound healing under the
instruction of the IBCLC or other healthcare providers.
It would be helpful for the chiropractor to familiarize themselves
with the prescribed interventions as well as the supportive measures to treat many of the comorbid conditions.
Part of the chiropractor’s role may be to help support the
parents who have trepidation about recommended procedures.
The chiropractor may also offer encouragement for
parents having difficulty being compliant with protocols
that may be required to help their infant attain competent
feeding, ranging from a frequent pumping schedule to
wound care and stretching after the revision of oral tethered
tissues (lip, tongue, or buccal ties). The recognition that
many of these interventions serve to prevent early cessation
of breastfeeding  is critical but the chiropractor is ideally
suited to evaluate and explain the implications of musculoskeletal
dysfunction as it relates to current dysfunction as
well as potential problems that could arise in the future if
To underscore the importance of correcting altered oral motor
function (whether structural, neurological, or mechanical),
there has been an association with a wide variety of
developmental issues. Some that have been (or are currently)
under multidisciplinary exploration include failure to
thrive,  airway dysfunction, SIDS, aerophagia (resulting in
colic and reflux),  dental caries,  oral motor dysfunction,
malocclusion, [36, 37] decreased patency of the sinuses, narrowed
palatal architecture, snoring, sleep apnea and sleep
disordered breathing, [38-40] disrupted immune function (including
tonsillar hypertrophy), gastrointestinal dysfunction,
and challenges in speech and articulation. [41, 42]
There are far reaching effects because of the intimate relationship
between the musculoskeletal and the nervous systems.
Structure affects function and vice versa. Mechanical
dysfunction can result in a lack of peripheral mechanoreceptor
input to the central nervous system (CNS) which can
influence a range of functions from the level of alertness to
the modulation of visceral (mastication, swallowing, vomiting,
peristalsis, glandular secretion, bladder control) and
somatic (posture and general muscle tone) activities.
Local and global lack of mobility of the connective tissue
(fascia) and articulations of the cranium, spine and extremities
(due to injury, edema, adhesions, and compensations)
can result in traction of the fascia which can also cause a
mechanical barrier or alter afferent input to the CNS. 
Breathing and eating are the neonate’s primary driving
physiologic functions. The neurologically competent neonate
will draw his or her first breath and seek the breast
immediately when there is no interference.  If anything
impedes the accomplishment of these initial goals, compensations
will be developed as rapid plastic connections
are made in the neonatal brain. This neuroplasticity assures
survival under adverse conditions even at the expense of
structural changes to achieve physiologic homeostasis.
Even the neonate impaired by genetics, pharmaceutical intervention,
or birth injury will frequently demonstrate this
amazing ability to create compensatory neuronal pathways
to accomplish these functions so basic to survival.
Structural interference impeding breathing may take other
forms. For example, the use of the infant car restraint system,
the “baby bucket,” results in an infant positioned in
a flexed posture who may not be able to inspire with sufficient
capacity to supply the required oxygen to maintain
sustainable pO2. Premature or impaired infants like those
with posterior tongue ties may be at even higher risk. 
The neonate uses six cranial nerves, 22 bones connecting
at 34 sutures, and 60 voluntary and involuntary muscles
in order to accomplish a smooth suck, swallow, breath sequence. 
When the movement at any of these articulations
is decreased or impeded, there is an associated cascade of
movements that are influenced by the original mechanical
dysfunction. Mechanical dysfunction (Table 1) can result in
an immediate challenge to the neonate’s ability to breathe
and feed. Mechanical dysfunction that interferes with critical
life sustaining activities (such as breathing and eating)
also results in an engagement of the sympathetic nervous
system. The sympathetic nervous system responds to low
pO2 and the question, “Where’s my next meal coming
from?” Accordingly, the brain rapidly creates new plastic
circuits in an effort to urgently resolve the problem. Compensations
ensue that may be functional or dysfunctional.
In the short term, the impact of these compensations on respiratory
function, milk transfer, the infant’s sleep patterns,
and maternal stress level may be significant. Compensatory
patterns may have long term effects as previously outlined.
Mechanical dysfunction also prompts nociceptive input to
the central nervous system. Nociception (pain) via the spinoreticular
tract can result in activation of the sympathetic
nervous system (via the amygdala and the thalamus) with
an associated exaggeration of infantile reflexes; altered respiration and infant sleep patterns; increased difficulty integrating sensory input; decreased digestion; and increased
irritability – all manifestations of autonomic dysregulation.
An unmedicated neurotypical neonate will seek his mother’s
breast for nourishment if left to his own devices. In utero
constraint, a difficult labor and delivery, and interventions
– both non emergent and emergent – employed during a
home birth or in a hospital setting may thwart the neonate’s
ability to nurse by altering normal biomechanical function
and perhaps development (Table 2). The most direct way
to effect immediate change for the neonate is to address any
neuromusculoskeletal problems impeding normal function.
The level of intervention will depend on the level of
complexity of the dysfunction. The earlier the intervention,
the greater the chance of attaining competency.
A thorough history and evaluation will facilitate management
(including appropriate referrals) for your patient.
From learning the details of the birth to recognizing key
posturing or head position, a detail-oriented approach is
critical. Specific questions are designed to elicit specific information
about the breastfeeding relationship.
To determine appropriate management, every practitioner
who interfaces with the dyad needs to look at form and
function through a discerning lens and differentiate neuromusculoskeletal
from other issues (Table 3). Chiropractors
need to take into account the observations of the parents
and caregivers who will often describe alterations in function
in minute detail (Table 4).
Examine the infant layer by layer. Indulge in observation
and know that books exist to name things. A full assessment
of all systems should be routinely performed with special
attention given to neuromusculoskeletal integrity. Neurologic
responsiveness, reflexes, and muscle tone should be
assessed as well as the soft tissue structures (including skin
turgor, color and temperature, fascial tension, and development
of muscle mass); osseous structures to rule out fracture
or displacement; and articulations to rule out hyper or
hypomobility of the joints, capsular swelling, and muscle
symmetry surrounding the joint.
Visual assessment (Table 4) as well as passive palpation can
reveal many clues to the cause of the breastfeeding dysfunction.
For example, reflexes like rooting and suckling can be
stimulated digitally or, in a homebirth, simply observed
while the neonate is lying prone across the mother’s chest
and abdomen. A neurotypical neonate will spontaneously
commando crawl (stepping reflex), root, latch, and suckle
while palming the breast (Babkin) without assistance. Even
the initial assessment of the suck, swallow, breath synchrony47
can be performed by observing and listening, If
the neonate is unable to do this unassisted, a chiropractic
examination may reveal the cause (Table 5).
When evaluating an infant with breastfeeding dysfunction
a “whole child” approach needs to be adopted as there are
many factors that could interfere with successful latch and
transfer including injured muscles, fractured clavicle, hip
dysplasia, neurologic interference from an anoxic event, or
an extended half-life of an administered medication. Although
supplementation by bottle may be possible (whether
with breastmilk or an artificial milk replacement), it may
prove to be just as challenging for the impaired neonate
and ultimately more serious interventions like a nasogastric
tube could be necessary.
Diligent evaluation and differential diagnosis are critical in
the neonate who is having difficulty feeding. A collaborative effort between chiropractors and other health care providers
while utilizing an IBCLC for primary breastfeeding
evaluation and support is often the most efficacious means
to restoring competency for the breastfeeding dyad.
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