There has been a lot of discussion among the medical community about the impact of tongue and lip restrictions on breastfeeding and oral health in general. Over my now almost 50-year career of nursing and lactation support, this discussion has grown from a “no big deal, just fix it” question to an “it’s an imagined problem” to where things stand now – with camps saying it’s overdiagnosed to camps saying that it’s underdiagnosed and undertreated. There are many social media groups for both moms and professionals discussing the issue and in some cases, strong battle lines are drawn. Here is my opinion.

Personally, I have had two children with restricted lingual frenulums. One received a revision at 5 days by the old GP that delivered her. The other delivered many years later, was not diagnosed and was not treated. I nursed them both, the first for 10.5 months (in a day when everyone bottle-fed) and the second 3.5 years. Both had dental issues later in life.  That’s my personal experience and occurred before I was a board certified lactation consultant. My experience says that with a genetic capacity for excellent milk supply and determination, breastfeeding can happen for some moms with babies with oral restrictions, but sometimes it can’t. There was no Facebook back then with thousands of mothers looking for support that they can’t find in their local medical community. I survived. Does that make it ok to not treat oral restrictions?

Professionally, over the course of my career, I have helped thousands and thousands of women breastfeed.  Some of the most difficult cases have been with babies with oral restrictions. And many of these have additional difficulties to overcome, some as secondary issue caused by the oral restrictions, some separate but equally challenging issues. Below are some of my conclusions.

Oral restrictions affect muscles in the body. Babies use their whole bodies to breastfeed. Sucking is the mechanism by which babies get nutrition, comfort and explore their world. When that is disturbed by difficulties of attachment due to weakness or inability to move the tongue (which is another muscle), their world is turned upside down. Compassion and understanding go a long way to increasing patience with a baby who doesn’t understand and who is biologically driven to nurse. All babies want to nurse, but oral restrictions impeded their ability to do with ease.

First, it is important to note that muscle tension can affect tongue effectiveness, giving an appearance of restriction. That is why it is important to have an experienced diagnostician who can distinguish between a mechanical restriction (like a tongue-tie) versus muscles in tension preventing movement and range of motion. Proper diagnosis is the first key to dealing with inhibited tongue function.

Next, if a mechanical restriction is diagnosed, an experienced and knowledgeable provider is the second key in improving function. The provider must know how to do a complete release and be able to show the parents what that looks like when it is accomplished, and give proper guidance for post-revision care. In some babies, there are benefits to doing pre-release physical therapy, occupational therapy, etc. if baby is showing signs of compensation that can be helped even before release is done.

The third key is effective and consistent after care done once the baby’s restrictions is released. Babies who can’t suck effectively, often develop muscle tension in other places than the tongue as they try to compensate for poor tongue function. This can result in lots of tension, pulling away from the breast, biting, etc. Some babies will develop or may have accompanying torticollis, high body tone, etc.  Body work, physical therapy, effective and frequent tummy time, baby-wearing, and skin to skin care can help calm and relax a baby. This must be done in a pattern that is effective and rewarding for baby.  Some babies need care from a speech language therapist. If baby is being supplemented, the choice of supplementation device may change as baby improves. See my post for more information on the impact of devices on breastfeeding competency. Protect your milk supply while working on any latch issues as supply is driven by the degree and frequency of emptying the breast. See the link above for more information on that as well.

A lactation consultant should reevaluate baby after a release because latch techniques may need adjustments once baby has full range of motion of the tongue. It takes time to work through and retrain baby to latch comfortably and effectively. Most moms report it takes 2-4 weeks. Follow-up assessment during this time is important to make sure healing is progressing and function is improving. The IBCLC can further refer to body workers, speech therapy, physical therapy as needed.

Above all, when taking the journey through breastfeeding difficulties, including oral restrictions, remember that the breast is and should be not a battle ground but a sanctuary for babies. Keep baby close and comfortable (that’s skin to skin care). Keep baby at the breast, even if you have to supplement away from the breast. Breastfeeding can be an after meal snack even if your supply is low. Your journey may not be easy, but your bond can be strong as you work through challenges.

Research shows that the number one reason for moms not meeting their breastfeeding goals is low supply. Research shows that milk supply is heavily dependent on what happens in the first 3 days.  Here are a few tips that will protect your supply and ease baby’s transition from womb to world.

What To Know:

1. Babies are not born knowing that sucking is related to hunger satiation. Sucking is a reflex that brings comfort first, food second. Babies do not know hunger before birth.
2. Caring for babies skin to skin provides warmth, moisture and transfer of protective good bacteria from mom to baby. Research has shown that babies cared for this way have less jaundice, better sugar levels, better temperature maintenance and fewer infections than those cared for away from mom’s skin. Delaying bathing to allow time for vernix (the thick creamy coating in skinfolds and coating skin) helps baby absorb good bacteria from mom. This is especially important for babies who have delivered by Cesarean Section.
3. Most babies, when placed on mom’s chest immediately after birth, will begin crawling, searching and rooting activities within the first hour after delivery. Interestingly, mother’s milk is most readily available at that time due to birth hormones. Babies who get this early dose of colostrum are protected from low blood sugar and the gut is provided a protective layer of mother’s helpful bacteria. This early latch also starts the milk production process and helps prevent delays in milk coming in.
4. Baby’s first sucking experiences help develop baby’s sucking behavior. Finding the breast for herself while crawling on her belly encourages a wide-open mouth and tongue forward. Repeated practice sessions – offering the breast with early feeding cues whenever baby demonstrates those – helps the imprinting process. Leaving baby’s hands unwashed and uncovered helps baby find her way to the breast.
5. Frequent feedings in the first 100 hours (10-12 per 24 hours) encourages a more rapid transition from colostrum to milk production. Tight swaddling may interfere with natural feeding rhythms.
6. Feeding both breasts, and repeating as necessary, helps a baby associate sucking with obtaining milk.
7. IV fluids, blood pressure issues etc. can cause the areola around the nipple to be firm and make latching more difficult for the baby. Reverse pressure softening and areolar expression can remedy this and make latching easier.
8. When babies are latched well, you should be able to hear a few swallows, even in the first day of nursing.
9. What goes in must come out: that means a baby who is getting milk from the breast will have wet diapers and poop. This starts at one a day and increases by an additional wet and poop for each day of life. By 5 days, a baby should be wetting 6-8 times and pooping 3-5 times per day.
10. Nipple tenderness should be resolved by day 5.

What To Expect:

First 24 Hours: Baby should nurse within two hours, if placed skin to skin with mom and allowed to remain there.  Some babies will sleep 4-6 hours and then begin nursing every 1.5-3 hours.  Some babies do not take the recovery sleep. Babies may nurse for a few minutes, others for half an hour.

Second 24 Hours: Babies should start waking up more, nursing for longer periods. During the second night of life, babies may nurse more frequently and seem hungrier, wanting to nurse off and on all night. Milk often comes in after this frequent nursing period. Switching breasts frequently and breast compression helps protect nipples and improves supply.

Third 24 Hours:  Milk volumes increase, breasts become firmer. Nursing sessions should last 10-30 minutes. Be sure to nurse both breasts, changing breasts whenever baby starts to fall asleep.

What To Do:

1. Keep mother and baby together, 24 hours a day. Do not separate unless medically necessary.
2. Put baby on mom’s chest immediately after birth. Mom’s head should be raised so she can see and follow her instincts to help baby with latch. Delay bathing for at least the first 24 hours. When bath is done, leave hands unwashed.
3. GIVE THE BABY TIME. Don’t worry if baby doesn’t immediately latch to the nipple. Let her fuss a bit, move back and forth to seek the nipple and find it herself. Do not force the nipple into her mouth or push her head onto the nipple. Do not push on her back. Baby has natural instincts to feed that are most active when he is on his belly and feels supported by mom’s body.
4. If mom’s areola is firm or nipple appears flattened, perform Reverse Pressure Softening and/or Areolar Expression to help baby draw nipple far back onto his tongue. 
5. Use breast compression to keep milk flowing if baby seems to fall asleep quickly after latching. This is a firm but gentle squeezing of the breast a few inches back from the nipple. Squeeze and hold while baby is drinking; release while he rests and repeat until baby is not swallowing.
6. Change breasts every few minutes when baby slows down on sucking and swallowing. Repeat breasts until baby is satisfied and asleep.

1. If your baby is too sleepy to latch (this can happen from medications mom is given during labor), express directly into baby’s mouth or hand-express colostrum and syringe or spoon feed to baby. This will help prevent low blood sugar for the baby and prevent unnecessary formula supplementation. Breast milk is more effective at increasing baby’s blood sugar than formula because it is self-digesting. Do this every 2 hours until baby shows interest and starts latching by himself. 
    
2. If your baby has not started latching by 12 hours after birth, ask for a hospital breast pump and begin pumping as well as manual expression to give your supply a jump start. If your baby begins latching but is still having difficulty after 24 hours (causing nipple pain, no swallowing), start pumping. Pump 10 times/day the first three days, then 8 times/day after that until baby is doing well.  Research shows that moms who begin hand-expressing AND pumping in the first two hours when baby is unable to nurse well, have twice as much milk at 10 days as those who delay.  WATCH THIS VIDEO: http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
3. Avoid pacifiers and bottles until baby is latching well. It usually takes about 2 weeks for babies to imprint at the breast.
4. Keep track of baby’s output. The My Medela App is free and will help you keep track of feedings and baby’s wets and poops.
5. If you are still having trouble with latch or have nipple damage after the 5th day or you have cracked or bleeding nipples, get hands-on individual help.
6. Laid-back breastfeeding with mom comfortably supported and baby’s weight on her and not a pillow should be practiced throughout breastfeeding. If mom has a sore neck and shoulders from breastfeeding, it’s a sign that she is not comfortable and is working too hard. Babies take at least 6 weeks past their due date to become automatic breastfeeders and to have more control over their head and neck muscles.

If you have time and resources, please take a comprehensive prenatal breastfeeding class. Prenatal Classes help get the whole family on the same page and reduce stress. Classes are offered in many locales, including Nova Birth Services at (615) 669-6399 and most Maternity Hospitals. 

1. Use a Dr. Brown’s 4 oz with standard (not wide-mouth) bottle. The valve in the Dr. Brown’s bottle encourages baby to suck and not remove milk by compression. Shorter, wider bottles encourage biting.
2. Put baby on her side in a flexed position, propped with her head higher than her bottom. Her neck should be naturally curved with the chin sticking out a little. Her head should be lined up with her body, not turned to one side or the other. If your baby is older, you can sit baby upright on your lap, supporting her head behind the neck with one hand. Don’t put her in the crook of your arm or on your forearm – this may lean her back too far, causing the milk to come out of the bottle more quickly when she is not sucking. Remember, baby’s back should be rounded, not arched, hips flexed and chin forward in either position.
3. Tilt the bottle so milk is NOT in the nipple at first. This will not cause baby to swallow air, but instead get her used to sucking a few sucks without milk, like breastfeeding. Use the nipple of the bottle to tease the baby’s lips, stroking from the top lip to the bottom, trying to get her to stick the tongue out over the bottom lip and open very wide. Stroke down gently from the center of the top lip to the center of the bottom lip. Be patient, as it may take several strokes at first for her to get the idea.  When she starts to get the tongue out, tilt the nipple towards her palate and encourage her to take it in all the way to the back of her tongue. Baby’s tongue should cover her gums and be over her bottom lip  This will encourage her to suck, not bite, the bottle. Her lips should flange out, touching the nipple collar. If she doesn’t take the nipple in very far, gently twist and work it back further onto her tongue until her lips touch the collar. If she gags, take the bottle out and start over. The tip of the nipple should rest on the back of baby’s tongue (like the breast nipple during breastfeeding) and not in the front of her mouth. If baby does not close mouth and cup tongue around the nipple, try supporting her chin with a finger and pressing upward. Do not tip the bottle up and completely fill the nipple as this will cause milk to flow too quickly. Air in the nipple will not cause gassiness! Babies swallow air when milk is flowing too quickly and they attempt to breathe and swallow at the same time.
4. When baby is older and stronger, you can hold baby in sitting position. Cross your legs or put one foot up on a stool to allow your leg to help support baby’s back. Hold the bottle as level as possible, just allowing milk to come into the nipple. This puts baby in charge and encourages her to use her tongue correctly.
5. After 30 seconds or so of swallowing, tilt the bottle back so milk is not in the nipple. Allow baby to rest and catch her breath. As baby begins to empty the bottle, you can lean her head back slightly, but no more than 45 degrees. On her side, you can turn her slightly upward to keep milk in the bottle nipple tip.
6. If your baby is using the side position, you may find she is more efficient on one side than the other. If that is true, use the best position for majority of feeding but finish on the other side. You may also try lying on your back with her lying across your chest.
7. Watch for swallowing (slight pause in the open-close motion of sucking). Help her to pace herself by removing the bottle if she seems to be pushing it with her tongue, does not pause to breathe, milk is spilling out of her mouth or she needs to burp. It should take her 15-20 minutes to finish a bottle.
8. Some babies require chin support to get started especially if they have been using bottles that have short nipples, wide bases and where milk comes when baby bites down on the bottle teat. Keep working with above techniques until baby gets the hang of sucking instead of biting the bottle nipple.
9. Offer the breast after feeding for comfort-nursing as often as possible. This will help improve digestion and keep baby interested in breastfeeding.

Note: Baby is on mom’s lap with her butt against mom’s stomach, not sitting upright. Baby’s head is higher than her bottom. Bottle nipple is tilted up and milk only half-fills the nipple. Both lips are flanged out and touch the collar of the bottle.

Baby-Led Bottle-Feeding by Jane Kershaw Revised 12/2021

Adapted from “Bottle-Feeding as a Tool to Reinforce Breastfeeding by Dee Kassing, BS, MLS, IBCLC. J Human Lact 18(1), 2002

Strategies for Moms Anticipating Breastfeeding Difficulties

This page is designed for moms who have previously experienced breastfeeding difficulties or have been informed by a skilled provider that they MIGHT have difficulty breastfeeding. These strategies do NOT guarantee that mom will avoid these problems, but serve as a sample of actions that moms have taken that have proven successful in their breastfeeding journey.

Flat or Inverted Nipples

A flat nipple is one that, when the areola is compressed about an inch behind the nipple, flattens out and appears level with the surround areola or becomes thick and barely protrudes past the surface.  An inverted nipple pulls behind the surface of the areola and may pull inward into the breast.

Prenatally:  Try Supple cups starting at least 8 weeks before delivery. Check out  for product information. Begin using these as per instructions. Consider purchasing softshells for inverted nipples  to wear over the supple cups to allow longer periods of wearing to help correct the condition prior to delivery.

After Delivery: Try Latch Assistant by Lansinoh. This can be used on the nipple itself or placed over a nipple shield (if needed) to draw the nipple out or to pull inside the shield before latching.

Supple cups can also to be used in the same way.

History of Latch difficulties with delayed or slow onset of Stage 2 of lactogenesis.

Research has shown that optimal breast stimulation and expression of colostrum during the first 72 hours after delivery can double milk output at 10 days.

1. Initiate breastfeeding within the first hour after delivery with mom in laid-back position, using biological nurturing approach. See:  for more basic tips.  If areola is tight (feels like your chin or the end of your nose), use reverse pressure softening and areolar expression to increase nipple availability before baby latches.  Once baby has latched, remain reclined throughout the feeding. Mother to recline at feeds for 6-8 weeks. Reclining means mom is leaned back between 15-70 degrees (not straight up) with her back and neck and arms supported.  Baby’s weight is on mom’s body not away from her on a pillow.  Mom should not have to push on baby’s head or back for her to reach the breast. Switch breasts when baby starts to pause a lot (usually every 5 minutes or so). At 24 hours, begin softening and expression before every feed, even if you don’t think your areola is firm.
2. Ask for a hospital breast pump to be brought to you right away, along with syringes for milk collection. If your baby is not latching well by 12 hours, begin using breast pump in addition to hand-expressing. 
3. Offer the breast every 2 hours until 10:00 at night, and then every 3 hours during the night. If baby is too sleepy to latch, hand express about 10 minutes. If baby isn’t latching consistently by 24 hours, but you are not separated, add pumping for 15 minutes to help speed up onset of milk production. Give any colostrum to the baby by finger-feeding. This is for first 3 days of life. Pump early, pump often!
4. If your baby cannot latch to the breast or stops latching, ask for a small and a large nipple shield. Try both to see if baby can latch to either. Ask for demonstration from your care provider.  If you have not started pumping yet, begin doing so. Pumping in the first 3 days should be about 15 minutes using the Symphony initiation program. Once your milk starts coming in, use the maintenance program and move the vacuum up to at least 10 bars on the screen up to maximum comfort vacuum (a bit uncomfortable but not painful).  Ask for written instructions for pump use. Plan on taking a rental pump home from hospital if needed. Remember milk does not start squirting until Day 7 after delivery.
5. Check baby’s suck using your thumb to see if baby is drawing your thumb back to the back of her tongue or is only “peanut butter sucking” on the tip of your thumb. Sometimes a little suck training before latch can correct what is just a habit baby has at birth.
6. If no comfortable strong latch is obtained, plan to see a lactation consultant around 4th-5th day (optimal time when milk surge normally begins and baby is more alert).
7. Monitor baby’s weight loss. If mom’s milk is not coming in quickly, have donor milk or ready to feed formula available for early supplementation as needed. Many organizations recommend hydrolyzed formula if human milk is not available.  If supplementation is needed in the hospital after the first day, ask for oral syringes and a feeding tube for easier finger feeding or at breast supplementation. If long-term supplementation is required, a Dr. Brown’s bottle and side-lying baby-led bottlefeeding technique can be used. 

Breastfeeding Assistive Devices 

• Latchassist by Lansinoh
• Hydrogels by Medela (2 pkgs)
• Nipple shields 20 and 24 (if not obtained from hospital)
• Bacitracin
• Medela Harmony manual pump
• Haaka milk collector
• Tube top – makes a comfortable holder for nursing pads, can be used as a pumping bra
• Dr. Brown’s 4 oz regular newborn bottle (not glass, not wide mouth)
• Microwave sterilizer bag (if you have a microwave)

From Hospital

• Oral syringes
• Pump kit
• Rental pump
• Feeding tube (used for finger-feeding or at breast supplementation)

A Word of Encouragement

DID YOU KNOW? 

In a study conducted with moms with history of breastfeeding difficulties, that 95% of them had success with following births – even if the previous breastfeeding experience was not what was expected or planned? This just validates that every breastfeeding experience is unique with a unique baby and a mom with a different (and growing) skill set! It’s just like childbirth – each birth, each mother-child relationship is different, but all are valuable!