11/22/2017
Understanding Compensations
I frequently hear people try and disprove the impact of tongue tie on breastfeeding by saying something to the effect of “Well my child was tongue tied and we nursed just fine”. Not uncommonly, however, I have found that if you explore the statement more, nursing wasn’t actually normal. Remember that the concept of normal may be tainted by what someone has read, been told by their doctor, or influenced by family. What if “normal” to a mom meant that, like her mom experienced, breastfeeding was always uncomfortable and they stopped at 3 months due to diminished supply? What if normal is explained away as “well, I just dried up”? In my experience, if someone with knowledge truly investigates whether breastfeeding is normal or not, they will often find things that are not normal.
Does this mean that everyone needs intervention? Of course not. My concept of normal/ideal is going to be very different than many of my patients’ concepts of normal. I am here to support them in the decisions they make, whatever they may be. Part of that responsibility is explaining how a child is compensating when a tongue tie is present. Just because a baby can work around the presence of a tie does not mean that something can’t be done to improve how nursing is going. I argue that continuing to rely on compensations potentially shortens the breastfeeding relationship. What are some of these compensations?
1) Overuse of the lips - as shown in the picture, this baby uses the lips to hold on to the breast/bottle. The lips are often white on the inside immediately after feeding, but even at rest may demonstrate pallor. I call this the “two-toned lip” - pale on the inside and pink on the outside. The pallor is often accompanied by chapping or blistering, including a persistent central sucking blister.
2) Cheek dimpling - If the tongue cannot hold on to the breast, and the baby uses the lips instead, then the latch is almost always shallow. In this position, the tongue doesn’t even touch the breast (think of how you use a straw - your tongue is further back in your mouth and doesn’t need to touch the straw). Without tongue/breast contact, there’s no tongue vacuum generation, so the baby uses jaw muscles to generate the suction. The resultant vacuum frequently sucks in the cheeks during nursing, causing dimples.
3) Bottle use - This compensation is specifically mentioned for the primary care doctors out there. Often, they will focus on the normalcy of weight gain as a good thing for the baby. But if that normal weight gain is achieved or dependent on the use of a bottle to supplement breastfeeding, that’s a compensation. Both the American Academy of Pediatrics and World Health Organization recommend exclusive breastfeeding for the first six months. If mom wants to exclusively nurse but has to supplement with a bottle afterwards, then the onus is on us as doctors and lactation consultants to ask WHY the bottle is needed.
4) Ni**le shield - Ni**le shields are quite commonly used. Contrary to popular belief, I’m not anti-ni**le shield. I am anti-ni**le shield without a plan in place to examine why the shield is necessary. While not studied adequately, I consider ni**le shield use beyond the first month of age to be a screening tool for tongue tie - continuing to rely on a shield to get the baby to latch on or to latch on atraumatically needs investigation.
5) The use of an SNS - the supplemental nursing system, or any addition of milk/formula during nursing is technically a compensation. Can it be used responsibly? Absolutely. Moms with insufficient glandular tissue or insufficient milk product can use the SNS to keep the baby nursing. But the mom who has ample amounts of milk and is using the SNS to keep the baby nursing after letdown is doing so to mask the baby’s inability to draw milk out of the breast. That can jeopardize future supply and is often not sustainable.
These are only some of the compensations out there. There are more. But the algorithm to address those compensations should be the same. We need to stop focusing on the behavior of the baby (pursed lips, small mouth, needs a bottle/shield/SNS) and instead need to dig down to the root cause of the problem. That’s called “the practice of medicine”.
