Maternal Nipple Pain Research Articles

Sucking characteristics of successfully breastfeeding infants with ankyloglossia: a case series

Partial ankyloglossia is a congenital oral anomaly characterized by restricted movement of the tongue resulting from a lingual frenulum that is either short, inelastic, or is attached distally, too near or onto the gingival ridge (1). The prevalence of ankyloglossia is not well documented because of the lack of a standard definition or a reliable clinical method of classification (2). Studies of neonates, infants and adolescents quote the incidence of ankyloglossia to be between 0.1% and 10.7% (2,3). Recently, a resurgence of breastfeeding difficulties in infants with ankyloglossia has been reported, with a frequency ranging from 25% to 44% (3,4). Feeding difficulties associated with ankyloglossia include painful nipples (4–6), poor latch (6), reduced milk supply, neonatal dehydration (7) and decreased duration of breastfeeding (4). Controversy exists regarding the management and treatment of ankyloglossia (8), although studies show that in infants with feeding problems, frenotomy improves maternal nipple pain (5,6,9,10), latch scores (6,10), tongue action, milk transfer and milk supply (10). Fortunately, the majority of infants with ankyloglossia are able to breastfeed successfully. The controversy surrounding ankyloglossia most likely stems from the lack of knowledge of the effect the condition has on feeding, and in particular breastfeeding. Five fully breastfed infants with ankyloglossia presented for a research study designed to assess the sucking characteristics of normal breastfed infants. The study was approved by the Human Ethics Committee of The University of Western Australia. Sub-mental ultrasound scans of the infant oral cavity were made during a breastfeed to image tongue motion (Fig. 1A,B). Intra-oral vacuums were measured simultaneously via a supply line filled with sterile water connected to a pressure transducer (11). The test-weigh method was used to measure milk intakes for the monitored feed and three mothers measured every feed for a 24-h period (12). All infants recorded normal growth and the three mothers who measured every feed for a 24-h period recorded normal levels (range 478 to 1356 g per 24 h) (12). The data are shown in Table 1 (Infants 3–5). Infants 1, 2 and 3 displayed no compression of the nipple; however, weak vacuums were recorded for Infant 1 (Fig. 2A,B; Table 1). Infants 2 and 4 recorded strong maximum vacuums. Infant 4 had strong minimum vacuum and displayed compression of the base of the nipple on ultrasound (Fig. 2C,D). Infant 5 had very weak maximum vacuum and compression of the tip of the nipple (Fig. 2E,F). Mean maximum vacuums quoted in the literature range from )145 (11) to )197 mmHg (13) for breastfeeding infants. Mean minimum vacuum has been measured at )64 mmHg in one study of breastfeeding infants (11). The importance of the level of vacuum has become apparent with a recent study demonstrating an association between strong infant sucking vacuums and nipple pain (14). Conversely, similar to pumping vacuums (15), low sucking vacuums have been associated with reduced efficiency and effectiveness of feeding(16). Although these infants with ankyloglossia had intra-oral vacuums outside the normal range, they were able to obtain enough milk to grow satisfactorily and none of the mothers experienced nipple pain during feeding. It is possible that the vacuum exerted by the infant is influenced by both the restriction of tongue movement or nipple ⁄breast shape. Further research is required to investigate this. Ultrasound imaging during breastfeeding showed that two of the infants compressed the nipple. One infant compressed the base of the nipple and the other compressed the tip of the nipple. Previous ultrasound imaging of infants Acta Paediatrica ISSN 0803–5253

Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound

There is evidence that infants with ankyloglossia can experience breastfeeding difficulties including poor attachment to the breast, suboptimal weight gain, and maternal nipple pain, which may lead to early weaning of the infant. No studies have investigated the cause of these breastfeeding difficulties. The objective of this study was to determine the effectiveness of frenulotomy in infants experiencing persistent breastfeeding difficulties despite professional assistance by measuring changes in milk transfer and tongue movement during breastfeeding before and after frenulotomy. Twenty-four mother-infant dyads (infant age: 33 +/- 28 days) that were experiencing persistent breastfeeding difficulties despite receiving professional advice were recruited. Submental ultrasound scans (Acuson XP10) of the oral cavity were performed both before and >or=7 days after frenulotomy. Milk transfer, pain, and LATCH (latch, audible swallowing, type of nipple, comfort, and hold) scores were recorded before and after frenulotomy. Infant milk intake was measured by using the test-weigh method. For all of the infants, milk intake, milk-transfer rate, LATCH score, and maternal pain scores improved significantly postfrenulotomy. Two groups of infants were identified on ultrasound. One group compressed the tip of the nipple, and the other compressed the base of the nipple with the tongue. These features either resolved or lessened in all except 1 infant after frenulotomy. Infants with ankyloglossia experiencing persistent breastfeeding difficulties showed less compression of the nipple by the tongue postfrenulotomy, which was associated with improved breastfeeding defined as better attachment, increased milk transfer, and less maternal pain. In the assessment of breastfeeding difficulties, ankyloglossia should be considered as a potential cause.

Ankyloglossia in Breastfeeding Infants: The Effect of Frenotomy on Maternal Nipple Pain and Latch

The aim of this study was to measure the effectiveness of frenotomy in ankyloglossic infants, by quantifying the changes in latch and maternal nipple pain using standardized tools. Infants below 12 weeks of age were recruited from the Goldfarb Breastfeeding Program between August 2004 and February 2005. Infants were selected based on the Frenotomy Decision Rule for Breastfeeding Infants (FDRBI), a new clinical tool for future validation. Latch was assessed using the Latch Tool. Maternal nipple pain was assessed using R. Melzack's Short Form McGill Pain Questionnaire, consisting of the Pain Rating Index (PRI) and Present Pain Intensity (PPI). Frenotomy was performed, followed by repeat latch and pain assessments. Mothers also received breastfeeding counseling throughout and after the procedure. A telephone questionnaire was administered 3 months later. Twenty-seven (27) mother-infant dyads participated in the study. No complications were seen with frenotomy. All infants had an equal or higher latch score after frenotomy, with an improvement in mean latch score of 2.5 (p < 0.0001, 95% confidence interval [CI], 2.038, 2.925). Maternal pain scores decreased significantly after frenotomy, with mean improvements of -11.4 points (p < 0.0001, 95% CI, -15.544, -7.345) on the PRI subscale and -1.5 points (p < 0.0001, 95% CI, -1.952, -1.011) on the PPI subscale. Seventy-seven point eight percent (77.8%) of subjects were still breastfeeding after 3 months; 92% were pain free after 3 months; and 88% felt the frenotomy had helped them. Timely frenotomy and breastfeeding counseling is an effective intervention, improving latch and decreasing nipple pain.

Breastfeeding Update 2: Clinical Lactation Management

Breastfeeding Update 2: Clinical Lactation Management