Zoe is told that 7-month-old Madison fusses at the breast because she has tongue posture abnormalities but the baby is simply positionally unstable

Zoe has been told 7-month-old Madison fusses a lot at the breast because she uses wrong muscles to suck

Although this case is disguised and no patient is identifiable, it is consistent with real presentations in the clinic. Mothers regularly come in to see me with the same concerns as Zoe and have been given lists of similar exercises after seeing breastfeeding support professionals trained in bodywork therapy.

Zoe brought 7-month-old Madison to the clinic, having been told that her baby was using the wrong face muscles to suck, which caused her to fuss a lot at the breast. Zoe was told that as a result of this abnormal neuromotor function, Madison had developed abnormal tongue posture.

Little Madison would pull off after only a short period of suckling. Zoe had some ongoing nipple pain intermittently, too, though it wasn’t too bad right now. Zoe’s International Board Certified Lactation Consultant had diagnosed reflux, recommended a dairy free maternal diet, and advised Zoe that her baby was not only at increased risk of Attention Deficit Hyperactivity Disorder long-term, but also at increased risk of Sudden Infant Death Syndrome short term due to breathing problems.

The lactation consultant diagnosed posterior tongue-tie and an upper lip-tie, telling Zoe that Madison was using her lips to grab onto the breast instead of the proper muscles. Zoe was told that she could wait and see if the exercises improved these restrictions before considering surgical release. The lactation consultant also diagnosed an exaggerated startle reflex and suggested this was why Madison was waking excessively at night. Madison didn’t snore at nights, but was waking every 45 minutes or more.

Zoe’s baby girl sat quietly on her mother’s lap sucking a dummy (and breathing normally through her nose) as Maddie told me all of this, with some distress. When Zoe put Madison to the breast, she pointed out how Madison had an occasional chin quiver as she suckled. The lactation consultant had told her this was a sign of fatigue due to Zoe's compensatory muscle use.

Zoe's lactation consultant gave her written instructions for exercises she needed to do with Madison

Zoe showed me the instructions she’d been given for half a dozen or more exercises, which she was to do with Madison to strengthen Madison’s oral muscles and tongue. These were printed out on sheets of paper, each with diagrams and illustrations.

Zoe was to start with two or three of these exercise sessions a day, and then increase to five or six sessions a day. Zoe was to do these for two or three weeks after everything has improved.

• She was advised to put food into the side of Madison’s mouth to encourage certain tongue movements.

• She was advised to stretch the tongue with her fingers, and to play tongue games. These included a tug-of-war game with the tongue; tongue laterization; tongue protrusion; thrust challenge; deep tongue muscle releases; floor of mouth releases; and tongue huggies.

• She was advised to give Madison face massages. These included specific instructions for face, jaw, cheek, and tongue massages

• Madison was also given exercises for the diagnosis of tongue thrust challenges. She was told these exercises would also help with gag and palate desensitization.

• Other exercises this provider gave to Zoe included tracking her fingers along Madison's gum lines, placing pressure on the back of her tongue, pressure on the palate, and holding down the floor of the mouth for up to a minute. Some of the exercises included squeezing and pulling outward along the sides of the tongue. If the tongue wasn’t forward over the lower gums, or if the back of the tongue bunched up, humping, Zoe was to press gently down on the tongue (saying “down” at the same time) and to use forward traction.

• Zoe was instructed to perform these exercises before feeding or as a playtime activity and to be sure to stop them if Madison didn’t like it. She was instructed to do them while finger feeding if Madison needed more encouragement to do them. The sheet of instructions said that once the baby was happy to have gentle facial and oral stimulation, Zoe could progress onto other exercises.

Although the therapist’s instructions said the exercises were to always be done with the baby’s consent, some crying was also considered normal, according to the written instructions. Parents were advised to sing and smile and coax the baby to enjoy. They were advised to use deep breathing and visualisations themselves, for instance, of butter melting under their finger, as they applied pressure inside baby’s mouth.

What did I say to Zoe?

I found no abnormalities on physical examination of this baby. Yet Zoe had been prescribed highly intrusive and time-intensive exercises for a range of functional abnormalities diagnosed by the lactation consultant, which she was to do on her baby many times a day.

I believed that these exercises put Madison at risk of a conditioned dialing up with feeds. Zoe had also been frightened into thinking that if she didn’t comply, her precious baby might be at risk of long-term negative effects on her development.

Unfortunately, nothing in Zoe’s work with the lactation consultant had addressed Madison’s fussiness at the breast which I saw, as I watched Zoe breastfeed, related to positional instability. I could see that Madison was ‘too far around the corner’ and too high relative to Zoe’s breastfall when she fed, both common problems in older babies.

After I’d finished my assessments, I sat back down in my chair and held Zoe’s gaze for a while. She was fighting back tears, waiting to hear what I had to say. “Well … “ I said, gathering my thoughts. I shook my head slightly, took a deep breath, sighed.

"Zoe, we have a health system problem at the moment. It's no-one's fault. Everyone is devoted to doing the very best they possibly can for you and Madison. But we have a health system problem, where the research we need isn't funded and everyone is trained differently. What I'm going to say will seem quite different to what you've heard. But Madison is completely healthy and doesn't have any tongue function abnormalities.” I explained all the normal findings, one by one, and why Zoe didn’t have to worry about Madison’s development. I explained about reflux, and allergy, and why Madison didn’t fit those pictures. I explained what was actually going on when Madison breastfed, how positional instability made her so fussy at the breast.

I gently recommended that Zoe didn’t use any of the information or exercises she’d been given. I explained that Madison certainly had misalignment of her body clock settings, which affected her sleep and which we could deal with in a follow-up appointment, but that this was completely unrelated to her breastfeeding problems or to Madison's startle reflex.

Then we worked together with the gestalt method. Soon, as Zoe and I worked together, Madison stopped fussing at the breast. Zoe was astonished. We talked about frequent flexible breastfeeds, and sensory motor nourishment.

When I saw Zoe a week later, Zoe still couldn't believe the dramatic improvement in Madison's breastfeeding. Her baby didn’t have multiple abnormalities of anatomy and function! She didn't fuss so much any more! Her baby had simply been unstable in the way she was positioned at the breast.