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Influence of the Infant’s Anatomy
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Introduction© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

The newborn infant brings a unique set of anatomic structures, physiological activities, reflexive ­behaviors,
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and nutritional needs and stores to the breastfeeding relationship. The mechanical acts of latching, suckling, swallowing, and breathing must all occur in a synchronized interplay among anatomic structures,
physiological parameters, and the infant’s immediate environment. After birth, the fetus must transition
to extrauterine life and undergo extraordinary changes in an amazingly short time. Some of these changes
affect and are affected by breastfeeding. This chapter views breastfeeding from the perspective of the infant© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
and the structures and functions that he or she brings to the breastfeeding process.

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Functional Infant Anatomy and Physiology
Associated with Breastfeeding
To breastfeed effectively, an infant must engage in and coordinate the three basic processes of suck, swal-

nes & Bartlett Learning,
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Anatomic structures contributing
to these processes
are usuallyin close proximity
another and may overlap in function (Figure3-1). This
topic
is covered
depth by Wolf and Glass
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The oral NOT
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Source: Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation (4th ed.). Sudbury, MA: Jones and Bartlett.

© Jones
Bartlett
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In young infants, the fat pads passively provide the majority of positional stability.
As the infant grows, the fat pads diminish and the cheek muscles provide active stability.
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labial or maxillary frenum (the terms “frenum”
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the upper lip to the upper gum. It has been defined as a vertical band of lip tissue extending from the inside
portion of the upper lip and attaching to the alveolar mucosa of the maxillary arch (Kotlow, 2011a). A tightlabial frenum or “lip-tie” may create difficulty flanging the upper lip and maintaining a seal on the breast(Wiessinger & Miller, 1995), possibly resulting in sore nipples, decreased milk intake, and engorgement,
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Downward movement during sucking expands the size of the sealed oral cavity to create suction.
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in sealingoral cavity anteriorly
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Bolus formation

Normal Position and Movement
Position: Soft, with well-defined shape that is thin and flat with a rounded tip.
Rests in the bottom of the mouth, and not seen when the lips are closed.
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Movements should be rhythmic, wavelike, andin smallexcursions.
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Compression and suction should be present.

Abnormalities of Position and Movement
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Normal Position and Movement
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and lower alveolar ridges are aligned, with loose opposition.
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Movement: Wide or excessive jaw excursion, clenching or biting during sucking

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134  Chapter 3: Influence of the Infant’s Anatomy and Physiology
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PalateKey Functions
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Hard and soft palates should be intact with smooth contours.

Abnormalities of Position and Movement
Clefts of any portion of the palate, high arched hard palate, bifid uvula, decreased movement ofsoft palate© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

Source: Glass, R. P., & Wolf, L. S. (1994). A global perspective on feeding assessment in the neonatal
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intensive care unit. American Journal of Occupational Therapy, 48(6), 514–526. © 1994 by the American
Occupational Therapy Association, Inc. Reprinted with permission.

■■ &ABartlett
receding jawLearning,
positions the tongue
obstructionof the airway.
© Jones
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A receding jaw can contribute to sore nipples unless the chin is brought closer to the breast.
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Breastfeeding creates beneficial forces on the development of the jaws during a period of very rapid
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increasing in size). Bottle-feeding causes the buccinator muscle (used for obtaining milk from anes & Bartlett Learning,
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bottle) to become hypertrophic (enlarged or overgrown), which can alter the growth trajectory of
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and grow appropriately for facilitating normal craniofacial growth. This development also allows forthe ideal positioning of the mandible for tooth eruption (Gomes, Thomson, & Cardoso, 2009).
■■
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ence©
onJones
the growth
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wereNOT
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more retrusive mandible, with facial growth described as dolichocephalic (or long face). Breastfedchildren had a mandibular arch that determined a more brachycephalic growth (or short face).
■■
Medeiros, Ferreira, and de Felicio (2009) reported that 6- to 12-year-old children who had beenbreastfed had better mobility of the tongue and jaw than children who had been bottle-fed. The
orofacial
structuresLLC
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During breastfeeding the tongue actively brings the nipple into the mouth, shapes the nipple andinto a teat,and stabilizes
the teat’s position.
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During bottle-feeding the tongue is not needed to draw the artificial nipple into the mouth, but theNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
tongue still helps stabilize the position of the nipple.
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lifts for swallowing).
■■
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configuration, the tongue is theof increasing
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cavity to create negative pressure/suction.
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The tongue provides compression against NOT
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complexteat (Bosma, Hepburn,Josell, & Baker, 1990).
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the tongue elevate and curl to provide the framework or a cylindrical pathway for the movement of
milk (Tamura, Horikawa, & Yoshida, 1996).
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neonatal
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ling, especially in the adaptation that allows the curling of the lateral edges of the tongue (Iskander& Sanders, 2003).
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Carrascoza
andORcolleagues(2006) studied the effects of the use of feeding
the oral facial
opment of children who were breastfed and those who were bottle-fed. They reported the following:

The tongue of bottle-fed infants tended to rest in the mandibular arch, indicating somewhat hypotonic tongue muscles compared with the resting position of the tongue of breastfed infants. The
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Sucking movements of breastfeeding place the tongue in the palatal region of the central incisors,
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preventing air from passing through the mouth, which favors nose breathing. While this type ofbreathing heats, humidifies, and filters air prior to reaching the lungs, it is also considered the functional matrix for growth of the maxilla. The passage of air through the nose exerts pressure on thepalate, resulting in the lowering and expanding of the structure, which allows the face bones toaccompany general body growth.
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin■■
In bottle-fed infants, the tongue rests in an unphysiological position that promotes mouth breathing
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breathing.
result can be maxillary atresia (narrowing ofNOT
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Hard
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Wolf
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Glass
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bility of the nipple when drawn into the mouth and working in conjunction with the tongue in the
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136  Chapter 3: Influence of the Infant’s Anatomy and Physiology

compression of the nipple–areolar complex. The contour of the palate is shaped in utero and after birth© Jones & Bartlett Learning, LLC© Jones & Bartlett Learninby the continuous pressure of the tongue against the palate when the mouth is closed. A palate with a
NOT ofFOR
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be an indication of an abnormality or a restriction
tonguemovement.
Palmer (1998) described the palate as being almost as malleable as softened wax while in the earlystages of oral cavity development. It can therefore be subject to alterations, depending on what is placedin the mouth (artificial nipples, intubation, pacifiers). Pressure from objects can easily mould the shape© Jones& Bartlett
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tongue action. An appropriately shaped palate aligns the teeth properly and does not infringe upward,
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Snyder (1995) describes size parameters of the reference palate as being 0.75 inch (2 cm) in width(as measured from the lateral aspects of the alveolar ridges midway to the junction of the hard and soft
palates) and approximately
1 inch (2.5 cm) from©
theJones
anterior superior
alveolarLearning,ridge to the hardand softnes & Bartlett Learning,
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junction. Wilson-Clay and Hoover (2002)
measured
the SALE
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98 infants
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DISTRIBUTIONNOTFORDISTRIBUTION
35 weeks of gestation to age 3 months by inserting a gloved finger to a depth that triggered sucking. The
length from lip closure to the hard and soft palates’ juncture ranged from 0.75 to 1.26 inches (1.9–3.2 cm).
Palatal variations have been described as narrow, grooved or channeled, high, flat, V-shaped, short, long,and bubble.
Hohoff,Rabe, Ehmer,
and HarmsLearning,(2005) describeLLC
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as alreadyexhib© Jones& Bartlett
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iting rugae (ridges or folds), which are also present on the adult hard palate. These rugae or ridges are
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thought to help anchor the breast in the mouth so it does not slip or slide out of position during sucking(Crelin, 1976). The maxilla of the newborn is further characterized by a system of grooves (Figure 3-2).
By the age of 5 years, the lateral palatine ridges are no longer apparent and the palate becomes similar tothat of the adult. Epstein’s pearls are white or yellow inclusion cysts that may be present on the palate andare remnants of epithelial tissue trapped during palatal fusion. These cysts generally disappear within a© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
few weeks of birth.

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Soft Palate (Velum)

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lature is attached. The soft palate makes up the posterior third of the palate, is fleshy and moveable, andFOR SALE ORraises
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and notOR
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boundary between the hard and soft palates has traditionally indicated how far back into the mouth thenipple should extend at maximum suction. However, Jacobs, Dickinson, Hart, Doherty, and Faulkner(2007) demonstrated under ultrasound that only about 25% of infants in their study positioned the nipple
at exactly the junction of the hard and soft palates. The mean distance from the tip of the nipple to the
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of thehard andsoft palates was
5 mm in breastfeeding
couples with no nipple
pain or milktransfer issues,
illustrated
most
infants did not draw the nipple–areola as far into
the FOR
mouth asNOTSALE OR DISTR
NOTwhich
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Inspired air passes through the nasal cavity, where the palatine bone or hard palate separates the oral
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NewbornNOT
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Nomenclature of Palatal Structuresh		frenum labiia		 outer alveolar groovei		frenulum of cheekb		 alveo-palatinal sulcus
p		papilla incisiveb′		 postero-lateral sulcus© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
1		alveolar wallb + b′ tooth germ groove
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2		tektal
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transitory palatal fold3		dental molar walld		 anterior palatal groove4		lateral palatine ridgee		 anterior sulcus
5		palatal vaultf		 antero-lateral sulcus
g		 lateral sulcus

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Source: Hohoff, A., Rabe, H., Ehmer, U., & Harms, E. (2005). Palatal development of preterm and low birthweight
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newborn. Head and Face
Medicine, I, 8. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308841/?tool=pubmed.

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The pharynx, a soft tube involved in swallowing, is divided into three regions: the nasopharynx; theNOTFOR SALE OR DISTRNOTFOROR DISTRIBUTION­oropharynx,
whichis theSALE
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or laryngeal pharynx, which is the area and the structures between the epiglottis and the sphincter at the
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The larynx is composed primarily of cartilage and contains structures necessary for producing sounds
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tongue and folds down during swallowing to close and seal off the inlet to the larynx and trachea, thereby© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
preventing liquid and food from entering the airway. At rest, it is elevated and allows air to flow freely
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through thelarynxinto thetrachea.

Trachea
The trachea is a semirigid tube composed of semicircular rings of cartilage connected to each other andto theAs it Learning,
descends, it branches
go to eachlung.
© Jones& larynx.
Bartlett
LLCinto the two primary bronchi© thatJones& Bartlett
Learning, LLC
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Hyoid BoneThe hyoid is a small, free-floating bone that is the nexus of connections between the structures involved in the
anatomy and physiology of sucking, swallowing, and breathing as well as in head and neck control. The hyoid
is held in position by seven connections: to the scapula, sternum, cervical vertebrae, laryngeal cartilage, tongue,
nes & Bartlett Learning,
LLC bone. When the hyoid moves
© up
Jones
& Bartlett
Learning,
LLC conmandible, and temporaland forward
during swallowing,
the appropriate
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help open the entry to the esophagus. TheNOT
muscles
attached
to the hyoid
involved in the bulk of
mechanical breastfeeding behaviors, and their ability to function optimally depends on the position of the headand neck. Movement of the hyoid bone is a direct indication of swallowing. Abnormal movement of the hyoid
is considered an indication of a sensory-deficit or abnormal motor response (Sonies, Wang, & Sapper, 1996).

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Esophagus© Jones & Bartlett Learnin
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The esophagus is the tube through which food passes on its way to the stomach, propelled by smooth andstriated muscles that create peristalsis. It terminates at the stomach at the lower esophageal sphincter,which relaxes during peristalsis to allow food or fluid to enter the stomach. The lower esophageal sphincter remains closed at rest and provides protection from the upward flow or reflux of stomach contents
into the esophagus. The oral, pharyngeal, and laryngeal structures are in close proximity during the early© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
months of life. Because these structures and functions are interrelated, structural defects or disorganized
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functional problems in one area may adversely affect other areas. NOT FOR SALE OR DISTRIBUTION

MusclesMore than 40 muscles participate in the complex process of coordinating the movement of food and air
through the oralcavity. Muscles act in synchrony
function
effect lip movement,
allowLLC
graded jaw
nes & Bartlett Learning,
LLC
©and
Jones
&toBartlett
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movements, influence the shape and action of the tongue and cheeks, elevate the soft palate to seal the
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NOTa bolus
FOR
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protect the airway, and move and clear
of food.

Neural Control

Just as the anatomic structures and functions of suck, swallow, and breathe overlap, so too do the nerves© Jones& Bartlett
Learning,
LLC© Jonesthat innervatethese structuresand functions.
Six cranial
nerves overlap in neural function
to enable &theBartlett Learninsuck, swallow,
andbreathefunctions(Table3-1).
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Reflexes
Full-term infants come equipped with a number of well-developed reflexes that aid in securing food in asafe and efficient manner.

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC■■
Swallowing
is
seen
in
the
fetus
as
early
as
12
weeks
of
gestation.
Infants
are bornwith considerable
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NOT
FOR
SALE
OR DISTRIBUTION
experience in swallowing from the routine ingestion of amniotic fluid before birth.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  139
TABLE 3-1
© Jones & Bartlett Learning, LLC

Cranial NOT
NervesFOR
Associated
with
Suck,
Swallow, and Breathe
SALE
OR
DISTRIBUTION
Cranial Nerve© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Function

I—Olfactory nerve (sensory)

Responsible for the sense of smell, which also affects theperception of taste.
© Jones& Bartlett
Learning,© Jones& Bartlett
Learning, LLC
V—Trigeminal(sensoryand motor)LLC Channels sensory informationfrom the mouth(suck), soft
NOT FOR
SALEbranch
OR DISTRIBUTIONpalate (swallow), nose (breathe)
NOT FOR SALE OR DISTRIBUTION■■ Maxillary
Gathers sensory input from the cheeks, nose, upper lip, teeth■■ Mandibular branch
Gathers sensory input from the skin over the lower jaw,■■ Ophthalmic branch (purely ­sensory
the lower lip, and lower teeth
and not involved with sucking,Motor aspect of the nerve innervates muscles that control­swallowing, or breathing)chewing.
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VII—Facial (sensory and motor)
Sensory fibers on the anterior two-thirds of the tongue for
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sweet, salty, and sour tastes. The motor fibers are involved
with the muscles of facial expressions and the salivary glands.
IX—Glossopharyngeal (sensory andSensory fibers on the posterior third of the tongue for bitter
motor)
taste. Motor fibers go to the muscles used in swallowing, tothe salivary glands, and innervate the gag reflex.
Jones& Bartlett
Learning,
LLC from the palate, uvula, pharynx,© Jones& Bartlett Learnin
X—Vagus©(sensory,
somatic,
andSensory information
larynx,NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
autonomic)
esophagus, visceral organs.
Motor connections to the pharynx, larynx, and heart.
Autonomic nervous system functions are involved in heartrate, smooth muscle activity in the gut, glands that alter
gastric motility, respiration, and blood pressure.
XII—Hypoglossal(motor)Contractionof the muscles©
of Jones
the tongue.& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
Involved in the peristaltic action in bolus preparation, sucking,NOT FOR SALE OR DISTRIBUTIONand swallowing.
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Source: Walker 2enes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC■■
Sucking is present by 24 weeks of gestation, with the fetus being capable of turning his or her head
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DISTRIBUTION
toward oral stimulation. Sucking is initiatedby stimulationin the OR
infant’smouth that causes theinfant to extend his or her tongue over the lower gum, raise the mandible, draw the nipple–areola
into his or her mouth, and initiate the sequence of sucking behaviors. Sucking is a reflex at birth,with the infant “obligated” to suck on anything placed in the mouth. By about 3 months, sucking
changes from reflexive or automatic to voluntary. Some parents see this transition as a breastfeeding
©who
Jones
Learning,
LLCif they have been given in combination© Joneswith& Bartlett Learnin
infantrefuses&toBartlett
suck on artificial
nipples (evenbreastfeeding
since early
afterORbirth).DISTRIBUTIONNOT FOR SALE OR DISTRNOT FORSALE■■
The gag reflex is apparent at 26 weeks of gestation and is quite strong in a newborn. At first it can be
stimulated when the posterior two-thirds of the tongue is touched. It gradually changes such that the
gag reflex is elicited farther back on the posterior one-third of the tongue.
■■
The phasic bite and transverse tongue reflexes appear at around 28 weeks of gestation. The phasic
reflex is seenas the rhythmic
opening and closing of the jaw
the gums
are stimulated.
The© Jones &bite
Bartlett
Learning,
LLC
©when
Jones
& Bartlett
Learning,
LLC
transverse
tonguereflex
is
seen
as
the
tonguegravitating
towardastimulus,
elicitedbytracingthe
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lower gum ridge and brushing the lateral edge of the tongue with the examiner’s finger.
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140  Chapter 3: Influence of the Infant’s Anatomy and Physiology■■

The rooting reflex is seen at 32 weeks of gestation and occurs in response to stroking of the skin
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
around the mouth. This mouth-orienting reflex is strongest around 40 weeks and fades after
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3 months.

Sucking Mechanisms
Components of sucking, swallowing, and breathing, along with the coordination between the three activ-© Jones&matureBartlett
Learning,
LLC© Jones&infant.
Bartlett
Learning, LLC
ities,
at different
times andrates depending on the gestationalage of the
For example,
expression(positive
pressure)
matures
beforesuction.
These
activities
also
need
to
occur
sequentially
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from the oral phase to the pharyngeal (swallowing) phase to the pulmonary or breathing phase while
ensuring that the swallow takes place during a safe phase of the respiratory cycle (Amaizu, Shulman,
Schanler, & Lau, 2008). Sucking at the breast involves a complex series of behaviors that have been studied
for a number of years by various means. Changing research modalities have allowed researchers and clinicians to refine
their understanding of how this©
process
unfolds.
nes & Bartlett Learning,
LLC
Jones
& Bartlett Learning, LLC

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NOTFORSALEtoOR
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Ardran, Kemp, and Lind (1958) were among
the first
researchers
visualize
the breast inside theinfant’s mouth. In their study the breast was coated with a barium sulfate paste, and radiographic
films were made while the infant nursed. Infants were positioned on a couch with the mother leaning over the baby, which may have prevented a deep latch and partially accounted for observations
that have since been refined with newer imaging techniques. Notable was the confirmation that the
© and
Jones
Bartlett
Learning,
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nippleareola &weredrawn into
the mouth to LLC
the junction of the hard and soft©
palatesand that
the nipple
extended
about three times its resting length, forming thenipple–areolar
NOT
FOR SALE OR DISTR
NOTwidened
FOR andSALE
ORtoDISTRIBUTION
complex or a teat. These authors also described the action of the infant forming the nipple–areola
into a teat and drawing it far back into the mouth, with the tongue playing a major part in the sucking process and the breast being soft and pliable enough to allow this activity. According to theseauthors, “Any factor which causes edema or congestion [of the breast] will probably interfere with
Their
study was confinedvisualize
tongue actions.
© Jones &suckling.”
Bartlett
Learning,
LLC to the lateral plane and could
© not
Jones
&other
Bartlett
Learning, LLCIt
also
reliedon
x-rays,thehazardsofwhichhalted
the
use
of
this
type
of
research.
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The use of real-time ultrasound refined the interpretation of the sucking process at breast. Smith,Erenberg, Nowak, and Franken (1985) and Smith, Erenberg, and Nowak (1988) noted the following
points:1. Failure of the lips to form a complete seal is manifested on a scan by air leaking into the oralcavity.
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LLC© Jones & Bartlett Learning, LLC
2. Tongue and jaw movements compress the nipple, which is highly elastic, elongating it along
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NOTandFOR
OR diameter.
DISTRIBUTION
with 2 cm of areola to twice its resting length
to 70%SALE
of its original
3. During the peristaltic action of the tongue, the teat is compressed 60% more in the verticaldirection and widens by 20% in the lateral direction.
4. The buccal mucosa and musculature (sucking pads, buccinator muscle) move inward as the
tongue is depressed. This maintains a tight seal on the nipple–areola, conducts the milk
© Jones& Bartlett
Learning,
towardthe central
depression in
the posterior LLC
portion of the tongue, and allows©
theJones
milk to & Bartlett Learnin
beNOT
propelled
towardthe oropharynx.
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OR DISTRIBUTION■■
Weber, Woolridge, and Baum (1986) described both feeding movements and the coordination ofsucking, swallowing, and breathing:
1. The action of the tongue in a breastfed infant was described as a rolling or peristaltic undulation in an anterior to posterior direction, whereas in bottle-fed infants the tongue worked© Jones & Bartlett
Learning,
LLCmotion; when not sucking, the© Jones& Bartlett
Learning, LLC
in an up-and-down
piston-type
breastfed infants
maintained
their
grasp
on
the
nipple,
with
the
teat
still
moderately
indentedbythetongue.
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2. The lateral margins of the tongue cupped around the nipple, forming a central groove.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  141
FIGURE©
3-3Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
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FORonSALE
CompleteNOTSuck Cycle
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A

B

C

D

© Jones & Bartlett Learning, LLC
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E

A. The suck cycle is initiated by a welling up of the anterior tip of the tongue. Simultaneously, the lower jaw rises toconstrict the base of the nipple, “pinching off ” milk within the ducts ofthe teat.
B. The tongue moves along the underside of the nipple, pushing against the hard palate. This wavelike action
squeezes milk from the nipple.
C and D. This wave of compression passes beyond the tip of the nipple, pushing against the soft palate. The
levator muscles of the palate contract and rise to seal off the nasal cavity.
E. The cycle ends at the posterior base of the tongue. Tongue compression and negative pressure within themouth maintain the tongue in close conformation to the nipple and the palate, drawing milk into the mouth. A
lowering of the jaw allows milk back into the nipple.

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Source: Lauwers, J., & Swisher, A. (2011). Counseling the nursing mother: A lactation consultant’s guide (5th ed.).
Sudbury, MA:
Jones & Bartlett
Learning. Learning, LLC© Jones& Bartlett© Jones & Bartlett Learnin

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3. One- to 3-day-old infants showed distinct interruptions of their breathing movements whena swallow occurred, whereas in infants 4 days and older, the breathing trace appeared as a
© Jones & Bartlett
Learning,
LLC with swallows occurring at©the
Jones& Bartlett
Learning, LLC
smooth uninterrupted
movement
natural boundary
betweenexpiration
inspiration.
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Figure 3-3, a graphic rendering of ultrasound studies, summarizes the dynamics of a complete suck cyclethat was postulated from this study (Woolridge, 1986).
Woolridge and Drewett (1986) also noted the importance of taking into account both positive andnegative pressures. Fluid movement during breastfeeding occurs from an area of high pressure inside thebreast—createdLLC
by fluid volume and the milk ejection
reflex—toarea of lowLearning,pressure insideLLC
the infant’s
nes & Bartlett Learning,© Jones&anBartlett
mouth,
where
suctionorvacuumiscreatedbysealingtheoralcavityandenlarging
it
when
the
jaw and
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tongue drop. During bottle-feeding, either suction or compression can be the predominant determinantof efficient fluid flow, depending on the type of nipple and opening in the nipple. Preterm infants are able
to express milk from a bottle without applying vacuum (Lau, Sheena, Shulman, & Schanler, 1997), andalthough they may effectively feed from a bottle, they can demonstrate difficulty in removing milk fromthe breast.©This
finding&suggeststhat themechanics ofLLC
milk removal from a bottle versus©fromthe breast
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Bartlett
Learning,
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are different (Meier, 2003). Although infants can receive some milk by compressing an artificial nipple, in
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the absence of negative pressure (i.e., in infants who cannot develop sufficient suction), adequate amountsof milk may be lacking unless modifications are made to the nipple.
Current, more sensitive ultrasound studies describe the infant sucking dynamic (Figures 3-4
and 3-5) as follows (Geddes, Kent, Mitoulas, & Hartmann, 2008; Jacobs et al., 2007):■■ &Negative
pressuredraws the LLC
nipple–areola into the mouth, usually
several &millimeters
anteriorto© Jones
Bartlett
Learning,© Jones
Bartlett
Learning,
LLC
thejunction
of
the
hard
and
soft
palates,
forms
a
teat,
and
holds
it
in
place
with
a
baselinevacuumof
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION–60 mm Hg over the entire breastfeeding.

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142  Chapter 3: Influence of the Infant’s Anatomy and Physiology
FIGURE©
3-4Jones & Bartlett Learning, LLC

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UltrasoundImagesof Intra-Oral
CavityDuring Breastfeeding© Jones & Bartlett Learning, LLC
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A© Jones & Bartlett Learnin
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NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
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B© Jones & Bartlett Learning, LLC
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NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTIONC

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Source: Reprinted from Geddes, D. T., Kent, J. C., Mitoulas, L. R., & Hartmann, P. E. (2008). Tongue movement and
FOR SALE ORintra-oral
DISTRIBUTIONNOTFOR SALE
OR DISTRIBUTION
vacuum in breastfeeding infants. Early Human
Development,
84, 7.

The motion of the tongue during a suck cycle does not show a peristaltic action (as in bottle-feeding),© Jones& Bartlett
Learning,
LLC© Jonesbut rather
the tongue
is up and inapposition withthe hard palate, with the anterior
tongue &notBartlett Learnin
indentingnipple.SALE OR DISTRIBUTIONNOT FOR SALE OR DISTR
NOTtheFOR■■
Vacuum is generated as the tongue and jaw move down, which allows milk flow from the nipple.
When the posterior part of the tongue lowers, milk ducts in the nipple open and milk flows into theinfant’s mouth. Peak vacuum coincides with the tongue at its lowermost position.
■■
As the tongue moves back up, vacuum decreases and milk flow ceases. Milk ducts within the nipple© Jones &andBartlett© Jones& Bartlett
LLC
milk flowLearning,
cannot be seenLLC
on ultrasound. The tongue captures
the milk thathas flowed Learning,
into thenipple,holding
it
in
place
until
the
tongue
and
jaw
lower
again,
with
the
milk
subsequently
flowing
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  143
FIGURE©
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Changes NOT
in InfantTonguePosition
DuringOne Complete Suck Cycle© Jones & Bartlett Learning, LLC
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Source: Reprinted from Geddes, D. T., Kent, J. C., Mitoulas, L. R., & Hartmann, P. E. (2008). Tongue movement andintra-oral vacuum in breastfeeding infants. Early Human Development, 84, 7.

© Jones & Bartlett Learning, LLC
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into the oral cavity. This mechanism ensures that milk is not constantly flowing into the oral cavity but is apportioned into manageable boluses so that excessive swallowing does not interfere withbreathing and oxygenation.

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
McClellan,
Sakalidis,
Hepworth, Hartmann, and Geddes (2010) investigatedinfantSALE
sucking using
ultraNOT FOR
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sound and measured the nipple diameter and placement of the nipple within the infant oral cavity during breastfeeding. They found that the nipple diameter does not remain consistent along the length of
the nipple during sucking, and changes in nipple diameter associated with tongue movement were alsosignificantly different. All nipple diameter measurements significantly increased between the tongue-up
and tongue-down movements, which the authors concluded was not consistent with a peristaltic tonguenes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
action. Sakalidis and colleagues (2012a) found that there was a difference in tongue movement between
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DISTRIBUTION
NOT
FOR
SALE
OR
and non-nutritive sucking at the breast.
Duringnutritive
sucking,
theDISTRIBUTION
infant’s midtongue lowered farther and the sucking was significantly slower compared to non-nutritive sucking.
In contrast, using ultrasound videos to describe the sucking sequence, Monaci and Woolridge(2011) reported that during non-nutritive sucking prior to eliciting the milk ejection reflex, the infant’s
tongue engaged in a peristaltic motion. After the milk ejection reflex, a swallow was seen correspond© suck
Jones
Bartlett
Learning,
LLC(tongue depression) was seen,© similar
Jonesing to eachand a&more
pronounced
vacuum action
to &theBartlett Learnin
previously
discussed
description
Geddesand Jacobs. Therefore it is thought that infants
mayFORuse both
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SALE OR DISTR
NOTFOR
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DISTRIBUTION
a peristaltic tongue action to move the milk into the oropharynx and a tongue depression to generate vacuum, which allows milk from the breast to enter the oral cavity of the infant (Woolridge, 2011).
Woolridge (2012) identified both propulsive or peristaltic movements of the tongue as well as extractive or vacuum application during feedings at the breast. While each of the two types of tongue move© Jones& Bartlett
Learning,
LLC© Jones& Bartlett
Learning,
LLC
ments
may be capableof removing
milk independently, they are more
likely to complement
each
other
and
act
synergisticallytoaccomplishthemostefficientmethodofremoving
milk
from
the
breast.
Thus
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144  Chapter 3: Influence of the Infant’s Anatomy and Physiology

sucking seems to be a dynamic process, shifting between peristaltic movements and vacuum-generating© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
movements, possibly in response to the varying rate of milk release from the breast. Vacuum-generating
SALE OR DISTR
NOT
FOR
SALE
DISTRIBUTION
movementsof thetonguemay beORsuperimposedon the peristaltic movements of theNOT
tongueFOR
and aregenerated as part of the same practice. Mothers can remove milk by positive pressure only, as with manual expression and the milk ejection reflex, or by negative pressure, as with a breast pump. However,unless milk ejection occurs (positive pressure) when using a pump, mothers may not express very much
milk. Vacuum seems to be the driving force working in concert with an intact milk ejection reflex to© Jones& Bartlett
Learning,© Jones& Bartlett
Learning, LLC
ensuremaximum milk
expressionLLC
when using a breast pump. Mothers
using a breast
pump experiencemaximum
milk
yield
in
the
shortest
time
when
using
the
highestcomfortablevacuum.
Most
the
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milk is collected during the first two milk ejections, occurring on average within the first 8 minutes
after the start of the first milk ejection (Kent et al., 2008). Whereas too little vacuum may be problematic in removing milk from the breast, too much vacuum has also been shown to present potential
problems. McClellan et al. (2008) studied two groups of mothers: those experiencing nipple pain during or after feedings
pain. In spiteof ongoing professionalnes & Bartlett Learning,
LLC and a control group with no© complaints
Jones &ofBartlett
Learning,
LLC
by International Board Certified LactationNOT
Consultants,
of motherswith persistent nipple
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DISTRIBUTION
FORinfants
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OR DISTRIBUTION
pain applied significantly stronger vacuums and transferred less milk than infants not causing pain. Allcomponents of the suck cycle were stronger, with the baseline vacuum or seal on the breast 61% stronger
and the peak vacuum being 31% stronger in the infants causing the persistent nipple pain. These infantsalso applied more vacuum than an electric breast pump at the mothers’ maximum comfort vacuum
values. Mothers
maintained
their milk
supply throughexpressing breastmilk if their ©
nipples
were &
tooBartlett Learnin© Jones& Bartlett
Learning,
LLC
Jones
painful for direct breastfeeding.
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Surface electromyography has shown differences in facial muscle activity between breastfeeding
and bottle-feeding (Gomes, Trezza, Murade, & Padovani, 2006). Cup feeding is closer to breastfeeding
than is bottle-feeding, relative to the use of facial muscles during feeding. The masseter muscle is important in infant feeding, especially because its movements govern the growth and positioning of the jaw.
Bottle-feeding reduces masseter muscle activity, increases buccinator activity, reduces jaw movements,© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
and causes the tongue to retract. Jacinto-Goncalves, Gaviao, Berzin, de Oliveira, and Semeguini (2004)
NOT FORSALE
OR
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NOTFORandSALE
OR
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reported differences in the profiles of muscles used in sucking between
breastfed
bottle-fed
children.
Breastfed children presented higher activity for the mentalis and smaller activity of the orbicular oris
muscle compared with bottle-fed children. This effect persisted out to 3.5 years, which was the durationof the study.

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A number of infant sucking and breast functioning parameters have been measured that are of interest in
the understanding of sucking as well as in the assessment of what is in the range of normal and what may
constitute a deviation or alteration from the norm (Table 3-2).
Sucking patterns change over the course of a feed. The typical 1:1 ratio of sucking to swallowing
©the
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changes by
end of a&feed
to a ratio Learning,of 2:1 or 3:1 sucks
per swallow (Weber et al., 1986).
amount&ofBartlett Learnin
milk transferredtends beSALE
higher fromfirst breast suckled and lower from the second
breast.
PrietoNOT
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et al. (1996) showed a 58% decrease in amount of milk transferred from the second breast compared with
_ 9 g from the first breast and 27 ±_ 8 g from the second breast in infants aged 21–240 days.
the first: 63 ±Drewett and Woolridge (1981) measured 38.5 g from the first breast and 21.8 g from the second breast in
5- to 7-day-old infants. The volume of milk per suck also changes, with more than a 50% reduction frompeak
seen Learning,at the end of thefeed on the second breast. The ©
intakeof the &infantsin theseLearning,studies© Jones& volume
Bartlett
LLC
Jones
Bartlett
LLC
was
not
limitedbythemilk
supplyavailablebutratherbythebehavioroftheinfantinregulating
hisor
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
her own intake.
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2.83 mm (range 1.1–5.9 mm)© Jones & Bartlett Learning, LLC
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Breast function parameters
Mean diameter of lactiferous ducts before milk ejection

Volume of milk per suck

© Jones & Bartlett Learning, LLC
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Source: Walker 2e© Jones & Bartlett Learnin
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6.45 mm ± 0.98 mm
86 seconds
35 g
24.4 g/minute56 s
121 ± 11 s to 149 ± 12 s

Chetwynd et al., 1998
Chetwynd et al., 1998
Shawker, Sonies, Stone, & Baum, 1983

Ramsay & Gisel, 1996
Woolridge, How, Drewett, Rolfe, & Baum,
1982; Bowen-Jones et al., 1982

Bowen-Jones, Thompson, & Drewett, 1982
Chetwynd, Diggle, Drewett, & Young, 1998

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Increase in cross-sectional area of ducts following milk ejection
Length of time ducts remain dilated per each milk ejection
Average yield for each milk ejection
Milk flow rate from breast
Time from beginning of sucking to milk ejection
Time to milk ejection with pumpKron & Litt, 1971
Egnell, 1956

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Number of sucks per burst at beginning of feed
Number of sucks per burst at end of feed
Velocity of peristaltic wave motion of the tongue

73–3.6 mm Hg
200–300 g
28 mm Hg
10 to 20 mm Hg

Prieto et al., 1996

Reference© Jones & Bartlett Learning, LLC
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36–126 (mean 74) per minute
0.77 second (s)
0.7 s
1.28
0.5–0.6 s with no milk flow
0.9–1.0 s at a flow rate of 0.5 g/suck
0.14–0.21 mL at beginning of a feed
0.01–0.04 mL at the end of a feed
11 (with considerable variation)
5 (with considerable variation)
15 cm/second

Infant mechanics
Cycles (sucks)
Duration of a suck
Duration of rest
Sucks per second
Intersuck interval© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION–50 ± 0.7 mm Hg–50 to –155 mm Hg–197 ± 1 to –241 mm Hg–70 to –200 mm Hg

Value

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Infant positive pressure ranges
Baby’s tongue
Baby’s jaw
Full breast
Additional pressure of milk ejection reflex

Infant negative pressure ranges
Mean pressure
Average range of pressure
Maximum pressure range
Basal resting pressure to keep nipple in mouth

Parameter

Infant Sucking and Breast Functioning Parameters

TABLE 3-2

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Kent, Ramsay, Doherty, Larsson, &Hartmann, 2003
Kent et al., 2003
Ramsay, Kent, Owens, & Hartmann, 2001
Ramsay et al., 2001
Ramsay et al., 2001
Kent et al., 2003
Kent et al., 2003

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146  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Infants suck in bursts separated by rests, typically defined as a sequence of sucks with intersuck© Jones & Bartlett Learning, LLC© Jones & Bartlett Learninintervals of less than 2 seconds (Woolridge & Drewett, 1986). The sucking rate on the breast varies as a
NOTSALE OR DISTR
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OR DISTRIBUTION
function NOTof milk FOR
flow rate(Bowen-Jones,
Thompson, & Drewett, 1982); the higher the milk
flowFORrate, theslower the sucking rate. The intersuck intervals (within bursts) range from 0.5 to 1.3 seconds dependingon milk flow rates, leading these researchers to conclude that there was not a distinct separation of nutritive and non-nutritive sucking at breast (as with bottle-feeding) but rather a graded distribution between
the two. Ramsay and Gisel (1996) measured a higher sucking rate in breastfed infants compared with© Jones& Bartlett
Learning,© Jones&wereBartlett
Learning,
LLCbottle-fed
infants andshowed that LLC
infants spent 50% more time sucking
when theyalert than
when
they
were
asleep.
Also
noted
was
that
infants
identified
in
this
study
as
havingfeedingdifficulties
demonNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
strated shorter continuous sucking bursts and shorter sucking times than infants who had no problems
feeding. Infants who later showed some feeding difficulties were already exhibiting poorer feeding ability
shortly after birth.
Bromiker et al. (2006) demonstrated that full-term infants of insulin-managed mothers with diabetes had poorer
sucking patterns. These infants
suckingLearning,
bursts and 42 fewernes & Bartlett Learning,
LLC©averaged
Jones5.2&fewer
Bartlett
LLCsucks
5-minute interval. This finding is consistentNOTwith descriptions
by Pressler,
Hepworth, LaMontagne,
FOR SALE ORper
DISTRIBUTIONFOR SALE
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Sevcik, and Hesselink (1999) of significantly poorer performance for motor processes and reflex functioning in infants of insulin-managed mothers with diabetes. These infants may be less neurologicallymature, which would help explain the decrease seen in the number of sucks and number of bursts per
5-minute interval. Thus clinicians may wish to monitor these infants more closely, especially during theearly days©when
breastfeeding
is being Learning,established. LLC
Jones& Bartlett© Jones & Bartlett Learnin
Moral and colleagues (2010) found that in 3- to 4-week-old infants who were exclusively bottle-fed,
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the mechanics of sucking showed fewer suck movements and the same number of pauses but of longer
duration when compared to exclusively breastfed infants. In infants who were mixed fed (by both bottle
and breast) there were 8.7% fewer suction movements compared to exclusively breastfed infants. Aizawa,
Mizuno, and Tamura (2010) found that jaw and throat region movements differ between breastfed andbottle-fed infants. Jaw and throat region movements were significantly smaller during breastfeeding than© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
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feeding. These differences were partly due to the difference in the angleof themouth
demonstrated
during each type of feeding. These studies refute some of the marketing claims of artificial nipples being
advertised as equivalent to feeding at the breast.
Ramsay, Kent, Owens, and Hartmann (2001) found that milk intake was related to the number ofmilk ejections experienced by the mother rather than the total time an infant spent at the breast. Eachnes & Bartlett Learning,
LLCa certain amount of milk available© Jones
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LLCby themilk ejection makes
to the &infant,whereasLearning,
the vacuum applied
infantaffects
how
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milk
is
removed.
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Swallowing

More than two dozen muscles are involved in the process of swallowing. Coordination of swallowing withsuck and breathing is fundamental to effective and safe feeding. There are three phases of swallowing: oral,
© and
Jones
& Bartlett
Learning,
LLC© Jonespharyngeal,
esophageal.
The pharyngeal
swallow isthought to achieve rhythmic stability
as early&asBartlett Learnin
32–34 weeks
of gestation(Gewolb,OR
Vice,DISTRIBUTION
Schweitzer-Kenney, Taciak, & Bosma, 2001). To
enableFOR
them toNOTSALE OR DISTRNOTFOR SALE
work in tandem, swallowing, sucking, and esophageal motility are linked together within a control center
originating in a central pattern generator in the brainstem (Jean, 2001). Swallowing in the infant is initiated when the milk bolus accumulates either in the space between the soft palate and the tongue or in thespace between the soft palate and the epiglottis.
© Jones &There
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Jones
& act
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are differences
betweenLLC
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to theof swallowing.
Intheinfant,
the
hyoid
and
larynxarelocatedhigher
in
the
neck
and
the
pharynxissmaller.
AstheinfantNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
grows and matures, the hyoid and larynx migrate downward, the epiglottis and soft palate are no longer
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  147
FIGURE 3-6© Jones & Bartlett Learning, LLC© Jones & Bartlett LearninLongitudinal
ImagesORof theDISTRIBUTION
Neck of a Breastfeeding Baby during Swallowing.
carotid
NOTTheFOR
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NOTUltrasound
FOR SALE
vessels are situated anterior to the esophagus. The bolus of breast milk is outlined in the lower
pharynx/esophagus. (A) No bolus is present. (B) The bolus expands the pharyngeal area as it moves
inferiorly. (C) The bolus is narrowed as it passes into the upper esophageal region. (D) The bolus isalmost cleared. Peristalsis is apparent on realtime imaging.

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Source: Geddes, D. T., Chadwic,k L. M., Kent, J. C., Garbin, C. P., & Hartmann, P. E. (2010). Ultrasound imaging of
NOT FORSALE
OR
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
infant swallowing during breastfeeding. Dysphagia, 25, 183–191.

in direct approximation after 3 to 4 months of age, and more mature protection of the airway allows thenes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
infant to cease relying on specialized anatomic structures and configurations to support sucking, swalFOR SALE ORlowing,
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
and breathing.

Respiration ceases for a short period during swallowing. Geddes, Chadwick, Kent, Garbin, andHartmann (2010a) found a significant correlation between swallow apnea and the movement of milk
through the pharyngeal area, as detected by ultrasound.
Figures 3-6 and 3-7 show the progression of a milk bolus as it traverses the three phases of swallow© Jones&The
Bartlett
Learning,
LLC© Jones& Bartlett Learnin
ing in a breastfed
infant.
respiratory
phase at whichswallowing is timed differs between
2 weeks and2 monthsNOT
of age andhas been
attributed
a critical window of neural development occurring
that
NOTduring
FOR
SALE OR DISTRFOR
SALE
OR toDISTRIBUTION
time (Kelly, Huckabee, Jones, & Frampton, 2007). Swallowing in breastfed infants is typically followed by
expiration. Mizuno, Ueda, and Takeuchi (2002) studied the effects of different fluids on the coordination
between swallowing and breathing during bottle-feedings. When receiving breastmilk, compared withformula or distilled water in the bottle, the infants showed a significantly higher breathing rate. Swallows© Jones& Bartlett
Learning,
LLC less often with breastmilk©inJones
Bartlett
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followedby inspiration
were demonstrated
the bottle.&
The
authors concluded
that
expressed
breastmilk
ismoresuitableforneonates
becauseof
thebettercoordination
betweenswalNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
lowing and breathing, making subclinical aspiration less likely.
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148  Chapter 3: Influence of the Infant’s Anatomy and Physiology
FIGURE©
3-7Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
OR DISTRNOTFORofSALE
OR DISTRIBUTION
Schematic
Diagramsthe Progressionof the Milk Bolus in a Breastfed Infant. NOT(A) NoFOR
bolus SALE
ispresent. (B) The bolus expands the pharyngeal area as it moves inferiorly. (C) The bolus is narrowed
as it passes into the upper esophageal region. (D) The bolus is almost cleared. Peristalsis is apparent
on realtime imaging.

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Source: Geddes, D. T., Chadwick, L. M., Kent, J. C., Garbin, C. P., & Hartmann, P. E. (2010). Ultrasound imaging of© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
infant swallowing during breastfeeding. Dysphagia, 25, 183–191.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  149

Swallowing can and should be assessed. Both the healthcare provider and the mother are encour© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
aged to assess swallowing at each feeding in the early days to ensure milk transfer has occurred. Although
NOT FORSALE OR DISTR
NOT
FOR
OR mimicking
DISTRIBUTION
an infant’s
jaw may
moveSALE
up and down,breastfeeding, jaw movement is not indicativeof milktransfer. Signs of swallowing include the following:
Deep jaw excursion (as opposed to shallow, biting, or chewing-like movements)
Audible sound of swallowing■■of the throat during© Jones &Visualization
Bartlett Learning,
LLCa swallow© Jones & Bartlett Learning, LLC■■
Vibration on the occipital region of the infant (a hand placed on the back of the baby’s head may feel
NOT FOR theSALE
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swallow as a vibration)■■
Movement of the throat felt by a finger over the trachea■■
A small sound made by a puff of air from the nose■■
A “ca” sound from the throat■■■■

CliniciansLLC
can assess swallow sounds by cervicalauscultation
with a stethoscope
if theyLLC
are uncernes & Bartlett Learning,© Jones& Bartlett
Learning,
tain that swallowing of milk is taking place.
FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION■■■■

Placement of a small stethoscope adjacent to the lateral aspect of the larynx provides access to thesounds of the pharyngeal swallow (Vice, Heinz, Giuriati, Hood, & Bosma, 1990).
In the absence of definitive evidence of swallowing, pre- and postfeed weights could be taken, if necessary, to validate whether milk transfer took place.

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Breathing© Jones & Bartlett Learnin
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Breathing must also be coordinated while feeding. The airway is protected during sucking and swallowing and must remain stable (resist collapse) during feeding, because sucking and swallowing occur in a
rapid sequence. The patency of the airway can be affected by the sleep state, structural abnormalities,
positionof the neck,rate of milk flow,
maturation (preterm vs. full term),
illness, &or central
nervoussys© Jones& Bartlett
Learning,
LLC© Jones
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Learning,
LLC
tem involvement. Increasing neck flexion causes the airway to become more prone to collapse; conversely,
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increasing neck extension helps increase the resistance to collapse. Some infants who suffer respiratory
distress or who are premature may adopt an extended head and neck position because this posture makes
it easier for them to breathe.
Breathing always takes precedence over feeding. Feeding difficulties can sometimes be an indicatorof breathing problems, either from faulty positioning or an anatomic or physiological aberration in thenes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
infant. Positioning such infants at the breast may include subtle adjustments in the position of the head
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proper shoulder girdle support to allow infants
to remain
ventilated
they feed. Althoughinfants prefer to breathe through their noses, they are not obligate nose breathers. Infants can breathethrough their mouths for short periods of time, but it is accomplished at the expense of respiratory efficiency (Miller et al., 1985).
The bulk of research looking at suck, swallow, breathe synchrony has been conducted during bottle© Jones
Bartlett
Learning,© Jones& Bartlett Learnin
feeding (Mathew,
1991a;&Mathew& Bhatia,
1989; Meier,LLC
1988, 1996). Repeated airway closure
during swallowing has
been shown
interruptOR
breathing.
The more rapid milk flow from soft artificial
nipples
with
NOT
FOR
SALE OR DISTR
NOT
FORtoSALE
DISTRIBUTION
large holes results in more frequent swallowing, less frequent opportunities for breathing, and significantly increased interruption in ventilation (Duara, 1989; Mathew, 1991b). These breathing alterations are
more pronounced in preterm infants but also occur in full-term infants (Mathew, 1988; Mathew & Bhatia,
1989). Sucking during bottle-feeding interrupts breathing more frequently and for more sustained durations
suckingLearning,
during breastfeeding
Kavanaugh,
Mangurten,
1990).
© Jones& thanBartlett
LLC(Meier, Lysakowski, Engstrom,© Jones& &Bartlett
Learning,
LLC
Duringbottle-feedings,
infantsalternateclusters
of
sucks
and
breaths.
Duringbreastfeeding,breathing
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is integrated into the sucking bursts. The suck–breathe pattern during breastfeeding suggests that infants
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150  Chapter 3: Influence of the Infant’s Anatomy and Physiology

may manipulate sucking parameters to control milk flow and accommodate breathing in such a way that
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
apnea, bradycardia, and fatigue do not occur (Meier, 2001).
SALE OR DISTR
NOTbottle
FOR
SALE
OR DISTRIBUTION
Differingsystems
can affectoxygenation and how swallows are distributedNOT
during FOR
feedings.
Goldfield, Richardson, Lee, and Margetts (2006) demonstrated that swallowing during breastfeeding was
distributed nonrandomly and occurred at the peaks of intraoral sucking pressures. A group of infants inthis study using a Playtex bottle system displayed a pattern of sucking, swallowing, and breathing thatwas more similar to the physiological norm of breastfeeding than the pattern observed in a group of© Jones& Bartlett
Learning,
LLC© Jones& isBartlett
Learning, LLC
infants
using an Avent
bottle system.
If infants need to be supplemented
and a bottle
chosen to provide
extra
milk,
clinicians
may
wish
to
choosethosebottlesthat
disrupt
breastfeeding
the
least
(Peterson&
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Harmer, 2010).

Clinical Implications

nes & Bartlett Learning,
LLC© Jones
Bartlett
Learning,
LLCintake
Alterations in an
infant’s functional anatomy andphysiology&related
to feeding
may affect milk
FOR SALE ORtoDISTRIBUTION
NOT
FOR
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OR
DISTRIBUTION
a greater or lesser extent. During breastfeeding evaluations and especially if an infant presents withfeeding problems, it is important to include an assessment of the infant’s anatomic structures related tobreastfeeding and their functioning.
Assessment of the Lips.
■■

The lips should present with the following characteristics:© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
The NOT
lips should
appearsoft atOR
rest, remainclosed when awake and asleep, have a bow-shaped
upper
NOT FORSALE OR DISTR
FOR
SALE
DISTRIBUTION

lip, and have a well-defined philtrum (the median groove between the upper lip and the nose).
Both the upper and the lower lip should flange or flare outward when attached to the nipple/areola.
■■
The lips should be parted at a wide angle when measured from the corner of the mouth for properlatch. Aizawa et al. (2010) measured oral angles of breastfeeding and bottle-feeding infants, showing
the angleLearning,of the opened LLC
mouth of breastfed infants while©nursing
was&approximately
double© Jones &that
Bartlett
Jones
Bartlett Learning,
LLC
that of infants sucking on standard artificial nipples. The angle at the corner of the mouth of infants
NOT FOR feeding
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NOT
FOR
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OR
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the breast ranged from 112 degrees to 152 degrees, while infants sucking on a standard
artificial nipple had an oral angle ranging from 55 degrees to 72 degrees.
■■
The lips should exert slight pressure to maintain a seal.
■■

Alterations may include the following:nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC■■
Cleft lip: There is a great variation in cleft lip presentation, ranging from a small notch in the upper
FOR SALE OR DISTRIBUTION
NOTORtheDISTRIBUTION
lip, either unilateral or bilateral, to a complete
cleft FORthroughSALE
the lip into
nostril and through theupper alveolar ridge. A cleft in the lip compromises the seal needed to create negative pressure in
the oral cavity. Many mothers fill the gap in the lip by manipulating the areola, their thumb, andthe breast tissue to cover the defect. Infants with clefts of the lip are capable of generating suction,
especially if the cleft is small (Reid, Reilly, & Kilpatrick, 2007). “Kissing” sounds heard during the© Jones& Bartlett
LLCintermittently, which may compromise© Jonesmilk& Bartlett Learnin
feeding
indicate thatthe anterior Learning,seal is being broken
intakewith eachsuck(Glass &OR
Wolf,DISTRIBUTION
1999).
NOT FOR SALE OR DISTR
NOT
FOR
SALE
■■
Loose, floppy, or asymmetrical lips: This problem can be associated with generalized hypotonia, partial paralysis or underdevelopment of the facial nerve (cranial nerve VII), facial asymmetry, andmouth droop or immobility. Any of these conditions may result in failure to form a seal for the oralcavity, causing periodic breaks in suction, inability to generate suction, smacking sounds, and/or© Jones &milk
Bartlett
Learning,
Jones&thereBartlett
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leaking fromthe cornersLLC
of the mouth. Asymmetrical lips©
may
be seen if
is nerve Learning,damageormuscleweaknessoneither
side
of
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face,
causing
one
side
of
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mouth
to
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becomeNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
slack on the weaker side.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  151

Retracted (forming a tight horizontal line over the mouth), pursed, or hypertonic lips: Increased© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
tone may impair latch-on and active suckling, damage the nipple, and result in poor milk transfer.
NOT
FORLip
SALE OR DISTR
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FOR
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OR DISTRIBUTION
Pursedlips mayresultfrom feedingwith artificial nipples that encourage mouth andlip closure.
retraction may also result from poor positioning where the neck or shoulder girdle is in extension.
■■Tight (or short, inelastic) labial frenulum: This alteration may impede the flanging of the upper lip
over the areola, as a restriction in the range of motion of the upper lip interferes with the upward
and outward movement of the lip. An indication of a tight labial frenulum or “lip-tie” is an infant© Jones &who
Bartlett
Learning,
LLC© Jones& Bartlett
Learning,
LLC
purses thelips rather thanflaring out the upper lip, resulting
in a shallower,
ineffective
latch.
This
could
resultinnippleabrasion,
painfulor
impropersucking,difficulty
achievingaproperNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
latch, or awkward positioning attempts by the infant (Wiessinger & Miller, 1995). Lip-tie may further contribute to reduced milk transfer, slow weight gain, fussiness from excessive air intake, coliclike symptoms, reflux, poor drainage in areas of the breast, reduced milk supply, and persistence of
these problems after normal interventions have been tried. Kotlow (2004a; 2004b; 2011a) developed
a classification
to aid &in theclinical diagnosisof thisLLC
conditionnes & Bartlett Learning,
LLCof maxillary frenum attachments© Jones
Bartlett
Learning,(Figure 3-8). Class I is a normal attachment
and requires
intervention.
Class II attaches mostly
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into the gingival tissue. Class III attaches just in front of the anterior papilla, and class IV attaches
into the papilla and extends into the hard palate. The papilla is the small bump of tissue just behind
the area where the upper front teeth will erupt. Clinicians may wish to check for lip-tie when tonguetie (ankyloglossia) is present and when normal interventions for common problems are ineffective.
Lip-tiebe revisedby clipping Learning,or by using a dental
laser.
© can
Jones& Bartlett
LLC© Jones & Bartlett Learnin■■
Corresponding alterations in cheek functioning: Lips and cheeks work together. Deviations or alterNOT FOR SALE OR DISTR
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FOR
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ations in function in one affect the efficiency and functioning in the other.
■■

Assessment of the Cheeks. The cheeks should appear soft, be symmetrical, have well-defined sucking pads, and maintain good tone during sucking. Cheeks with low tone or that are unstable may be© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
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FIGURE 3-8

Kotlow classification of infant maxillary frenum attachment

nes & Bartlett Learning, LLC
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Class IIIII
NOTClass
FOR
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DISTRIBUTION
just in front of the
Attaches mostly into thegingival tissue

anterior papilla*© Jones & Bartlett Learnin

Class IVNOT FOR SALE OR DISTR
Attaches into the papilla*
extending into the hard palate*The papilla is the small bump of tissue just behind
the area where the upper front teeth will erupt.

© Jones& Bartlett
Learning,
LLC L. (2010). Why can’t my baby©breastfeed:
JonesThe& effects
Bartlett
Learning, LLC
Source:Used with permission
from Kotlow,of an abnormal
maxillary
frenumattachment.
Retrievedfrom
http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf
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152  Chapter 3: Influence of the Infant’s Anatomy and Physiology

pulled inward during the generation of vacuum, appearing as dimpled cheeks. In addition, they may© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
contribute to reduced suction overall. Damage to cranial nerves VII (facial) and V (trigeminal) (either
NOT
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prenatallyNOT
or frommechanicalforcesduringdelivery) could produce weakness or low tonein thecheeks,rendering them less able to sustain sucking during feeding. A tongue that is retracted or that lodges
behind the lower gum line during sucking also produces dimpled cheeks. Dimpled cheeks indicate incorrect latch and/or suckling. Preterm infants have diminished sucking pads, such that the buccal surfacesof the cheeks may not come in contact with the mother’s nipple–areola. This contributes to reduced sta© Jones& andBartlett
Learning,
LLC© advise
Jones& Bartlett
LLCbilityweaker structural
supportduring feedings. Clinicians canmothers
to use the Learning,
Dancerhand
position,whichallowsthemother’s
fingers
tocompresstheinfant’s
cheeks,placingthe
innercheeksNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
in contact with the nipple/areola. Preterm infants may have difficulty both in opening their mouths wide
enough and in closing their mouths over the areola.
Assessment of the Jaw.

The lower jaw or mandible is typically in a neutral position at rest, with thenes & Bartlett Learning,© Jones
Bartlett
Learning,
lips touching. ItLLC
moves in a smooth manner, correctly
graded &to engagein coordinatedsmallLLC
excursions
a rhythmic quality. Several alterations in the
structureof thejaw are OR
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In a recessed or retracted jaw structure (not caused by muscle tension or the normal slight recessof the newborn’s jaw), the lower gum ridge is posterior to the upper gum ridge. The tongue is usually of normal size but is positioned farther back in the mouth. In utero, micrognathia can interferewith the normal positioning of the tongue, contributing to lack of fusion of the palatal shelves, and© Jones
Bartlett
Learning,
LLC positioning, the tongue may© Jonespotentiallylead to&a cleft
palate. Becauseof its posterior
be unable&toBartlett Learnin
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move forward enough to engage in normal movements. The infant may also have difficultyFOR
opening
the mouth wide enough to latch to the breast. Micrognathia frequently appears as part of various
syndromes such as the following:●● Pierre Robin syndrome, which also includes a small tongue and usually a wide, U-shaped cleft
palate. Infants have a great deal of difficulty breastfeeding, usually because of the cleft. They also
© Jones & Bartlett
LLC
Jonesof &Learning,
LLC
need to beLearning,
placed in a prone
position for feeding due to the©tendency
theBartlett
tongue to fallbackinto thethroat,obstructing the airway.
NOT FOR SALE
OR
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION●● Hemifacial microsomia. In this condition, one side of the child’s face is underdeveloped, affecting mainly the ear, mouth, and jaw. It is the second most common congenital facial anomaly after
cleft lip/palate, occurring in 1 in every 3,000–5,600 live births. Involvement may range from mild,
with just minor jaw asymmetry, to severe, with additional eye, vertebral, and cardiac involvement, LLC
which is known as Goldenhar syndrome.
There
may be unequalcheek fullness
nes & Bartlett Learning,© Jones& Bartlett
Learning,
LLCdue tounderdevelopment of the fat pad and muscles. If the central nervous system is affected, then there
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may be asymmetry in facial movements. Underdevelopment of the jaw necessitates careful andcreative positioning and close monitoring of milk transfer and weight gain.
■■
Asymmetrical jaw or deviations to one side may be the result of asymmetrical muscle tone, a structural defect, positioning in utero, or torticollis. Torticollis may be caused by fibrosis (replacementwith connective tissue) of the sternocleidomastoid (SCM) muscle, resulting in rotation of the head
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
to the opposite side. The typical right-sided head position preference when supine, cranial flattening,
NOTtoFOR
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and NOT
long periods
the supineOR
positionwith the head turned to the right may contributea shortening of the SCM. Infants with localized head flattening (plagiocephaly) at birth have an increased
risk for other deformational anomalies, such as mandibular hypoplasia (underdeveloped lower jaw)
(Peitsch, Keefer, LaBrie, & Mulliken, 2002). Boere-Boonekamp and van der Linden-Kuiper (2001)
examined 7,609 infants from a general population and found that 10% of infants less than 2 months© Jones &ofBartlett
Learning,
LLC the head to one side and typically© Jones& Bartlett
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LLC
age had a preference
for holding
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side.
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torticollis has spent many weeks in utero withthe headturnedto oneORside DISTRIBUTION
while
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pushing on the opposite shoulder. Breastfed infants may have difficulty achieving a comfortable■■

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Functional Infant Anatomy and Physiology Associated with Breastfeeding  153

breastfeeding position with the shortened SCM muscle (Stellwagen, Hubbard, & Vaux, 2004). Other© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
physical features of infants with torticollis include misalignment of the eyes, asymmetry of the ears,
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OR
upwardtiltingof thelower jaw
andDISTRIBUTION
gum line, and limited neck movement. The mandible
is tilted
and not parallel with the upper jaw. Wall and Glass (2006) reported that mothers of infants withmandibular asymmetry may experience sore nipples, difficult latch, and reduced milk transfer.
Chin support and use of a nipple shield may be helpful. The most expeditious intervention during
the early days when an infant demonstrates torticollis/asymmetrical jaw is to position the infant at© Jones &theBartlett
LLC© switching
Jones positions& Bartlett
LLC
breast withLearning,
the head turnedto the preferred side. Rather thanto feedLearning,on thesecondbreast,theinfant
is
slid
over
in
the
same
position
to
feed
from
the
other
breast.
Stretching
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exercises may be prescribed or referral to an occupational or physical therapist may be necessary to
improve the condition.
■■
Alterations in jaw functioning may show up as exaggerated jaw movements, jaw clenching, wide
jaw excursions, clamping or biting down to achieve stability and hold onto the nipple, and low toneor poor control(TMJ).&The
TMJ may Learning,
be affected by birthnes & Bartlett Learning,
LLC of the temporomandibular©joint
Jones
Bartlett
LLCforces
or instrument deliveries and may have an NOT
altered orlimitedrange ofmovement.
This joint moves
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in rather intricate ways: up and down like a hinge and gliding forward and down. A limited opening of the mouth caused by the inability of the TMJ to move in a full cycle of opening and closing
may contribute to incremental latch-on in which an infant bites or nibbles his or her way onto thenipple rather than opening to a more optimal 160-degree angle. Wide jaw excursions beyond a 150to 160-degree
angle
be heardLearning,
as smacking sounds
withthe nipple–© Jones&may
Bartlett
LLCas the tongue loses contact ©
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areola. Jaw instability is common in preterm infants and those with low orofacial tone, resulting in
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an unstable base for tongue movements. Sucking can be inefficient, and if the lips are unable to close,
milk will leak from the corners of the mouth.
Assessment of the Tongue. The tongue should appear soft at rest, lying in the bottom of the mouth© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
with a well-defined bowl shape. It should appear thin and flat, with a rounded tip and cupped sides. TheNOT FORSALE
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tongue should neither protrude over the lips nor be seen when theNOT
mouth FORis closed.
It should
have
suf-

ficient tone and mobility to lift, extend, groove, and lateralize in a smooth and symmetrical manner.
When a finger is placed in the infant’s mouth, the tongue should cup around the finger, forming a distinct
groove, and move in a rhythmic manner either in and out or up and down. Sucking pressure should befelt equally over the entire surface of the inserted finger. Besides playing a major role in sucking andnes & Bartlett Learning,© Jones& Bartlett
Learning,
swallowing, theLLC
tongue is an important oral structurethat affects
the shape of
the palate, is LLC
involved inspeech,contributes
tothepositionoftheteeth,
andaffects
thedevelopment
of
the
face.
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Alterations of the tongue may include the following conditions:

In tongue-tip elevation, the tip of the tongue is in opposition to the upper gum ridge, making it difficult for an infant to latch to the breast.
■■
Bunched (compressed in a lateral direction), retracted, or humped (in an anterior–posterior© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin­direction) tongue may be part of an infant’s high tone. The tongue is unable to form a central groove
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in anyof thesepositions.
■■
A tongue with low tone may demonstrate little to no shape, may feel excessively soft, may protrude
over the lower gum ridge, or may appear excessively wide or large for the mouth.
■■
Tongue thrust (an in-and-out pattern of movement with a strong protrusion or push out of themouth) during active sucking may be associated with high tone and result in difficulty generating© Jones &negative
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
pressure.
■■
Tongue alterations
may be a sign of oral defensiveness or, with NOT
tongue FOR
protrusion,
may bea resultof
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respiratory problems where the infant positions the tongue forward to increase respiratory capacity.
■■

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154  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Tongue movement anomalies may be seen in cesarean-born infants from traction forces placed on© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
the cranial base during delivery. The hypoglossal canal, through which the hypoglossal nerve passes,
FORas SALE
can NOT
be disrupted
the head isOR
liftedDISTRIBUTION
through the cesarean incision (Smith, 2004). NOT FOR SALE OR DISTR■■
The action of the tongue can be altered by the use of artificial nipples. Whereas the shape of thehuman nipple–areola conforms to the inner boundaries of the infant’s mouth, the infant’s tongue
and oral cavity are obligated to conform to the parameters presented to them by the shape andrigidity of an artificial nipple. The artificial nipple positions the tongue behind the lower gum© Jones &(Figure
Bartlett
LLC© Jones
Bartlett
LLC3-9). IfLearning,a breastfed infant
were to do this at the breast, boththe upper&and
lower gumLearning,
would
be
in
opposition
to
each
other
and
the
infantwould
actuallybite
thenipple.
Suchascenariocould
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result in extreme pain for the mother along with nipple damage and little milk transfer. High-flow
artificial nipples may result in decreased oxygen levels due to rapid swallowing and limited intervals for breathing (Figure 3-10A). The artificial nipple (Figure 3-10B) does not fill the oral cavity,
alters the labial seal, may obliterate the central grooving of the tongue, and may result in forcesthat impingeon the alveolar ridges and press
them inward.
Even so-called
orthodontic
improvenes & Bartlett Learning,
LLC© Jones& Bartlett
Learning,
LLC
ments made to artificial nipples still force thenormalshapeSALE
and physiologicalaction of the tongue to
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change (Figure 3-10C).
■■
Recent research on the sucking action of infants on artificial nipples has been conducted in an effort
to manufacture artificial nipples that can claim to elicit similar sucking actions as on the breast.
Segami, Mizuno, Taki, and Itabashi (2012) studied an experimental artificial nipple with a wide base,a firmand a &
valve
at the baseLearning,such that milkLLC
flowed only when the infant exerted©shaft,Jones
Bartlett© vacuum.
JonesThey& Bartlett Learnin
concluded that there were no significant differences in perioral movements between breastfeeding■■

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FIGURE 3-9
The&Artificial
NippleCan Cause theTongue to Remain Behind the©Lower
Gum& Bartlett Learning, LLC© Jones
Bartlett
Learning,
LLC
Jones
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Nasal cavity

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Learning, LLC
Hard palate
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SoftOR
palate© Jones & Bartlett Learning, LLC
NOT FOR SALE Tongue
OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR
Epiglottis

Thyroid
cartilage

Esophagus

Trachea© Jones & Bartlett Learning, LLC
Source:Walker 2e
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FIGURE©
3-10
Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FORSALE OR DISTRNOTFOR SALE
OR DISTRIBUTION(A) Throat
conformation
for swallowing
within the bottle suck cycle. (B) Traditional
artificial
nipple does not fill the oral cavity. (C) Altered “orthodontic” artificial nipple alters tongue position,
compromising physiologic tongue action
A© Jones & Bartlett Learning,
LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Nasal cavity
Hard palate
Soft palate

Pharynx

nes & Bartlett Learning, LLC
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Tongue© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Thyroid
cartilage

Epiglottis
Esophagus

Trachea© Jones & Bartlett Learning, LLC
B
NOT FORSALE OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Nasal cavity
Hard palate
Soft palate© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

TongueEpiglottis

Thyroid
cartilage

Esophagus
Tracheanes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTIONC© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
Source:Walker 2e
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156  Chapter 3: Influence of the Infant’s Anatomy and Physiology

and feeding on this experimental nipple. However, one important difference was noted: The vacuum© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
generated during sucking on the experimental nipple was significantly smaller than that observed
FOR toSALE OR DISTR
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duringfeeding
on thebreast.OR
This DISTRIBUTION
would be of concern if an infant transferred a NOT
lower vacuum
the breast and such a weaker sucking pressure was unable to transfer milk efficiently from the breast.
The same observation of reduced vacuum application was seen in a study conducted by Geddes
and colleagues (2012) on the development of a new artificial nipple that relies solely on vacuum totransfer milk from the bottle. Baseline (–12 mm Hg vs. –31 mm Hg) and peak vacuum (–67 mm Hg© Jones &vs.Bartlett
Learning,
LLC© Jones& Bartlett
Learning,
LLC–122 mm Hg)
generation on
the experimental artificial nipple
was significantly
lower thanthatappliedatthebreast.
Duringthedevelopment
of
this
same
artificial
nipple,Sakalidis
andcolleagues
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION(2012b) again demonstrated that sucking pressures on the artificial nipple were lower than at thebreast. Use of artificial nipples that lower vacuum generation could have negative implications whenused by infants who already have a weak suck, reinforcing diminished vacuum application at thebreast. Woolridge (2012) found that under ultrasound, peristaltic movements of the tongue could be
visualizedLLC
when infants were sucking on a different
artificial
nipple, withLearning,both vacuum andperistalnes & Bartlett Learning,© Jones& Bartlett
LLC
tic tongue movements present during the same
feeding.
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Tongue-tie, or ankyloglossia, is one of the most common tongue alterations and can affect infant milk
intake and the integrity of the mother’s nipples. The exact incidence of tongue-tie is unknown, but
studies report a 4.2–4.8% incidence in general populations of newborns (Ballard, Auer, & Khoury, 2002;
Messner, Lalakea, Aby, Macmahon, & Bair, 2000). Definitions and descriptions vary. Fernando (1998)
Bartlett
LLC aspects of the frenum: “Tongue-tie© Jones& Bartlett Learnin
described©
theJonescondition&basedon bothLearning,visual and functional
is a congenital condition,
recognizedby anunusually
thickened, tightened, or shortened frenum
NOT[frenulum],
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OR
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which limits movement of the tongue in activities connected with feeding and which has an adverse
impact on both dental health and speech.” Hazelbaker (1993) defined tongue-tie as “impaired tongue
function resulting from a tight and/or short lingual frenulum which may or may not involve fibers of
the genioglossus muscle. Complete ankyloglossia can be defined as a ‘fusing’ of the tongue to the floor ofthe&mouth.”© Jones
Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
the range of motion of the tongue and affects
not FOR
only sucking
but also
NOT FOR Ankyloglossia
SALE OR limits
DISTRIBUTION
NOTSALE
ORspeech,
DISTRIBUTION
the position of the teeth, periodontal tissue (the tongue cannot clear residual fluid and food from the buccal cavities), jaw development, and swallowing. It has been associated with deviation of the epiglottis andlarynx, harsh breath sounds, and mild oxygen desaturation during sucking (Mukai, Mukai, & Asaoka,1991).
Tongue-tie is sometimes visualized during the newborn exam before hospital discharge. Mothersnes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
may complain of nipple pain and sore nipples, difficult latch, unsustained sucking, or the infant “popping”
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NOTofFOR
SALEdifficulty
OR DISTRIBUTION
and off the breast. Inability to transfer milk because
a mechanicalcan also lead to and present with insufficient milk, slow weight gain, engorgement, and plugged ducts. Observations of the breastfeeding may reveal milk leaking from the sides of the mouth, slow feeding, a clicking or smacking soundas the tongue loses contact with the nipple–areolar complex, sucking blisters on the infant’s lips, and distorted appearance of the nipple when released from the infant’s mouth. Tongue-tie has been described and
©the
Jones
& Bartlett
Learning,
LLC©ofJones& Bartlett Learnin
assessed byappearanceof the tongue,
the functioningof the tongue, or a combination
both parameters. TheNOT
affected
tonguehas variously
been described as heart shaped (Figure 3-11),NOT
notched,unableFOR
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OR DISTRIBUTION
to protrude beyond the lower gum or elevate to the roof of the mouth, unable to cup and form a central
groove, having a short and/or tight frenulum, having a thick or thin frenulum, having a frenulum attachedanywhere along the underside of the tongue, and being anchored in various places, from the lower alveolar ridge or farther back along the floor of the mouth. A tight or short frenulum may be less than 1 cm in© Jones& Bartlett
Learning,© Jones& Bartlett
LLC
lengthand feel tightwhen a fingerLLC
is placed under the midline of the
tongue (Notestine,1990). Learning,
Duringadigitalassessmentofthetongue,
it
may
be
felt
to
snap
back
to
the
mandibular
floor
becauseit
maybe
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unable to elevate or maintain extension for very long (Marmet, Shell, & Marmet, 1990).
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  157
FIGURE©
3-11
Jones & Bartlett Learning, LLC

NOTTongue
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Heart-shaped

tongue© Jones & Bartlett Learning, LLC
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Source: Walker 2e© Jones & Bartlett Learning, LLC
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Consistent definitions and assessment tools are scarce. Kotlow (2004a) classifies tongue-ties basedon the distance of the insertion of the lingual frenum to the tip of the tongue. A normal distance is
16 mm. Class IV is defined as a distance of 10–12 mm from the tip of the tongue; class III is a moderate
tongue-tie, with a distance of 7–9 mm from the tip of the tongue; class II is severe, with a distance of
4–6&mmfrom the Learning,
tip of the tongue;
and class I is complete, with a©
distanceof 0–3mm from thetip of© Jones
Bartlett
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thetongue(Figure3-12).
If
thisdistance
is
less
than
8
mm,
Kotlow(2004c)recommends
thatthefrenumNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
be revised.
Edmunds, Miles, and Fulbrook (2011) analyzed the evidence regarding tongue-tie to determine if
tongue-tie could have a significant impact on breastfeeding and if frenotomy was a viable option. They
found that for most infants, frenotomy offered the best chance of improved and continued breastfeeding and that the procedure did not lead to complications for the infant or the mother. Kumar and Kalkenes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC(2012) analyzed prospective cohort studies and randomized controlled trials regarding whether breastFOR SALE ORfeeding
DISTRIBUTIONNOTFOR SALE
ORin DISTRIBUTION
was adversely affected by tongue-tie andif frenotomy
was helpfulrectifying the associatedbreastfeeding problems. They found a strong association between the presence of tongue-tie and breastfeeding problems in neonates. Their analysis revealed that neonates with tongue-tie are at increased risk
for breastfeeding difficulties and that those with breastfeeding difficulties should be immediately referred
to a lactation consultant with experience in handling this situation. They also stated that the presence© Jones&breastfeeding
Bartlett Learning,
LLC
Jonesfor&aBartlett Learninof tongue-tie
along withdifficulties in an
infant should constitute a valid©indicationreferral for
frenotomy.
data confirmedthat frenotomy usually results in very rapidNOT
improvement
FOR inSALE OR DISTR
NOTFORTheSALE
OR DISTRIBUTION
the symptoms associated with tongue-tie.
Some mothers present with excoriated nipples caused by the infant’s tongue being unable to engage
in the peristaltic anterior-to-posterior movement used to extract milk. The compression between thegums and the up-and-down movements of the tongue may result in abrasions on the upper aspect of© Jones
Bartlett
Learning,
LLCgum ridge or rugae of the hard
© Jones& theBartlett
Learning,
LLC
the&nippleas it rubs
against the upper
palate or onundersideof thenippleasitexperiences
frictionovertheuncovered
lower
gum.
If
the
frenulumisattached
at
the
very
tip
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of the tongue, the tongue can actually curl under. Tongue-tie restricts the tongue to a limited range of
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158  Chapter 3: Influence of the Infant’s Anatomy and Physiology
FIGURE©
3-12
Jones & Bartlett Learning, LLC

NOT FORofSALE
Kotlow Classifications
Tongue OR
Tie DISTRIBUTION© Jones & Bartlett Learning, LLC
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nes & Bartlett Learning,
A. ClassLLC
1: 0–3 mm from tip of
tongueFOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones& 2:
Bartlett
B. Class
4–6 mmLearning,from tip of LLC
NOTtongue
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C. Class 3: 7–9 mm from tip of© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR© Jones & Bartlett Learnin
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D. Class 4: 10–12 mm from tip of

tongue© Jones &tongue
Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
NOT FORSALE
OR
DISTRIBUTION
FOR liptie
SALE
OR DISTRIBUTION
Source: Kotlow, L. (2011b). Infant reflux and aerophagia associated withNOT
the maxillary
and ankyloglossia(tonguetie). Clinical Lactation, 2, 25–29.

nes & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
FOR SALE ORmovements
DISTRIBUTIONNOTORDISTRIBUTION(Figure 3-13), making it problematic
if the FOR
tongue SALE
tip remains
unableto elevate as the jaw

drops and/or interferes with the posterior tongue’s movements in swallowing. Infants often engage in a
number of compensatory movements to facilitate milk intake, such as reliance on negative pressure toobtain milk, fluttering action of the tongue as it seeks the nipple, chewing motions, biting actions to holdonto the nipple, and head movements to help with swallowing.
© Jones& Bartlett© Jones& Bartlett Learnin
Tongue-tie
is usuallyan isolatedLearning,
condition, but LLC
it can be seen as part of congenital
syndromes.
It is moreNOT
commonin boysthan ingirls,and is often familial. If the mother has a small
breast,if theNOT
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breast is highly elastic, and if the infant can draw in enough of the areola, breastfeeding may not become
compromised. In a small study of five breastfed infants with tongue-tie, Geddes, Kent, and colleagues(2010b) found that in these mothers, nipple pain, milk intake by the infant, and milk production were
not impacted by the tongue-tie. This finding suggests that some mothers may have certain breast, nipple,© Jones& supply,
Bartlett
Learning,
LLC that allow infants with ©
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Learning, LLC
milk
or milk
ejection characteristics
tongue-tie
breastfeed
successfully.
However,
failuretocorrect
thetongue-tie
at
this
stage
may
simplypostponetheprocedure
until
problems
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
with eating, dentition, and speech require it at an older age.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  159
FIGURE©
3-13
Jones & Bartlett Learning, LLC

NOTCauses
FORProblems
SALEElevating
OR DISTRIBUTION
Tight Frenum
Tongue© Jones & Bartlett Learning, LLC
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Frenum© Jones & Bartlett Learning, LLC

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Source: Walker 2e© Jones & Bartlett Learning, LLC
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Assessment of the Hard Palate. The hard palate should be intact, smoothly contoured, and appear as if

the tongue would comfortably fit within its contours. Several alterations of the hard palate have been noted.

■■

Cleft lip and cleft palate constitute the fourth most common congenital disability, affecting 1 in 700

in theUnited States.LLC
A cleft of the palate can include©
theJones
hard and/or
soft palate, Learning,with or© Jones &children
Bartlett
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LLCof the lip; can be unilateral or bilateral; NOT
and may
exhibitvaryingOR
degreesof
NOT FOR without
SALEinvolvement
OR DISTRIBUTIONFORSALE
DISTRIBUTION

severity and involvement. Clefting may occur as an isolated event or may be part of a syndrome suchas Pierre Robin syndrome or Turner syndrome. A submucous cleft of the hard palate can sometimes
be felt as a notch or depression in the bony palate when palpated with a finger. Although tongue
movements during sucking may be normal, compression can be generated only if there is adequate
hard palate surface to compress against; sealing of the oral cavity is always compromised with bothnes & Bartlett Learning,
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hard and soft palate clefts (Glass & Wolf, 1999). Feedings are long, and if signs of aspiration, such
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as frequent coughing, choking, sputtering, NOT
or colorFOR
change,SALE
are observed,
position changes may berequired or assistive devices may be needed to ensure adequate intake (Edmondson & Reinhartsen,
1998). Usually, no airway obstruction or swallowing abnormalities are present, but with clefts of thepalate, air is vented through the cleft, making it difficult to impossible to achieve vacuum, depending
on how much of the palate is involved. Infants born with a cleft lip only usually have fewer problems© Jones
Bartlett
Learning,
LLC© Jones & Bartlett Learnin
breastfeeding
than&thosewith palatal
defects.
■■
Breastfeeding
infants
with clefts
supplying pumped breastmilk) provides the samediseaseproNOT
FOR
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tection as for any other infant. Indeed, breastmilk is especially important in reducing the otitis
media that infants with cleft palate are so prone to develop. Breastfeeding encourages the proper useof the oral and facial musculature, promotes better speech development, and, when the infant is atbreast, helps normalize maternal–infant interactions.
© Jones
Bartlett
Learning,
LLC© Jones&Weight
Bartlett
Learning, LLC■■ &Infants
with cleft
lip/palate areat an increased risk for insufficient
milk intake.
gain, numberoffeedings,
intakeat
each
feeding,anddiapercountsmust
bemonitoredtodetermine
the
need
for
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supplemental breastmilk or other foods (Dowling, Danner, & Coffey, 1997).
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160  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Poor feeding skills may sometimes be seen in newborns with cleft palate or cleft lip/cleft palate, and© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
are even more commonly seen in infants with Pierre Robin syndrome, along with other syndromes.
FOR
SALE OR DISTR
NOT
FOR
SALEcleft
ORlipDISTRIBUTION
Many
infants
with isolated
and/or palate have normal feeding skills and NOT
experienceproblems only with vacuum generation, slow feedings, and nasal regurgitation. Actual oral motor dysfunction seen in infants with various syndromes can include minimal jaw excursions and absence of
normal jaw and tongue movements for long periods. Reid, Kilpatrick, and Reilly (2007) found thatbabies with smaller clefts such as cleft lips and minor soft palate clefts were more likely to generate© Jones &normal
Bartlett© Jones& Bartlett
Learning,
LLC
levels Learning,of suction on aLLC
bottle than infants with larger clefts,
but not always
for a longtime.
Infants
with
cleft
lip
and
palatewerealsoreported
to
have
lower
compression
readings
ontheartiNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
ficial nipple. This decreased compression could be due to the absence of palatal tissue against whichto press the nipple or it could be a learned behavior from feeding with compressible bottles/nipples,
which deliver milk regardless of whether suction or compression is generated.
Masarei et al. (2007) looked at bottle sucking patterns of infants with unilateral cleft lip and palate and of LLC
infants with a cleft of the soft palate
at least&two-thirdsof thehard palate. LLC
They foundnes & Bartlett Learning,
© and
Jones
Bartlett
Learning,
two patterns of feeding—one in which the infants
not produce
identifiablesucking burst, but
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used a continuous disorganized pattern, and one in which the infants generated a short rhythmic
sucking burst/pause pattern that was sustained for only 2 to 3 minutes followed by sucking disorganization. Sucking rates of these infants were more rapid than in infants with no cleft—109.26 sucks
per minute in infants with clefts compared with 75.05 sucks per minute in infants without clefts.
Infants
with clefts&
generatedcompression
or positive
while infants© Jones
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without clefts generated positive pressure for 26% of the feeding. Infants with clefts demonstrated
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an inconsistent range of tongue and jaw movements, arrhythmic tongue and jaw movements, andan altered rate of sucking. Many of these sucking alterations appear to be attempts by the infants tocompensate for the anatomic abnormalities. Lacking enough vacuum for milk removal, infants compensated with faster and more compressions or positive pressure generation to remove milk by using
mechanical ability that they possessed. While this study looked at feeding patterns on a bottle, it is© Jones &alikely
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
that infants with cleft defects will also attempt to compensate in a similar manner at the breast.
NOT FOR Clinicians
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might wish to visualize the entire mouth (including NOT
the hardFOR
and soft
palate) ORof an infant
who is demonstrating the feeding patterns just described. Feeding inefficiency is predictive of poor
feeding in young infants. Neonates transferring less than 2.2 mL/minute of milk and infants transferring less than 3.3 mL/minute of milk are highly predictive of poor feeding skills (Reid et al., 2006).
■■
If the infant is unable to withdraw sufficient milk from the breast, expressed breastmilk can benes & Bartlett Learning,
LLC a supplemental tube feeding© Jones
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LLC
provided throughdevice at&breastor througha special bottle-feeder.
Mothers
will
need
an
electricbreastpump
andapumpingplan
toprovidebreastmilk
andmaintain
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an adequate supply. They may use alternate massage when the infant is at breast or hand express
milk directly into the infant’s mouth, but the infant may be unable to adequately drain the mother’sbreasts, increasing the risk of insufficient milk supply, engorgement, plugged ducts, and mastitis
unless the breasts are more thoroughly drained at each feeding (Biancuzzo, 1998).
■■
Some©infants
may &be fitted
with a palatal
obturatorLLC(a prosthesis molded to fill the cleft
provide&anBartlett Learnin
Jones
Bartlett
Learning,
©and
Jones
“artificial” palate). This device is designed to provide a solid surface against which to compress the nipNOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
ple and seal the oral cavity to facilitate achieving negative pressure for milk withdrawal. It may also help
to decrease the amount of time it takes for each feeding, reducing the fatigue for both infant and parents.
■■
Managing the infant with a cleft defect is typically accomplished by a team of healthcare professionals, with surgeries, treatment, and therapy that can continue for many years. Because most orofacial
are immediately
apparent
after birth, it is important that
healthcare&providersexperienced© Jones &clefts
Bartlett
Learning,
LLC© Jones
Bartlett
Learning, LLC
with feeding cleft-involved infants be readily available to parents. Parents are especially concerned
NOT FOR SALE
ORissues,
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ORquickly
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about feeding
and nurses caring for mothers of newborns
with orofacial
clefts should■■

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Functional Infant Anatomy and Physiology Associated with Breastfeeding  161

refer mothers to lactation specialists/consultants experienced with the associated feeding complica© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnintions (Byrnes, Berk, Cooper, & Marazita, 2003).
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■■
Other
palatalvariations
suchOR
as a DISTRIBUTION
bubble palate (Figure 3-14) may also impede NOT
breastfeeding.
A
bubble palate is defined as a “concavity in the hard palate, usually about 3/8 to 3/4 in (1–2 cm) indiameter and 1/4 in (1/2 cm) deep” (Marmet & Shell, 1993). Because of the position of the mother’snipple relative to the bubble, the nipples can become abraded, inflamed, and sore if the nipple rubs
against the anterior ridge of the bubble. Weight gain problems may also ensue if the infant is unable© Jones &toBartlett
Learning,
LLC1997).
© Jones & Bartlett Learning, LLC
transfer sufficient
milk (Snyder,

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The soft palate generally has thinner mucosa than the hard palate
and may be somewhat darker in color. It is firm but spongy, the uvula should be in the midline and intact,
and the soft palate should not sag to either side. The following notes relate to alterations of the soft palate:
Assessment of the Soft Palate.

■■
Cleft of the soft palate and uvula is always midline. Submucous clefts are a subgroup of clefts withnes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
intact mucosa lining the roof of the mouth that can make it difficult to see when looking into the
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mouth. The underlying muscle and bone areNOT
at leastFOR
partially
divided,OR
indicating
insufficient medianfusion of the muscles of the soft palate. A submucous cleft may be identified by the presence of a bifid
uvula, a very thin translucent strip of mucosa in the middle of the roof of the mouth, and a notch at
the back edge of the hard palate that can be felt with the fingertip. Reiter and colleagues (2012) founda potential role of maternal smoking during pregnancy in the formation of a submucous cleft palate,© Jones& Bartlett
Learning,
LLC that predisposed for orofacial© Jones& Bartlett Learnin
especially
if the infants
had particular
genetic variants
clefts. Infants
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may experience swallowing difficulties and persistent middle-ear disease. Damage to the glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X) may cause a paralysis of the

FIGURE 3-14

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Bubble palate© Jones & Bartlett Learning, LLC
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162  Chapter 3: Influence of the Infant’s Anatomy and Physiology

soft palates, which will sag on the affected side. Babies with this type of cleft suck rhythmically but© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
generate only weak suction and may feed for prolonged periods but transfer little milk, resulting in
NOT FORSALE OR DISTR
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FOR gain.
SALE
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inadequate
TheyORmay havenasal snorting, frequent sneezing, or regurgitation
through
the nares. Clefts of the soft palate will not be detected on digital exam. The examiner needs to visualize the soft palate by using a light and a tongue depressor on the posterior tongue.
■■
A congenital short palate can result in velopharyngeal insufficiency, as can insufficient tissue repairof a cleft palate (Morris & Klein, 2000).
© Jones
Bartlett
LLCwhen the hard palate has a cleft.
© Jones
Bartlett
Learning,
LLC■■ &Thesoft palateLearning,is typically involved
This can &resultin an open
nasopharynx
duringswallowing
andreflux
of
milk
into
the
nasal
cavity,swallowing
of
air
into
the
stomNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
ach, and, if ear tubes are present, milk sometimes leaking through the tubes and out the ear.
Not all clefts are identified at birth or on day 1, with delayed detection of clefts experienced by some families. Habel, Elhadi, Sommerlad, and Powell (2006) found that isolated cleft palates that were U shaped
were more often detected on day 1 than were narrow V-shaped clefts (Figure 3-15). A delay in detection isnes & Bartlett Learning, LLC
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Clefting that Might be Missed without Direct Visualization of the Palates. (A) Broad U-shaped cleft
palate extending one-third way into the hard palate. (B) Narrow V-shaped cleft palate at the junctionof the soft and hard palates© Jones & Bartlett Learning, LLC
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nes & Bartlett Learning, LLC
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NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
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Source:Habel, A., Elhadi,N., Sommerlad,S., & Powell, J. (2006). Delayed detectionof cleft palate:
An audit of newborn
examination.
Archivesof
DiseaseinChildhood,91,
238–240.
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Functional Infant Anatomy and Physiology Associated with Breastfeeding  163

more likely in the case of small narrow clefts in the soft palate. Digital examination of the infant’s mouth© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
can miss small clefts, and in the presence of symptoms (e.g., feeding difficulties, nasal regurgitation), a
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visual examinationof themouth shouldbe performed. The tongue needs to be sufficiently
depressed
visualize the back of the mouth with a flashlight.
Assessment of the Nasal Cavity, Pharynx, Larynx, and Trachea. These structures can be assessedwith varying tests and instruments when significant deviations from normal are suspected. Alterations© Jones& Bartlett
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Jones
Bartlett
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LLC
in swallowing
and Learning,breathing or problems
suck,swallow,&breathe
may alert
the
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anatomic
or structural defect, such as the following: NOT FOR SALE OR DISTRIBUTION

Choanal atresia—occlusion of the passage between the nose and pharynx by a bony or membranous
structure.
■■
Vocal cord anomalies or paralysis.
■■
Edema from trauma such as intubation, extubation, or suctioning.
nes & Bartlett Learning,
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Structural narrowing such as subglottic stenosis.
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NOT(softening
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Instability of a structure, such as tracheomalaciaof the tracheal
cartilage) or laryngomalacia (softening of the tissues of the larynx, typically when the epiglottis bends over and partiallyobstructs the opening to the larynx). Infants with tracheomalacia, laryngomalacia, and laryngotracheomalacia also have a higher incidence of gastroesophageal reflux (Bibi et al., 2001).
■■
Spasms of a structure, such as laryngospasm.
■■© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

Because these
are not readily
visible, the clinical presentation, feeding and health
NOThistory,
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behavioral observation of a feeding are necessary to gather data for a feeding plan and/or referral. Infants
may present with one or a combination of signs and symptoms. The underlying cause of the problems
may be unclear because similar signs and symptoms may reflect different etiologies. Complex medical
diseases and conditions (e.g., bronchopulmonary dysplasia, cardiac problems, cerebral palsy, genetic syndromes)
may also produce
some ofLLC
the following signs and symptoms
if they &are Bartlett
not related tostruc© Jones& Bartlett
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tural or anatomic defects. Infants presenting with these symptoms should be checked by their primary
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care provider and may be referred to a specialist or undergo testing (Arvedson & Lefton-Greif, 1998) todetermine the primary problem:

Noisy breathing
Chronic congestion■■
Inadequate
weight gainnes & Bartlett Learning,
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Refusal to feed
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Apnea/bradycardia■■
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Cyanosis, pallor, or sweating■■
Wheezing, stridor, or suprasternal retractions■■
Excessive drooling■■■■© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

Dependingon theFOR
type andextentORof interferencewith feeding at the breast, modifications
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ranted in such elements as total body positioning, flexion or extension of the head, use of a nipple shield,
expression of milk, and use of alternate feeding devices.
Assessment of the Esophagus.

The most common disorder related to the esophagus in an infant© Jones& Bartlett Learning,© Jones& Bartlett
Learning, LLC
is gastroesophageal
reflux (GER),LLC
although other esophageal disorders
can interferewith swallowing(e.g.,
upper
or
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esophageal
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esophageal
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sion, or mechanical obstruction) (Arvedson & Lefton-Greif, 1998). GER entails the passive backflow
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164  Chapter 3: Influence of the Infant’s Anatomy and Physiologyof ­stomach contents into the esophagus and implies a functional or physiological process in a healthy© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
infant with no underlying systematic abnormalities. This disorder is associated with a transient relaxNOTcontents
FOR toSALE OR DISTR
FOR
SALEsphincter
OR DISTRIBUTION
ation of NOT
the lower
esophageal
due to fundal stimulation, which allows gastricwash back into the lower esophagus and often be regurgitated. GER (spitting up) generally peaks
between 1 and 4 months of age and is seen in 40–65% of healthy infants. The supine position and theslumped seated position can exacerbate reflux during the times that the lower esophageal sphincter
relaxes (Jung, 2001). Some infants with frequent GER have an inflamed throat and a hoarse cry. Infants© Jones
Bartlett
Learning,
LLC
Jones& Bartlett
LLC
may&archtheir neckand back when
feeding, may gag or cough, and©engage
in chewing
motionsLearning,(ruminationor“cudchewing”).
Infantswithanunexplained
chronic
coughshouldbeevaluatedfor
GER
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION(Borrelli et al., 2011). Jadcherla and colleagues (2012) looked at how GER might be influenced by certain
feeding mechanics and found that at least in preterm infants, feeding duration and feeding flow rate
modifications could significantly reduce GER events. In bottle- and gavage-fed infants, slowing down
the feeding and decreasing the milk flow rate significantly reduced the total number of GER events.
The authors speculated
milk&andair over a Learning,short period ofLLC
time could
nes & Bartlett Learning,
LLC that a large volume of swallowed© Jones
Bartlettto the gastric distention and fundal NOT
stimulationthat
precipitate
events. Applying thisFOR SALE ORcontribute
DISTRIBUTION
FOR
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ORGER
DISTRIBUTION
finding to the breastfeeding situation might suggest that in infants with GER, mothers might wish toelicit the milk ejection reflex before putting the baby to breast to reduce the volume and speed of milk
intake. Mothers might also consider extending the feeding time by allowing some periods of rest to
prolong the feeding.
Gastroesophageal
disease Learning,(GERD) is a pathologicalprocess characterized©byJones
clinical fea© Jones &reflux
Bartlett
LLC& Bartlett Learnintures such as regurgitation with poor weight gain, irritability, pain in the lower chest, possible apnea andNOT
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OR
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cyanosis, wheezing, laryngospasm, and possibly aspiration, chronic cough, and stridor. An infant with
GERD may have more than five episodes of reflux per day, regurgitate approximately 28 g per episode,and refuse or show irritability during feedings (Arguin & Swartz, 2004). Some infants with GERD do notrespond to medication. In infants with more severe GERD, an abnormal hyperextension of the neck withtorticollis (Sandifer syndrome) may be seen.
© Jones&Infants
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
with GER or GERD may demonstrate feeding resistance, arching at the breast, limited feedNOT FOR
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ORDISTRIBUTION
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ing time at the breast, and discomfort when fed in the cradle position.
infants
feed betterwhenbreastfed in an elevated position of 45 degrees or more (Boekel, 2000; Wolf & Glass, 1992). After eachfeeding, infants should be kept upright, as in a front pack carrier or wrap, rather than slumped down in
an infant seat or immediately put in a supine position. Care must be taken when using a sling so as not toincrease intra-abdominal pressure.
nes & Bartlett Learning,
LLCdescribes tongue-tie and maxillary© Jones& as
Bartlett
Kotlow (2011b)
lip-tiepotential Learning,
contributors toLLC
symptoms
typically
associatedwithrefluxandcolic.
The
association
is
the
large
amount
of
air
that
can
be swalFOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
lowed and the inability of the lips to form a complete seal on the breast. Once a maxillary lip-tie and/or
a tongue-tie is released, the lips can form a more complete seal and the tongue remains in contact with
the nipple/areola, reducing the intake of air. Alcantara and Anderson (2008) report that chiropractic andcranial-sacral therapy may provide relief for some infants suffering from GER.

© Jones & Bartlett Learning, LLC
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Putting
All Together© Jones & Bartlett Learnin
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The infant’s feeding anatomy and associated physiology come together at feeding times in a complex
series of actions that must occur in synchrony to ensure transfer of sufficient milk from the mother’sbreast into the infant. Guidelines for assessing the breastfeeding mother and infant have emphasized theimportanceof the Learning,visual assessment
conducted in a coordinated manner(Walker,
Assessment
is© Jones& Bartlett
LLC© Jones& 1989).
Bartlett
Learning,
LLC
thefoundationofprofessional
practice.
Breastfeeding
assessment
is
part
of
the
community
standardof
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
care for hospital maternity units. The Committee on Fetus and Newborn of the American Academy of
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Tools  165

Pediatrics (2004) recommends that a number of criteria be met before any newborn discharge, including© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
two items specific to breastfeeding:

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1. The infant has completed at least two successful feedings, with documentation that the infant is able
to coordinate sucking, swallowing, and breathing while feeding.
2. The mother’s knowledge, ability, and confidence to provide adequate care for her baby are documented by the fact that she has received training and demonstrated competency regarding breastor bottle-feeding.
TheLLC
breastfeeding mother and baby©should
be assessedby trained
staff© Jones &feeding
Bartlett
Learning,
Jones& Bartlett
Learning,
LLC
regarding breastfeeding position, latch-on, and adequacy of swallowing.

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Tools
Tools have been developed to predict future problems or to help identify mothers who are at risk for earlynes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
weaning. Assessing breastfeeding activities using a systematic approach can be undertaken in a number
FOR SALE ORofDISTRIBUTIONNOT FOROR DISTRIBUTION
ways. Some clinicians use (or adapt) one of a numberof shortSALE
clinical assessment
tools that have beendeveloped for the following purposes:

Organize the breastfeeding assessment
Identify both normal and abnormal patterns at the breast■■
Determinewhethertransfer Learning,has occurred LLC© Jones&milk
Bartlett© Jones & Bartlett Learnin■■
Document and chart breastfeeding behaviors
NOT FOR SALE OR DISTR
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FOR
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OR
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Direct professional intervention and patient education to areas where it is needed■■
Serve as a communication vehicle among professional caregivers■■
Establish evaluation and teaching standards■■
Reduce inappropriate supplementation■■
which infants are at risk for early weaning© Jones&Predict
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC■■
Recognize mother–baby pairs in need of referrals and follow-up■■■■

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Using a clinical assessment tool helps objectively document feedings and may be expedient in thehospital or clinic setting. Some of the tools assign a score with cut-off points that serve as a basis formaking referrals. Several have been shown to be predictive of risk for early weaning and are also used
to justify the need for more intensive breastfeeding assistance. Not all tools have been shown to bevalid (i.e., the tool measures what it states it measures) and/or clinically reliable (i.e., it consistently
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
measures the intended behavior). However, the tools that assess feedings at the breast depend on the
FOR SALE ORclinician’s
DISTRIBUTION
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observation of a feeding and do not NOT
rely on FOR
subjective
descriptionsof “good, fair, poor” ornumber of minutes at each breast, descriptions that are inappropriate, inaccurate, and of little clinicalrelevance.

Infant BreastfeedingTool© Jones & Assessment
Bartlett Learning,
LLC© Jones & Bartlett Learnin
MatthewsNOT(1988) FOR
noted that
InfantOR
Breastfeeding
Assessment Tool (IBFAT) scores (Table3-3) FOR
were notNOT
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DISTRIBUTION

predictive of abandonment of breastfeeding but rather illustrated that sucking behaviors improved
over time. There was a significant difference in breastfeeding competence between infants of first-time­mothers, who took a mean of 35 hours to establish effective breastfeeding, compared with infants ofmultiparous mothers, who took a mean of 21.2 hours to establish effective breastfeeding. A longer period
to establish
effectivebreastfeedingLLC
was also associated with the timingof drug administrationlabor,© Jones& Bartlett
Learning,© Jones& Bartlett inLearning,
LLC
as
83.4%
of
primiparous
mothers
receivedalphaprodine(Nisentil)
within
1–4
hours
beforedeliverycomNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
pared with 45% of multiparous mothers.
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166  Chapter 3: Influence of the Infant’s Anatomy and Physiology
Table 3-3
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Infant Breastfeeding
NOT FOR Assessment
SALE ORTool
DISTRIBUTION
Component

3

2

1

0

Readiness to feed

Started to feed
Needed mild
Needed vigorous
Cannot be roused
readily without
stimulation
stimulation to© Jones & Bartlett Learning,
LLC to start feeding
effortfeed© Jones & Bartlett Learning, LLC
Rooting
effectively Needed coaxing
RootedNOT
poorly,FORDid
not tryOR
to root
NOT FORSALE OR Rooted
DISTRIBUTIONSALEDISTRIBUTION
at onceto rooteven with coaxing
Fixing (latch-on) Started to feed atTook 3–10 minutes Took > 10 minutes Did not feedonce
to start feeding
to start feeding
Sucking
Sucked well on one Sucked off andSome sucking
Did not suckpatternon, but
for shortnes & Bartlett Learning,
LLC or both breasts© needed
Jones &efforts
Bartlett
Learning, LLC
encouragement
periods

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Maximum score: 12
Score of 10–12 = effective vigorous feeding
Score of 7–9 = moderately effective feeders
Score 0–6 = effective sucking rhythm not established© Jones& Bartlett
Learning,
LLC© Jones&inBartlett Learnin
Source: Adaptedfrom Matthews,
M. K. (1988).
Developing an
instrument to assess infant breastfeeding
behaviour
the early neonatal period. Midwifery, 4, 154–165.
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTR

The IBFAT does not assess swallowing, which can be a drawback in its use unless swallowing is
included in the “sucking pattern” measurement score. Matthews (1991) also observed that mothers can© Jones
Learning,
LLC
Jones
Bartlett
LLC
use&
theBartlett
IBFAT to assess
their infants’feeding progress, with infants©
whoscore the&highest
havingLearning,mothers who
are morewith the feeding. Primiparous mothers hada significantly
higherOR
percentage
NOT FOR
SALE
ORpleased
DISTRIBUTIONNOTFOR SALE
DISTRIBUTION
of feedings at which they were dissatisfied, with low scores tending to occur predominantly during thefirst 48 hours after birth. Mothers’ satisfaction or positive feedback is important in the maternal decision to continue breastfeeding and persevere during breastfeeding difficulties. Mothers who experience
dissatisfaction during the early time after birth will need more intensive support to curtail the negative feedback generated
breastfeed.
infant who
does not achievea scorenes & Bartlett Learning,
LLC when an infant struggles©toJones& An
Bartlett
Learning,
LLC
in the 10 to 12 range of the IBFAT upon discharge from the hospital should be referred for follow-up
FOR SALE OR(Matthews,
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
1993).

Latch Assessment Documentation Tool

This latch assessment tool (Table 3-4) was developed to serve as a quick and easy method for document© Jones
Bartlett
Learning,
LLC© sucking.
JonesEach& Bartlett Learnin
ing a mother’sability to&attach
her baby
properly to thebreast and to observe the infant’s
component
was defineda plus OR
or minusused to indicate whether the behavior was present
absent,NOT orFOR
SALE OR DISTRNOT
FOR andSALE
DISTRIBUTION
respectively. If any component of the latch assessment is charted as insufficient, the nurse writes a progress note to detail the deviation or variance as well as to chart what corrective action was taken. Use ofthis form served to visually remind nurses to follow up with mothers who needed assistance to latch theirinfants successfully (Jenks, 1991). Swallowing was not evaluated as a separate component but was men© Jones& Bartlett
Learning,
LLC© Jones& Bartlett
Learning, LLC
tionedas part of theadequate suction
measurement (e.g., “suck/swallow
ratio is 1–2/second”).
No numericalscore
isassignedtothefeedingeffort;however,
this
tool
is
designedtoidentify
breastfeedingproblems
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
so that a plan of care can be initiated as early as possible.
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Tools  167

TABLE 3-4
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
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Latch Assessment
Documentation
NOT FORSALE OR Tool
DISTRIBUTION

Parameter© Jones& Bartlett
Learning,
LLC
Baby’sgum line placed
over mother’s
lactiferous sinuses
NOT FOROR DISTRIBUTION
Both SALE
lips are flanged

Code+ (Normal and Sufficient)- (Insufficient)© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Complete jawbone movement
Tongue is positioned under the areola
Adequate suction

Source: Adapted LLC
from Jenks, M. (1991). Latch assessment
the hospital.Learning,
Journal of Human
Lactation,nes & Bartlett Learning,© documentation
Jones & in
Bartlett
LLC
7, 19–20.
FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

Breastfeeding Assessment Tool

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

Inaccurate, inadequate, or subjective/qualitative descriptions of breastfeeding in the hospital perpetuate
SALE OR DISTR
NOTinFORSALE
ORtheDISTRIBUTION
inconsistencies
care andsometimes
communication of useless information. In an NOTeffort toFOR
improvebreastfeeding assessment, the Breastfeeding Assessment Tool was developed to improve documentation of objective observations of breastfeeding status (Bono, 1992). Although nurses resisted filling out
another form, practices supportive of breastfeeding increased with the improved awareness of the necessity of such documentation. Tools such as the Breastfeeding Assessment Tool, which includes audible© Jones& Bartlett
Learning,
LLC help prevent hospital staff©from
Jones& Bartlett
Learning,
LLC
swallowing
as a component
to be assessed,
minimizing
the importanceof
NOT FORSALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
ongoing assessment of the breastfeeding couple.

Systematic Assessment of the Infant at Breast (SAIB)
It is recommended that each component of the SAIB (Table 3-5) be evaluated as part of an initial breast-

feeding assessment
the motherand babyLearning,are dischargedLLC
home. Thenes & Bartlett Learning,
LLCand completed at least once©before
Jones& Bartlett
SAIB
delineatestheessential
componentsofabreastfeeding
episodethatarecentraltoeffectivebreastFOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

feeding and milk transfer. It emphasizes the importance of assessing for and documenting that swallowing has occurred. Without an assessment of swallowing, it cannot be assumed that the infant has received
any milk. A continuing pattern of no audible swallowing signals the need for careful investigation into
the cause (Shrago & Bocar, 1990).

© Jones & Bartlett Learning, LLC
NOT FORSALE(MBA)OR DISTRIBUTION
Mother–Baby
Assessment
Tool© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

The MBA tool (Table 3-6) focuses on the mother’s and baby’s efforts in learning to breastfeed and tracks
the progress of both partners (Mulford, 1992). The total number of pluses yields a numerical score thatindicates the effectiveness of the breastfeeding session:■■ &ABartlett
score of 3 orlower indicatesthat one partner (mother or baby)
tried to initiate
breastfeedingbut© Jones
Learning,
LLC© Jones& Bartlett
Learning,
LLC
the
other
was
not
ready.
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION■■

A score of 4 or 5 indicates that the infant was put to the breast but did not latch.
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168  Chapter 3: Influence of the Infant’s Anatomy and Physiology
TABLE 3-5
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
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Systematic
Assessmentof the Infant
at BreastNOTFOR SALE
OR DISTRIBUTION
Alignment

Infant is in flexed position, relaxed with no muscular rigidity.
Infant’s head and body are at breast level.
© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC■■ Infant’s head is aligned with trunk and is not turned laterally, hyperextended, or hyperflexed.
■■ Correctalignmentof infant’s body is confirmed by an imaginaryNOT
line from
ear toSALE
shoulderOR
to DISTRIBUTIONNOT FORSALE
OR DISTRIBUTION
FOR
iliac crest.
■■ Mother’s breast is supported with cupped hand during first 2 weeks of breastfeeding.
■■■■

Areolar Grasp■■ Mouth is open
widely; lips are not pursed.
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC■■ Lips are visible and flanged outward.
FOR SALE OR■DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION■ Complete seal and strong vacuum are formed by infant’s mouth.
■■
■■
■■
■■
■■

Approximately ½ inch of areolar tissue behind the nipple is centered in the infant’s mouth.
Tongue covers lower alveolar ridge.
Tongue is troughed (curved) around and below areola.
No clicking or smacking sounds are heard during sucking.
© Jones& Bartlett
Learning,
LLC sucking.
© Jones & Bartlett Learnin
No drawingin (dimpling)of cheek pad
is observed during

NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
Areolar Compression■■■■

Mandible moves in a rhythmic motion.
If indicated, a digital suck assessment reveals a wavelike motion of the tongue from the anterior mouth
toward the oropharynx (a digital suck assessment is not routinely performed).

© Jones& Bartlett
Learning, LLC
AudibleSwallowing
NOT FORSALE
OR
DISTRIBUTION■■ Quiet sound of swallowing is heard.
■■■■© Jones & Bartlett Learning, LLC
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Sound may be preceded by several sucking motions.
Sound may increase in frequency and consistency after milk ejection reflex occurs.

Source: Adapted from Shrago, L., & Bocar, D. The infant’s contribution to breastfeeding. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, 19, 209–215.
nes & Bartlett Learning,
LLC
FOR SALE OR DISTRIBUTION

■■
■■
■■

© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

A score of 6 indicates possible milk transfer.
A score of 7 or 8 gives clearer evidence of milk transfer.
A scoreof 9 or 10 scoredconsistently
over a numberof feedings indicates the need for
only minimal© Jones& Bartlett
Learning,
LLC© Jones& Bartlett Learnin
follow-up.

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The higher the MBA score, the more effective the breastfeeding episode. A low score indicates the needfor assistance from a skilled lactation specialist or consultant.

Via&Christi
BreastfeedingTool© Jones
Bartlett
Learning,Assessment
LLC© Jones & Bartlett Learning, LLC
The
Via
ChristiBreastfeeding
Assessment
Tool(Riordan&Riordan,2000) FOR
(Table 3-7)
assignsa scoreof
NOT FOR SALE OR DISTRIBUTION
NOT
SALE
OR
DISTRIBUTION
0, 1, or 2 to five factors. Scores range from 0 to 10.

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Tools  169
TABLE 3-6
© Jones & Bartlett Learning, LLC

Mother–Baby
ToolOR DISTRIBUTIONNOT Assessment
FOR SALE© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Steps/Points

What to Look For/Criteria#1 Signaling:
1

Mother watches and listens for baby’s cues. She may hold, stroke, rock, talk to© Jones & Bartlett Learning,© Jones&fussy.
Bartlett Learning, LLC
baby. She LLC
stimulates baby if he is sleepy, calms
baby if he is
1
Baby
gives
readinesscues:
stirring,
alertness,rooting,sucking,
hand-to-mouth,
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE
OR DISTRIBUTION#2 Positioning:
1

vocal cues, cry.

Mother holds baby in good alignment within latch-on range of the nipple. Baby’s
body is slightly flexed, entire ventral surface facing mother’s body. Baby’s headnes & Bartlett Learning, LLC and shoulders are supported.
© Jones & Bartlett Learning, LLC
1
Baby roots well at breast, opens mouth wide, tongue cupped and covering lower gum.

FOR SALE OR DISTRIBUTION#3 Mixing:
1

NOT FOR SALE OR DISTRIBUTION

Mother holds her breast to assist baby as needed, brings baby in close when his
mouth is wide open. She may express drops of milk.
1
Baby latches on, takes all of nipple and about 2 cm (1 inch) of areola into mouth,
suckles, demonstrating
recurrent burst-pause sucking pattern.
© Jones &then
Bartlett
Learning, aLLC
© Jones & Bartlett Learnin#4 Milk transfer:
FOR
SALE OR DISTR
NOT
FOR
SALE
OR
DISTRIBUTION
1Mother reports feeling any of the following: thirst, uterine cramps,NOT
increasedlochia,breast ache or tingling, relaxation, sleepiness. Milk leaks from opposite breast.
1
Baby swallows audibly; milk is observed in baby’s mouth; baby may spit up milk
when burping. Rapid “call-up sucking” rate (two sucks/second) changes to“nutritive sucking” rate of about 1 suck/second.
© Jones & #5
Bartlett© Jones & Bartlett Learning, LLC
Ending: Learning, LLC
1 OR DISTRIBUTION
Mother’s breasts are comfortable; she lets babyNOT
suckle until
he isSALE
finished.OR
AfterDISTRIBUTIONNOT FOR SALE
FOR
nursing, her breasts feel softer; she has no lumps, engorgement, or nipple soreness.
1
Baby releases breast spontaneously, appears satiated. Baby does not root whenstimulated. Baby’s face, arms, and hands are relaxed; baby may fall asleep.
The MBA is an assessment method for rating the progress of a mother and baby who are learning to breastfeed. For

every step, both LLC
mother and baby should receive a +©
beforeeither one
can be scoredLearning,on the followingLLC
step. If thenes & Bartlett Learning,
Jones& Bartlett
observer does not observe any of the designated indicators, score 0 for that person on that step. If help is needed at
FOR SALE ORany
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
step for either the mother or the baby, check “Help” for that step. This notation will not change the total score formothers and babies.

Source: Adapted from Mulford, C. (1992). The mother-baby assessment (MBA): An “Apgar score” for breastfeeding.
Journal of Human Lactation, 8, 79–82.

© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Immediate high risk: All mothers who have had breast surgery; all infants who have lost more than
10% of their birth weight■■
0 to 2 = High risk: Close, immediate postdischarge follow-up needed; phone call and visit to healthprovider Learning,
within 24 hoursLLC© Jones &care
Bartlett© Jones & Bartlett Learning, LLC
■■
3
to
6
=
Mediumrisk:
Postdischarge
phone
call
within
2
days;
visit
to healthcare
3 daysNOT FOR SALE OR DISTRIBUTIONNOTFOR provider
SALEwithin
OR DISTRIBUTION■■
7 to 10 = Low risk: Information given to mother and routine phone call■■

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170  Chapter 3: Influence of the Infant’s Anatomy and Physiology
TABLE 3-7
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Via Christi
Breastfeeding
Assessment
Tool
NOT
FOR SALE
OR DISTRIBUTION
Assessment Factors

0 Points

1 Point

Latch-onNo latch-on
Latch-on after
achieved
repeated attempts© Jones& Bartlett
Learning,
LLC 4–6 minutes
Lengthof time before
Over 10 minutes
NOT FORSALE
DISTRIBUTION
latch-onandOR
suckleSuckling
Did not suckle
Suckled but needed
encouragement
Audible swallowing
None
Only if stimulatednes & Bartlett Learning, LLC
evaluation
Not pleased
FOR SALE ORMom’s
DISTRIBUTION
Total Score:

2 Points

Score

Eagerly grasped breast
to latch on© Jones
0–3
minutes & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTION

Suckled rhythmicallyand lips flanged
Under 48 hours,
intermittent; over48 hours,
frequent© Jones & Bartlett
Learning,
LLC
Somewhat pleased
PleasedNOT FOR SALE OR DISTRIBUTION

Source: Adapted from Riordan, J. (1999). Via Christi breastfeeding assessment tool. Unpublished.

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

This tool was developed as an expedient way to assess excessively sleepy infants whose mothers received
NOTassessment
FOR SALE OR DISTR
FOR
SALE
OR
DISTRIBUTION
high doesNOTof labor
analgesia
and areat risk
for breastfeeding problems. This research-based
tool scores early breastfeedings to establish a risk category for assigning appropriate follow-up.

Latch-on Assessment Tool
The&Lactation
Assessment
Tool (Tableemphasizing
comprehensive© Jones
Bartlett
Learning,
LLC3-8) is a guided assessment© form
Jones
& Bartlett
Learning, LLC
assessment from prefeeding behaviors through latch-on and during the actual feeding process. WhenNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
used to study the elements of the feeding process that are thought to be related to nipple pain and damage,positioning errors were found to be related to pain, but no one element was shown to be the sole cause ofsore nipples. Rather, many aspects of the breastfeeding episode, especially the latching process, contributein elevating or reducing the mother’s level of pain (Blair, Cadwell, Turner-Maffei, & Brimdyr, 2003).

nes & Bartlett Learning, LLC
LATCH Scoring System
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Mothers who use the LATCH criteria after discharge have reported increased confidence in the ­assessmentof their infants’ breastfeeding and knowledge about when to seek help for ­breastfeeding ­problems(Hamelin & McLennan, 2000). Audible swallowing is an integral part of this tool, which ­evaluates theamount of help a mother needs to physically breastfeed. A composite score ranging from 0 to 10 is ­possible
in the LATCH
scoring&system(TableLearning,3-9), facilitating
the identification of needed ­interventions© Jones
Bartlett
LLC© Jones and& Bartlett Learnin
improving charting (Jensen, Wallace, & Kelsay, 1994). Breastfeeding behavioral changes can be ­followed
NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
over time, and the tool can also be used by mothers as a means of continuing assessment.

Breastfeeding Assessment Score
The Breastfeeding Assessment Score (Table 3-10) is designed to be administered before hospital discharge

to identify
infants Learning,at risk for breastfeedingof life &(Hall
et al., 2002).
Hall© Jones& Bartlett
LLC cessation in the first 7–10
©days
Jones
Bartlett
Learning,
LLC
et
al.
(2002)
demonstratedthatapproximately
10.5%
of
mothers
from
the
study
sample
of
1,075
women
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
had completely weaned by 7–10 days postpartum. Scoring with the tool ranges from 0 to 2, representing
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Tools  171

TABLE 3-8
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Latch-onNOT
Assessment
Tool/Lactation
Assessment Tool
FOR SALE
OR DISTRIBUTION
The Latching Process
Rooting
Gape© Jones
Bartlett Learning, LLC
■■ &
Suck
■■ SealNOT FOR SALE OR DISTRIBUTION

Height at the Breast

■■

■■

■■

■■

Angle of Infant’s Mouth Opening

160 degrees■■ 100 degrees■■ 90 degrees
nes & Bartlett Learning,
LLC■■ 60 degrees■■

FOR SALE ORInfant’s
DISTRIBUTION
Lip Position
■■
■■
■■

Top and bottom lips flanged
Top lip turned in
Bottom lip turned in
Top and bottom lips turned in■■

Nose opposite nipple
Too high© Jones & Bartlett Learning, LLC
Too low

Body Rotation NOT FOR SALE OR DISTRIBUTION■■■■

Chest to mother’s breast
Head only turned to breast

Body Relationship■■ Horizontal© Jones& Bartlett Learning, LLC■■ Angle
NOTFOR SALE OR DISTRIBUTION

Breastfeeding Dynamic

■■
■■
■■

Bursts 2:1 or 1:1
Occasional 8+:1
Sucks, no swallows© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
Rhythm of Mother’s Breast While
Infant’s Head Position
NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
Breastfeeding

■■

■■
■■
■■
■■

Nose and chin
Chin away
Nose away
Chin and nose away■■■■

Breast moves rhythmically
Breast stays stationary© Jones& Bartlett
Infant’s
Cheek LineLearning, LLC
NOT FORSALE
OR DISTRIBUTION■■ Smooth■■■■© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

BrokenDimpledSource: Adapted from Healthy Children Project 2000. (2000). Latch-on Assessment Tool (LAT). East Sandwich, MA:
Healthy Children Project.

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

low, moderate, or high risk of early weaning. The highest overall score is 10, with 2 points being subtracted for each of the three variables of previous breast surgery, maternal hypertension, and vacuum
extraction at delivery, creating a score range of –6 to +10. Results from the study were as follows:© Jones & Bartlett Learning, LLC

Score
No. of Mothers
Cessation Rate at 7–10 Days Postpartum
NOT FORSALE OR5%
DISTRIBUTION≥8705 of 1,075(37 of 705)<8
370 of 1,075
21% (77 of 370)

© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

The Breastfeeding Assessment Score identifies those mothers most in need of additional follow-up. The
370 women scoring lower than 8 on this screening tool represented about one-third of the study population,out Learning,
the significant LLC
need for continued professional lactation
support(Nommsen-Rivers,© Jones& pointing
Bartlett© Jones& Bartlett
Learning, LLC
2003).
The
mean
age
of
breastfeeding
cessation
was
5.4
days
(±
2.2),
suggestingastrongassociation
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
between events occurring during the first 3–5 days of life and the early abandonment of breastfeeding.
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172  Chapter 3: Influence of the Infant’s Anatomy and Physiology
TABLE 3-9
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

LATCHNOT
Criteria
FOR SALE OR DISTRIBUTION
0

1

2

L
Latch

Too sleepy or reluctant
No latch achieved

Repeated attempts
Grasps breast
Hold nipple in mouth
Tongue down
Bartlett Learning, LLC
Stimulate to suck © Jones
Lips&flangedRhythmic
sucking
NOT FORSALE
OR DISTRIBUTIONA
Audibleswallowing

None

A few with stimulation© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

nes & Bartlett Learning, LLC
FOR SALE ORTDISTRIBUTION
Inverted
Type of nipple

Spontaneous andintermittent < 24 hours
Spontaneous and frequent> 24 hours LLC© Jones & Bartlett Learning,

NOT
FOR SALE OREverted
DISTRIBUTION
Flat(afterstimulation)

C
Engorged
Filling
Soft
ComfortCracked, bleeding, large Reddened/small blisters or Tender© Jones &blisters,
Bartlett
Learning,
LLC(breast/nipple)
or bruises
bruises
Severediscomfort
Mild/moderate discomfort
NOT FORSALE
OR DISTRIBUTION
H
Hold (positioning)

Full assist (staff holds
infant at breast)© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Minimal assist (i.e., elevate No assist from staff
head of bed; place
Mother able to position/
pillows for support)
hold infant
Teach one side; mother© Jones & Bartlett Learning, LLC
does the other
NOT FOR SALE OR DISTRIBUTION
Staff holds and thenmother takes over

Source: Adapted from Jensen, D., Wallace, S., & Kelsay, P. (1994). LATCH: A breastfeeding charting system anddocumentation tool. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23, 27–32.

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Maternal Breastfeeding Evaluation Scale (MBFES)The MBFES (Leff, Jeffries, & Gagne, 1994) consists of 30 items divided into three categories identified asmaternal perceptions of successful breastfeeding: (1) maternal enjoyment/role attainment, (2) infantsatisfaction/growth, and (3) lifestyle/body image. The MBFES is designed to measure the positive and© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
negative aspects of breastfeeding that mothers deem important in defining successful breastfeeding.

NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION

Potential Early Breastfeeding Problem Tool
The Potential Early Breastfeeding Problem Tool (PEBPT) was developed to determine which breastfeeding problems rated highest among breastfeeding mothers (Kearney, Cronenwett, & Barrett, 1990). This
tool&uses
23 questions
with a 4-point
Likert scale questionnaire, giving
possible total
score of 88.Learning,
Higher© Jones
Bartlett
Learning,
LLC© aJones& Bartlett
LLC
scores indicate that more breastfeeding problems have occurred.

NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

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Tools  173

TABLE 3-10
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Breastfeeding
Score
NOT Assessment
FOR SALE
OR DISTRIBUTION
Variable0

Maternal age (y)Previous breastfeeding experience© Jones& Bartlett
Latching
difficulty Learning, LLC
Breastfeeding(hours between feedings)
NOT FOR SALE interval
OR DISTRIBUTION
Number of bottles of formula before enrollment(Babies were enrolled into the study if they
were at least 20 hours old.)< 21
FailureEvery feeding
>6
>2

1

2

21–24
> 24
None
Success©Half
Jones& Bartlett
Learning, LLC
the feedings< 3 feedings
3–6<
3
NOT FOR SALE OR DISTRIBUTION
1
0

Two points each should be subtracted for the presence of previous breast surgery, maternal hypertension during

nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
pregnancy, and/or
vacuum vaginal delivery.
FOR SALE ORSource:
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Adapted from Hall, R. T., Mercer, A. M., Teasley, S. L., McPherson, D. M., Simon, S. D., Santos, S. R., . . . Hipsh,
N. E. (2002). A breastfeeding assessment score to evaluate the risk for cessation of breastfeeding by 7 to 10 days of age.
Journal of Pediatrics, 141, 659–664.

© Jones & Bartlett Learning, LLC

H & H Lactation
Scale
NOT FORSALE OR DISTRIBUTION© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

The H & H Lactation Scale and its three subscales (maternal confidence/commitment to breastfeeding, perceived infant breastfeeding satiety, and maternal/infant breastfeeding satisfaction) are designed to measure
a mother’s perception of insufficient milk supply, a leading cause of premature weaning from the breast(Hill & Humenick, 1996). This tool can be used prospectively with both full-term and preterm mothers.

© Jones & Bartlett Learning, LLC
NOT FORSALE ORSelf-Efficacy
DISTRIBUTION
Breastfeeding
Scale (BSES)© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

The BSES (Dennis & Faux, 1999) is a 33-item self-report tool that assesses breastfeeding self-efficacy
expectations in new mothers. Self-efficacy is the mother’s perception regarding her ability to perform a
specific behavior—in this case, breastfeeding. The scale is designed to identify mothers with low breastfeeding confidence and to provide assessment information to assist the healthcare provider in creatingnes & Bartlett Learning,
LLCto the items identified as problematic© Jones(Dennis,& Bartlett
Learning,
LLC to acare plans specific1999). The
BSES was modified
version (BSES-SF) that keeps 14 itemsNOT
and deletes
items thatOR
wereDISTRIBUTION
shown to be redundant,
FOR SALE OR shortened
DISTRIBUTION
FOR18SALE
making it easier and quicker to administer (Dennis, 2003).

Breastfeeding Attrition Prediction Tool (BAPT)The BAPT (Janke, 1992) uses four subscales to measure the theory of planned behavior: positive breast© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
feeding sentiment (18 items), negative breastfeeding sentiment (9 items), social and professional support
NOT FORSALE OR DISTR
FOR(12SALE
ORoriginal
DISTRIBUTION(10 items),NOT
and control
items). The
tool used 49 items to help predict breastfeeding
status at
8 weeks postpartum.

Neonatal Oral-Motor Assessment ScaleassessesLearning,
28 characteristics
of sucking and is used to diagnose
both disorganizedand dysfunc© JonesThis&scaleBartlett
LLC© Jones& Bartlett
Learning, LLC
tional sucking (Palmer, Crawley, & Blanco, 1993). This differentiation is often subtle, necessitating thatNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

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174  Chapter 3: Influence of the Infant’s Anatomy and Physiology

users of the Neonatal Oral-Motor Assessment Scale be certified in the administration and scoring of the© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
tool. Deviations in sucking include a disorganized suck that is defined as a lack of rhythm of the total
NOT and
FOR
SALE OR DISTR
NOT (Crook,
FOR 1979),
SALE
DISTRIBUTION
sucking activity
withOR
the infant
demonstrating difficulty in coordinating sucking
swallowing with breathing. Clinical signs of disorganized sucking include labored breathing, color changes,
apnea, bradycardia, and nasal flaring (Palmer, 1993), often seen with premature infants. Dysfunctionalsucking is characterized by abnormality in orofacial tone that may present as minimal jaw excursions,excessively wide jaw excursions, tongue retraction, and/or flaccid tongue (Palmer, 2002). Such situations© Jones& Bartlett
Learning,© Jones&theBartlett
Learning,
LLC
usuallyrequire specializedreferralsLLC
and follow-up because dysfunctionalsucking in
neonate has
beencorrelatedwithdevelopmental
delay
at
24
monthsofage(Hawdon,Beauregard,&
Kennedy,
2000;
PalmerNOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION& Heyman, 1999).

Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

The NIDCAP is an infant behavior assessment system (Als, 1995) originally developed for preterm infantsnes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
that assesses behavior in the autonomic system (heart rate, respiration, skin color, startles, twitches,
FOR SALE ORgastrointestinal
DISTRIBUTIONNOTFORactive
SALE
OR DISTRIBUTION
signs), motor system (muscle tone,
posture,movements),
state system (level of

wakefulness, clarity of state, pattern of state transitions), and attention or interaction (availability, responsiveness). The observation is designed to provide data for descriptions of an infant’s strengths and weaknesses, current developmental goals, and recommendations for caregiving, including feeding. NIDCAP
observations have been used to guide modifications to the infant’s environment and to provide recom© Jones
Bartlett
Learning,
LLCfor compromised infants (Nyqvist,© Jonesmendations
to facilitate&optimalbreastfeeding
experiences
Ewald,&&Bartlett Learnin
NOT
FOR
NOT
FOR
SALE
OR
DISTRIBUTION
Sjoden, 1996a). Most users of the NIDCAP tool are certified in its administration and interpretation. SALE OR DISTR

Preterm Infant Breastfeeding Behavior Scale
The Preterm Infant Breastfeeding Behavior Scale was developed to describe the maturational steps anddevelopmental
stagesin preterm infant
operational
definitions ranging© Jones& Bartlett
Learning,
LLCbreastfeeding behavior through© Jones& Bartlett
Learning, LLC
from immature to mature behavior (Nyqvist, Sjoden, & Ewald, 1999). It is also used to reduce the delays in
NOT FORSALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
going to breast that commonly occur with preterm infants by quantifying the appearance of parameters
necessary for full breastfeeding (Nyqvist, Sjoden, & Ewald, 1999; Nyqvist, Rubertsson, Ewald, & Sjoden,
1996). Maturational steps in preterm infants’ breastfeeding behavior are scored for rooting, areolar grasp,
latching, sucking, longest sucking burst, and swallowing.

nes & Bartlett Learning,
LLC
Jones & Bartlett Learning, LLC
Mother–Infant
Breastfeeding Progress ©
Tool
FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

This tool was developed in recognition that both the mother and the infant contribute to the development and success of breastfeeding (Johnson, Mulder, & Strube, 2007). The Mother–Infant Breastfeeding
Progress Tool is designed to evaluate the presence of maternal and infant behaviors that are necessary forthe mother to independently latch her infant to the breast. The tool is used during breastfeeding and consists of eight items (Table 3-11). Rather than using a single score to identify or predict problems and guide© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnininterventions, the checklist is not scored but is used over time to assess whether progress toward effecNOT FOR
SALE OR DISTRNOT FORSALE
OR
DISTRIBUTION
tive breastfeeding
is being
made. Itis unclear
whether swallowing is included under nutritive
sucking.
If swallowing does not happen, then no milk transfer occurs and the infant is left undernourished eventhough he or she may be latched to the breast and the mother can independently breastfeed her infant.

Beginning
Breastfeeding
Survey© Jones& Bartlett
Learning,
LLC (BBS)© Jones & Bartlett Learning, LLC
The
BBS
is
designedtomeasurethemother’s
perceptionofherabilitybreastfeed
effectively
NOT FOR SALE OR DISTRIBUTION
NOTto FORSALE
OR during
DISTRIBUTION
the first few days postpartum (Mulder & Johnson, 2010). It is designed as a measure of breastfeeding
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Tools  175

TABLE 3-11
© Jones & Bartlett Learning, LLC

NOT FORSALE OR
DISTRIBUTION
Mother–Infant
Breastfeeding
ProgressTool© Jones & Bartlett Learnin
NOT FOR SALE OR DISTR

Mother responds to infant feeding cues
Mother goes no longer than 3 h between feedingattempts

Infant eagerly roots and latches
Infant grasps areolar tissue with mouth open wide,
lips visible and flanged outward
Nutritive sucking bursts noted© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
Mother independently positions self for feeding
Does not require assistance, including position pillows
NOT FORSALE
OR DISTRIBUTIONNOTFOR SALEOR
DISTRIBUTION
Mothercan independently
latch infant onto breast Does not require
any assistanceto position
herself
or infant for latch
No nipple trauma is present
Includes redness, blistering, bruising, bleeding, or
scabbing
No negative comments about breastfeeding
No comments that reflect insecurity about ability
to breastfeed
or satisfy Learning,
her infantnes & Bartlett Learning, LLC© Jones& Bartlett
LLC

FOR SALE ORSource:
DISTRIBUTION
NOTK.FOR
ORbreastfeeding
DISTRIBUTION
Adapted from Johnson, T. S., Mulder, P. J., & Strube,(2007). SALE
Mother-infant
progress tool: A

guide for education and support of the breastfeeding dyad. Journal of Obstetric, Gynecologic, and Neonatal Nursing
36, 319–327.

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

effectiveness for a single breastfeeding episode that has already occurred. Each item in the BBS is indicaFOR
SALE OR DISTR
FOR
SALE
tive of anNOT
infant ormaternal
need OR
that isDISTRIBUTION
met or unmet. There are 26 items in the tool, NOT
16 maternal
needitems and 10 infant need items. This tool potentially provides a quick and easy screening method that canbe completed during the hospitalization to determine which mothers would benefit from further breastfeeding support in the hospital and following discharge.

© Jones& Bartlett
Learning, LLC
Validity
and Reliability
NOT FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

The validity and reliability of breastfeeding assessment tools vary depending on a number of issues,
including the outcome criteria under study. Some tools were constructed for charting and descriptive
purposes, not necessarily for their predictive value. Efforts have been made to scrutinize a number ofbreastfeeding assessment tools to discover their usefulness in the clinical setting as well as in areas of policy and research. Howe, Lin, Fu, Su, and Hsieh (2008) reviewed seven clinical feeding assessment tools,nes & Bartlett Learning,
LLCto breastfed infants (IBFAT,©LATCH,
Jones& Bartlett
Learning,
LLC
five of which related
MBS,
Preterm Infant
Breastfeeding
Behavior
FOR SALE ORScale,
DISTRIBUTIONNOT FORSALE
OR
DISTRIBUTION
and SAIB). They reported that none was satisfactoryin terms
of being
empiricallyvalidated. Mixed
results of reliability and validity were noted for the LATCH and IBFAT, and limited evidence of psychometric properties was seen for the MBA and SAIB.

LATCH, IBFAT,
and MBA© Jones& Bartlett Learning, LLC© Jones & Bartlett Learnin
Riordan and
Koehn(1997)
assessedthree
tools, LATCH, IBFAT, and MBA, to ascertainNOT
whetherany orFOR
SALE OR DISTR
NOT
FOR
SALE
OR
DISTRIBUTION

all were accurate predictors of adequate infant intake, especially after discharge. Each tool uses different
components to assess effective breastfeeding. Interrater agreement among the tools was low on some of
the components. Agreement reached 0.90 (a number on which clinical decisions can be made) on two
items in the LATCH tool (audible swallowing and type of nipple), two items in the MBA (readiness to© Jones&andBartlett
Learning,
LLC© Jones
Learning,
LLC
feed
positioning),
and no itemsin the IBFAT. The study concluded
that none&of Bartlett
these tools was
reliable
or
valid
in
the
clinicalsetting.
No
tools
used
any
type
of
swallowcountorweightmeasurements
to
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
determine actual intake at a feeding; nor did the study use these techniques to test validity of the tools.
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176  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Raters were maternity nurses who viewed videotapes of feedings and were not present in the clinical set© Jones & Bartlett Learning, LLC© Jones & Bartlett Learninting where the feedings occurred.
NOT
SALE OR DISTRNOT FOR
SALE
Comparisons
amongexistingOR
toolsDISTRIBUTION
as a way to test validity may be difficult because
theyFORmeasurefeedings at the breast in different ways. Thus the results may not be highly correlated to one another(Riordan, 1998).
Hamelim and McLennan (2000) assessed the relationship between the use of the LATCH tool andbreastfeeding outcomes, determining that even after the tool went into use in the hospital setting, breast© Jones& Bartlett
Learning,© Jones& Bartlett
LLC
feeding
outcomes did
not improve.LLC
The authors concluded that the LATCH
tool lacked
predictiveLearning,ability.
This
result
could
have
been
relatedtohospitalpracticesthat
delayedthefirstbreastfeed
foranaverage
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
of 2 hours and to the fact that 30% of all infants in the study were supplemented with formula during
their hospital stay. Individual LATCH scores of breastfeeding sessions in the hospital setting were notcollected.
Adams and Hewell (1997) compared maternally derived LATCH scores and professional LATCH
nes & Bartlett Learning,
LLC relationships existed between© Jones& Bartlett
Learning,
scores to see whether
these measuresand maternalreports of LLC
satisfactionbreastfeeding. Their results showed moderatecorrelations
overall but
discrepancies in
FOR SALE ORwith
DISTRIBUTIONNOTFOR SALE
ORsignificant
DISTRIBUTION
specific areas. The weakest correlations between mother and professional assessments were in the areasof audible swallowing and positioning, where the maternal assessments were less accurate. These areas
involve assessing the infant’s contribution to breastfeeding rather than the mother’s contribution. As
the maternal scores increased on the LATCH, mothers ranked themselves as being more satisfied withbreastfeeding.
The interrater
agreement
between the researcher
forBartlett Learnin© Jones& Bartlett
Learning,
LLC and the clinic lactation©consultants
Jones &
total LATCH scores was 94.4%. The interrater agreement was greater than 85% (range, 85.7–100%) for
NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
each of the five LATCH components, supporting the reliability of the LATCH as an effective tool for professional assessment of breastfeeding and for the communication of those findings. This conclusion contradicts the findings of Riordan and Koehn, possibly because the Riordan study used maternity nurses
who evaluated videotaped breastfeeding sessions, whereas this study used lactation consultants who were
physically present to evaluate each feeding.
© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
Kumar, Mooney, Wieser, and Havstad (2006) determined whether LATCH scores assessed by proNOT FOR
SALE
ORDISTRIBUTION
NOTfessional staff during in-hospital stays were predictive of breastfeeding
at 6FOR
weeks. SALE
A score ofOR
9 or DISTRIBUTION
above
at 16 to 24 hours was the most discriminate of the five time periods examined. Women who met thiscriterion were 1.7 times more likely to be breastfeeding at 6 weeks compared with women with lower
scores. LATCH scores lower than 9 at 16 to 24 hours after birth should be an indicator that more intensive
breastfeeding support is needed.
nes & Bartlett Learning,© Jones
Learning,
Tornese etLLC
al. (2012) analyzed the relationshipbetween &theBartlett
LATCH scoreassessed in LLC
the first 24
after delivery and non-exclusive breastfeeding
discharge.
Their goal
to identify a cutoff for
FOR SALE ORhours
DISTRIBUTION
NOTat FOR
SALE
ORwas
DISTRIBUTION
the LATCH score for the purpose of identifying women with higher risk of non-exclusive breastfeeding
who may need additional lactation support. The rate of non-exclusive breastfeeding was inversely related
to the LATCH score, with non-exclusively breastfeeding infants scoring less (6.9) than infants exclusively
breastfed at discharge (7.6). The authors were unable to identify a single LATCH cutoff score that could
consistently
non-exclusive
breastfeedingat discharge.
their cutoff© predict
Jones& Bartlett
Learning,
LLC However, three subgroups©and
Jones& Bartlett Learninscores forNOT
exclusive
breastfeedingatdischarge
wereidentified.
Cesareandeliverywasconsideredamajor
NOT FOR SALE OR DISTR
FOR SALE OR DISTRIBUTION
risk factor for non-exclusive breastfeeding, and phototherapy and primiparity were considered minor
factors. In the high-risk group (either presenting with the major risk factor or both minor risk factors),
extra support should be provided regardless of the LATCH score. In the presence of both minor risk factors, extra breastfeeding support should be provided to all mothers with a LATCH score of 9 or below.
In &theBartlett
moderate-risk
group (presenceof one minor risk factor), the©LATCH
score
predictive fornon© Jones
Learning,
LLC
Jones&isBartlett
Learning,
LLC
exclusive breastfeeding and the need for extra support when it is equal to or below 6 when the risk factor
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
is phototherapy and 4 when the risk factor is primiparity.

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Tools  177

LATCH/IBFAT
and MBFES/PEBPT© Jones& Bartlett Learning, LLC© Jones & Bartlett Learnin

The LATCH
andFORIBFAT SALE
tools and OR
the MBFES
and PEBPT tools were assessed to see whether
relationNOTaFORSALE OR DISTR
NOT
DISTRIBUTION
ship existed between scores on the LATCH/IBFAT breastfeeding assessment and maternal satisfaction(MBFES) and breastfeeding problems (PEBPT) experienced at 1 week postpartum (Schlomer, Kemmerer,& Twiss, 1999). A moderate association was seen: As the scores on both the LATCH and IBFAT increased,maternal satisfaction scores increased and breastfeeding problem scores tended to decrease.
LATCH tool
was assessedLLC
for its validity in predicting breastfeeding
status
at 6 weeks postpar© Jones &The
Bartlett
Learning,© Jones& Bartlett
Learning, LLC
tum.
Mothers
whoscoredlower
onthe
comfortdomain(engorged,
cracked,or
bleeding
nipples)
were
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
less likely to be breastfeeding at 6 weeks, despite their intention to feed at least that long (Riordan, Bibb,
Miller, & Rawlins, 2001). The LATCH tool proved useful in identifying the need for follow-up with breastfeeding mothers at risk for early weaning because of sore nipples. The authors recommend that mothers
who score 2 or lower on the comfort measure be closely followed after discharge.
Riordan, Woodley,validity&andreliabilityLearning,of the MBFES LLC
as a way tones & Bartlett Learning,
LLC and Heaton (1994) tested
© the
Jones
Bartlett
directly measure maternal satisfaction with breastfeeding. The MBFES scale and subscales were posiFOR SALE ORtively
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
correlated with the length of time the mother intended to breastfeed as well as the length of time
she actually breastfed. Maternal satisfaction with breastfeeding was also positively linked to the length oftime mothers intended to breastfeed. The MBFES was found to be a valid and reliable tool and was usefulfor measuring outcomes of interventions such as breastfeeding classes or breastfeeding rounds.
Low breastfeeding satisfaction as measured by the MBFES appeared to be the most important pre© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
dictor of weaning at survey ages of 6 weeks and 3 months, even after adjusting for other breastfeeding
FOR ofSALE OR DISTR
NOT
FOR
SALE
OR
DISTRIBUTION
experiences (Cooke, Sheehan, & Schmied, 2003). Most breastfeeding problems were NOT
not predictive
weaning. Mothers with low breastfeeding satisfaction scores were 3–15 times more likely to wean during
the 2-week, 6-week, and 3-month survey periods in the Cooke study.

H &&HBartlett
Lactation Scale© Jones
Learning, LLC© Jones & Bartlett Learning, LLC
NOT FORSALE
OR
DISTRIBUTIONSALEORDISTRIBUTION
The H & H Lactation Scale and its three subscales were found to haveNOT
a high FOR
degree ofreliability
as wellasconcurrent and predictive validity when used prospectively with breastfeeding mothers of both full-termand preterm infants (Hill & Humenick, 1996). The tool’s predictive ability suggested that a mother’s perception of insufficient milk supply was most closely tied to her perception of infant satiety.

nes & Bartlett Learning, LLC
BSESFOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

Predictive validity for the BSES was demonstrated with positive correlations between BSES scores andinfant feeding patterns at 6 weeks postpartum. The BSES was found to be valid and reliable in predicting
which women would still be breastfeeding at 6 weeks (Dennis & Faux, 1999). In other words, the higher
the BSES score, the more likely the mother would be exclusively breastfeeding at 6 weeks postpartum.
& toBartlett
Learning,© Jones& Bartlett Learnin
The BSES©
wasJones
also shown
be significantly
related to LLC
breastfeeding duration and intensity(exclusivity).
LowNOT
antenatal
breastfeeding
self-efficacy
scoreswere
positively
relatedtobottle-feeding
at
1
week
NOT FOR SALE OR DISTR
FOR SALE OR DISTRIBUTION
postpartum. High self-efficacy scores at 1 week postpartum were related to mothers being more likely tocontinue to breastfeed until 4 months postpartum and to do so exclusively (Blyth et al., 2002). The BSES
has been translated into Spanish and replicated in a sample of 100 Puerto Rican women. It was foundto be a valid and reliable measure of breastfeeding confidence among Puerto Rican mothers (Torres,
Torres,Rodriguez,Learning,& Dennis, 2003).
This tool has also been translated
Mandarin
Chinese andLearning,shown© Jones& Bartlett
LLC
©into
Jones
& Bartlett
LLC
to be a reliable and valid instrument when administered to 186 Chinese mothers (Dai & Dennis, 2003).
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
The short form, BSES-SF, proved both valid and reliable in identifying mothers who needed additional

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178  Chapter 3: Influence of the Infant’s Anatomy and Physiology

interventions as well as pointing out that mothers who delivered via cesarean had lower self-efficacy in© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
breastfeeding than those who delivered vaginally (Dennis, 2003).

NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTR

BAPTJanke (1994) established construct validity of the BAPT by factor analysis. The original BAPT was able topredict breastfeeding status at 8 weeks in 73% of the mother studies (Janke, 1994). Shortening the instru© Jones& increased
Bartlett© Jones& attrition.
Bartlett
LLC
ment
its Learning,
reliability scoresLLC
while maintaining adequate predictionof early
TheLearning,
modiNOT FOR
SALE
DISTRIBUTIONNOT FORbefore
SALE
OR
fied BAPTwas ORan effective
predictor of 78% of women who stopped breastfeeding
8 weeks
andDISTRIBUTION
68%
of those who were still breastfeeding at that time (Dick et al., 2002). These results were consistent with
Wambach’s results that showed a mother’s attitude and sense of control were the strongest predictors ofbreastfeeding behavior (Wambach, 1997). Evans, Dick, Lewallen, and Jeffrey (2004) determined that the
BAPT was not an effective predictor of early breastfeeding attrition at either the prenatal or postpartum
nes & Bartlett Learning,© Jones & Bartlett Learning, LLC
administrationLLC
of the tool.

FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTIONBBSThe BBS demonstrated more than adequate internal consistency reliability for a new scale. The BBS was
positively correlated with breastfeeding self-efficacy. The group of mothers who were exclusively breast© Jones& Bartlett
LLC© Jones & Bartlett Learnin
feeding scoredhigher thaneither of theLearning,groups of partial
breastfeeding or full formula-feeding.

NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTR

Review of Assessment Tools

Ho and McGrath (2010) conducted a review of seven tools used to assess women’s attitudes, experiences,satisfaction, and confidence toward breastfeeding; the Gender-Role Attitudes toward Breastfeeding Scale(GRABS)developedby Kelley, Kviz,
Richman, Kim, and Short (1993)
to measure
new mother’s
atti© Jones& Bartlett
Learning,
LLC
©used
Jones
& Bartlett
Learning,
LLC
tudes
and
behaviors
towardbreastfeeding;the
Iowa
InfantFeeding
Attitudes
Scale(IIFAS)developed
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
by De la Mora and Russell (1999) to measure attitudes toward infant feeding and to identify factorsthat influence women’s decisions related to infant feeding methods; the MBFES; the BSES; the H & H
Lactation Scale; the Breastfeeding Personal Efficacy Beliefs Inventory (BPEBI) developed by Clevelandand McCrone (2005); and the BAPT. Overall, Ho and McGrath (2010) found that these tools were valid,reliable, and feasible self-report measures of attitudes, satisfaction, experiences, or confidence associatednes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
with breastfeeding. Clinicians should understand that modifying any of these tools or testing the tools in
FOR SALE ORpopulations
DISTRIBUTION
NOTFOROR properties
DISTRIBUTION
different than the ones in the studies
may alter
theSALE
psychometricof the tool andmay require testing of the modifications and new populations.

Summary: The Design in Nature© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin

The human
infant,althoughbornOR
immature
in many regards, is uniquely adapted to NOT
secure FOR
food and
SALE OR DISTR
NOT
FOR
SALE
DISTRIBUTION
nurturance from the maternal breast right from the start. Alterations in the infant’s anatomy andphysiology may temporarily (or rarely permanently) affect his or her ability to feed at the breast, butbreastmilk can almost always be fed to the infant. Prompt recognition of deviations and appropriate referrals and follow-up often permit breastfeeding or the provision of breastmilk in even the mostextremesituations.
All infants benefit
in the presenceof anatomicor© Jones& Bartlett
Learning,
LLC from human milk, especially© Jones& Bartlett
Learning,
LLC
physiological compromise.

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References  179

References© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
NOT ofFOR
SALE OR DISTR
NOT
FOR
SALE
OR DISTRIBUTION
Adams, D.,& Hewell,S. (1997).
Maternal
and professional assessment of breastfeeding. Journal
Human

Lactation, 13, 279–283.
Aizawa, M., Mizuno, K., & Tamura, M. (2010). Neonatal sucking behavior—Comparison of perioral
movement during breastfeeding and bottle feeding. Pediatrics International, 52, 104–108.
Alcantara, J., & Anderson, R. (2008). Chiropractic care of a pediatric patient with symptoms associatedgastroesophageal
reflux disease,
disorder &syndrome
and irritable© Jones &with
Bartlett
Learning,
LLC fuss-cry-irritability with sleep© Jones
Bartlett
Learning, LLC
infantsyndromeofmusculoskeletal
origin.
JournaloftheCanadian
Chiropractic
Association,
52,
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
248–255.
Als, H. (1995). Manual for the naturalistic observation of newborn behavior. Newborn Individualized
Developmental Care and Assessment Program (NIDCAP). Boston: Harvard Medical School.
Amaizu, N., Shulman, R. J., Schanler, R. J., & Lau, C. (2008). Maturation of oral feeding skills in preterm
infants. Acta Paediatrica, 97, 61–67.
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
American Academy of Pediatrics, Committee on Fetus and Newborn. (2004). Hospital stay for healthy
FOR SALE OR DISTRIBUTION
term newborns. Pediatrics, 113, 1434–1436. NOT FOR SALE OR DISTRIBUTION
Ardran, G. M., Kemp, F. H., & Lind, J. (1958). A cineradiographic study of breast feeding. British Journalof Radiology, 31, 156–162.
Arguin, A. L., & Swartz, M. K. (2004). Gastroesophageal reflux in infants: A primary care perspective.
Pediatric Nursing, 30, 45–71.
Arvedson,C., & Lefton-Greif,
M. A.Learning,(1998). Pediatricvideofluoroscopic swallow studies.
San Antonio,©J.Jones& Bartlett
LLC© Jones& Bartlett Learnin
TX: NOT
Communication
Skill Builders.
NOT FOR SALE OR DISTR
FOR SALE
OR DISTRIBUTION
Ballard, J. L., Auer, C. E., & Khoury, J. C. (2002). Ankyloglossia: Assessment, incidence, and effect offrenuloplasty on the breastfeeding dyad. Pediatrics, 110:e63. Retrieved from http://www.pediatrics.org/cgi/content/full/110/5/e63
Biancuzzo, M. (1998). Yes! Infants with clefts can breastfeed. AWHONN Lifelines, 2, 45–49.
Bibi, H., Khvolis, E., Shoseyov, D., Ohaly, M., Ben Dor, D., London, D., & Ater, D. (2001). The preva© Jones &lence
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest, 119,NOT FOR 409–413.
SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Blair, A., Cadwell, K., Turner-Maffei, C., & Brimdyr, K. (2003). The relationship between positioning, thebreastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.
Breastfeeding Review, 11, 5–10.
Blyth, R., Creedy, D. K., Dennis, C.-L., Moyle, W., Pratt, J., & Vries, S. M. (2002). Effect of maternal confidence onLLC
breastfeeding duration: An applicationof breastfeeding
self-efficacy
theory.LLC
Birth, 29,
nes & Bartlett Learning,© Jones& Bartlett
Learning,
278–284.
FOR SALE ORBoekel,
DISTRIBUTIONFORSALEOR DISTRIBUTION
S. (2000). Gastroesophageal reflux diseaseNOT(GERD)and thebreastfeeding
baby. Independent Study
Module. Raleigh, NC: International Lactation Consultant Association.
Boere-Boonekamp, M., & van der Linden-Kuiper, L. (2001). Positional preference: Prevalence in infants
and follow-up after two years. Pediatrics, 107, 339–343.
Bono, B. J. (1992). Assessment and documentation of the breastfeeding couple by health care profession© Jones& Bartlett
Learning,
LLC© Jones & Bartlett Learninals. Journalof Human
Lactation, 8,
17–22.
Borrelli, O.,
Marabotto,
C.,
Mancini,
V.,
Aloi,
M.,
Macri,
F.,
Falconieri,
P.,
.
.
.
Cucchiara,
S. (2011).
Role of
NOT
FOR
SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
gastroesophageal reflux in children with unexplained chronic cough. Journal of Pediatric Gastroenterology and Nutrition, 53, 287–292.
Bosma, J. F., Hepburn, L. G., Josell, S. D., & Baker, K. (1990). Ultrasound demonstration of tongue motions
during suckle feeding. Developmental Medicine and Child Neurology, 32, 223–229.
Bowen-Jones,
A., Thompson,C., &LLC
Drewett, R. F. (1982). Milk flow andbreastfeeding.
© Jones & Bartlett
Learning,© suckingJonesrate&during
Bartlett
Learning, LLC
Developmental Medicine and Child Neurology, 24, 626–633.

NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

nes & Bartlett Learning, LLC
9781449694654_CH03_131.indd
179
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OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

3/7/13 5:52 PM

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NOT FOR SALE OR DISTRIBUTION

180  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Bromiker, R., Rachamim, A., Hammerman, C., Schimmel, M., Kaplan, M., Medoff-Cooper, B. (2006).
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
Immature sucking patterns in infants of mothers with diabetes. Journal of Pediatrics, 149, 640–643.
NOT
FOR SALE OR DISTR
NOT
FOR
SALE
OR
Byrnes, A.
L., Berk,
N. W.,
Cooper,M. DISTRIBUTION
E., & Marazita, M. L. (2003). Parental evaluationof informinginterviews for cleft lip and/or palate. Pediatrics, 112, 308–313.
Carrascoza, K. C., Possobon, R. de F., Tomita, L. M., de Moraes, A. B. A. (2006). Consequences of bottlefeeding to the oral facial development of initially breastfed children. Journal of Pediatrics, (Rio J), 82,
395–397.
Chetwynd,
A. G., Diggle,
P. J., Drewett,
model&
forBartlett
sucking patternsof© Jones& Bartlett
Learning,
LLCR. F., & Young, B. (1998). A mixture© Jones
Learning,
LLC
breastfed
infants.
Statistics
inMedicine,
17,395–405.
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Cleveland, A. P., & McCrone, S. (2005). Development of the breastfeeding personal efficacy beliefs inventory:
A measure of womens’ confidence about breastfeeding. Journal of Nursing Measurement, 13, 115–127.
Cooke, M., Sheehan, A., & Schmied, V. (2003). A description of the relationship between breastfeeding
experiences, breastfeeding satisfaction, and weaning in the first 3 months after birth. Journal of
Human Lactation, 19, 145–156.
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
Crelin, E. (1976). Development of the upper respiratory system. Ciba Clinical Symposia, 28, 12.
FOR SALE ORCrook,
DISTRIBUTION
NOT
FOR
SALE
ORinDISTRIBUTION
C. K. (1979). The organization and control
of infantsucking.
Advances
Child Development andBehavior, 14, 209–252.
Dai, X., & Dennis, C. L. (2003). Translation and validation of the Breastfeeding Self-Efficacy Scale into
Chinese. Journal of Midwifery and Women’s Health, 48, 350–356.
De La Mora, A., & Russell, D. W. (1999). The Iowa Infant Feeding Attitude Scale: Analysis of reliability
and ©
validity.
JournalApplied Social
Psychology,LLC
29, 2362–2380.
Jones
& of
Bartlett
Learning,© Jones & Bartlett Learnin
Dennis, C.-L.
Theoreticalof breastfeeding confidence: A self-efficacy
NOTframework
FOR SALE OR DISTR
NOT(1999).
FOR
SALE underpinnings
OR DISTRIBUTION[Commentary]. Journal of Human Lactation, 15, 195–201.
Dennis, C.-L. (2003). The Breastfeeding Self-Efficacy Scale: Psychometric assessment of the short form.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, 734–744.
Dennis, C.-L., Faux, S. (1999). Development and psychometric testing of the Breastfeeding Self-Efficacy
Scale. Research in Nursing Health, 22, 399–409.
© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
Dick, M. J., Evans, M. L., Arthurs, J. B., Barnes, J. K., Caldwell, R. S., Hutchins, S. S., & Johnson, L. K.
NOT FOR (2002).
SALEPredicting
OR DISTRIBUTION
NOTFOR18,SALE
early breastfeeding attrition. Journal of Human
Lactation,
21–28. OR DISTRIBUTION
Dowling, D., Danner, S., & Coffey, P. (1997). Breastfeeding the infant with special needs. White Plains, NY:
March of Dimes.
Drewett, R. F., & Woolridge, M. (1981). Milk taken by human babies from the first and second breast.
Physiology and Behavior, 26, 327–329.
Duara, S. (1989).
Oral feeding containers and theirand ventilationin preterm
infants.
nes & Bartlett Learning,
LLC©influence
Joneson&intake
Bartlett
Learning,
LLC
Biology of the Neonate, 56, 270–276.
FOR SALE OREdmondson,
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
R., & Reinhartsen, D. (1998). The young child with cleft lip and palate: Intervention needs inthe first three years. Infants and Young Children, 11, 12–20.
Edmunds, J., Miles, S. C., & Fulbrook, P. (2011). Tongue-tie and breastfeeding: A review of the literature.
Breastfeeding Review, 19, 19–26.
Egnell, E. (1956). The mechanism of different methods of emptying the female breast. Journal of the Swed© Jones& Bartlett© Jones & Bartlett Learnin
ish Medical
Association,
40, 1–8. Learning, LLC
Evans, M.NOT
L., Dick,
M. J.,SALE
Lewallen,OR
L. P.,DISTRIBUTION& Jeffrey, C. (2004). Modified breastfeeding attrition
NOTprediction
FOR SALE OR DISTR
FOR
tool: Prenatal and postpartum tests. Journal of Perinatal Education, 13, 1–8.
Fernando, C. (1998). Tongue tie: From confusion to clarity. Sydney, Australia: Tandem Publications.
Geddes, D. T., Chadwick, L. M., Kent, J. C., Garbin, C. P., & Hartmann, P. E. (2010a). Ultrasound imaging
of infant swallowing during breastfeeding. Dysphagia, 25, 183–191.
Geddes,D. T., Kent,
J. C., McClellan,
H. L., Garbin, C. P., Chadwick,M., & Hartmann,
P. E. Learning,(2010b).
© Jones& Bartlett
Learning,
LLC
© L.
Jones
& Bartlett
LLC
Sucking characteristics of successfully breastfeeding infants with ankyloglossia: A case series. Acta
NOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Paediatrica, 99, 301–303.

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

nes & Bartlett Learning, LLC
9781449694654_CH03_131.indd
180
FOR SALE
OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

3/7/13 5:52 PM

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION
References  181

Geddes, D. T., Kent, J. C., Mitoulas, L. R., & Hartmann, P. E. (2008). Tongue movement and intra-oral© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
vacuum in breastfeeding infants. Early Human Development, 84, 471–477.
FOR
SALE OR DISTRNOTFOR V.
SALE
OR DISTRIBUTION
Geddes, D.
T., Sakalidis,
S., Hepworth,
A. R., McClellan, H. L., Kent, J. C., Lai, C. T., &NOT
Hartmann,
P. E.
(2012). Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding froman experimental teat that released milk under vacuum only. Early Human Development, 88, 443–449.
Gewolb, I. H., Vice, F. L., Schweitzer-Kenney, E. L., Taciak, V. L., & Bosma, J. F. (2001). Developmental patterns of rhythmic suckle and swallow in preterm infants. Developmental Medicine and Child
43,Learning,
22–27.
© Jones &Neurology,
Bartlett
LLC© Jones & Bartlett Learning, LLC
Glass,
R.
P.,
&
Wolf,
L.
S.
(1999).
Feedingmanagementof
infants
withcleft lipand palate
andOR
micrognaNOT FOR SALE OR DISTRIBUTION
NOT
FOR
SALE
DISTRIBUTION
thia. Infants and Young Children, 12, 70–81.
Goldfield, E. C., Richardson, M. J., Lee, K. G., & Margetts, S. (2006). Coordination of sucking, swallowing, and breathing and oxygen saturation during early infant breastfeeding and bottle-feeding.
Pediatric Research, 59, 1–7.
Gomes, C. F., Thomson, Z., & Cardoso, J. R. (2009). Utilization of surface electromyography during thenes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
feeding of term and preterm infants: A literature review. Developmental Medicine and Child NeurolFOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
ogy, 51, 936–942.
Gomes, C. F., Trezza, E. M. C., Murade, E. C. M., & Padovani, C. R. (2006). Surface electromyographyof facial muscles during natural and artificial feeding of infants. Journal of Pediatrics (Rio J), 82,
103–109.
Habel, A., Elhadi, N., Sommerlad, B., & Powell, J. (2006). Delayed detection of cleft palate: An audit ofnewborn
examination.
Archives ofLearning,
Disease in Childhood,© Jones& Bartlett
LLC 91, 238–240.
© Jones & Bartlett Learnin
Hall, R. T.,
Mercer,A. M.,
Teasley,OR
S. L.,DISTRIBUTION
McPherson, D. M., Simon, S. D., Santos, S. R.,NOT. . . Hipsh,
N. E.
FOR
SALE OR DISTR
NOT
FOR
SALE
(2002). A breastfeeding assessment score to evaluate the risk for cessation of breastfeeding by 7 to 10
days of age. Journal of Pediatrics, 141, 659–664.
Hamelin, K., & McLennan, J. (2000). Examination of the use of an in-hospital breastfeeding assessment
tool. Mother and Baby Journal, 5, 29–37.
Hawdon, J. M., Beauregard, N., & Kennedy, G. (2000). Identification of neonates at risk of developing© Jones &feeding
Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
problems in infancy. Developmental Medicine and Child Neurology, 42, 235–239.
NOT FORSALE
OR
DISTRIBUTIONFORSALE
DISTRIBUTION
Hazelbaker, A. K. (1993). The Assessment Tool for Lingual Frenulum NOT
Function(ATLFF):
Use inORa lactation
consultant private practice (Thesis). Pasadena, CA: Pacific Oaks College.
Hill, P., & Humenick, S. (1996). Development of the H & H Lactation Scale. Nursing Research, 45, 136–140.
Ho, Y.-J., & McGrath, J. K. (2010). A review of the psychometric properties of breastfeeding assessment
tools. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 39, 386–400.
Hohoff, A., Rabe,
H., Ehmer, U., & Harms, E. (2005).
Palatal developmentof preterm
and low birthweightnes & Bartlett Learning,
LLC© Jones& Bartlett
Learning,
LLC
infants compared to term infants—What do we know? Part 1: The palate of the term newborn. HeadFOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
and Face Medicine, I, 8.
Howe, T.-H., Lin, K.-C., Fu, C.-P., Su, C.-T., & Hsieh, C.-L. (2008). A review of psychometric properties of
feeding assessment tools used in neonates. Journal of Obstetric, Gynecologic, and Neonatal Nursing,37, 338–349.
Iskander, A., & Sanders, I. (2003). Morphological comparison between neonatal and adult human© Jones
Bartlett
Learning,
LLC 112, 768–776.
© Jones & Bartlett Learnin
tongues.
Annals of&
Otology,
Rhinology,
and Laryngology,
Jacinto-Goncalves,
S. R., SALE
Gaviao, M.
B., Berzin,F., de Oliveira, A. S., & Semeguini, T. A.NOT(2004).FOR
ElectroSALE OR DISTRNOT FOROR
DISTRIBUTION
myographic activity of perioral muscle in breastfed and non-breastfed children. Journal of Clinical
Pediatric Dentistry, 29, 57–62.
Jacobs, L. A., Dickinson, J. E., Hart, P. D., Doherty, D. A., & Faulkner, S. J. (2007). Normal nipple positionin term infants measured on breastfeeding ultrasound. Journal of Human Lactation, 23, 52–59.
Jadcherla,
S. R., Chan,
C. Y., Moore,
R., Malkar, M., Timan, C. J., & Valentine,
C. J.&(2012).
Impact Learning,of feed© Jones& Bartlett
Learning,
LLC© Jones
Bartlett
LLC
ing strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in
NOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
dysphagic neonates. Journal of Parenteral and Enteral Nutrition, 36(4), 449–455.

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9781449694654_CH03_131.indd
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182  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Janke, J. R. (1992). Prediction of breastfeeding attrition: Instrument development. Applied Nursing© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
Research, 5, 48–53.
NOT
FOR43,SALE OR DISTR
FOR
SALE ofOR
Janke, J. NOT
R. (1994).
Development
the DISTRIBUTION
Breastfeeding Attrition Prediction Tool. Nursing
Research,
100–104.
Jean, A. (2001). Brain stem control of swallowing: Neuronal network and cellular mechanisms. Physiology
Review, 81, 929–969.
Jenks, M. (1991). Latch assessment documentation in the hospital nursery. Journal of Human Lactation,
19–20.
© Jones &7,Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
Jensen,D.,
Wallace,S.,&
Kelsay,P.
(1994).
LATCH:
A
breastfeeding
chartingFOR
systemSALE
and documentation
NOT FOR SALE OR DISTRIBUTIONNOTOR DISTRIBUTION
tool. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23, 27–32.
Johnson, T. S., Mulder, P. J., & Strube, K. (2007). Mother-infant breastfeeding progress tool: A guide foreducation and support of the breastfeeding dyad. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 36, 319–327.
Jung, A. D. (2001). Gastroesophageal reflux in infants and children. American Family Physician, 64,
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
1853–1860.
FOR SALE ORKearney,
DISTRIBUTIONNOTFOR SALE
DISTRIBUTION
M., Cronenwett, L., & Barrett, J. (1990).
BreastfeedingproblemsORin thefirst week postpartum.
Nursing Research, 39, 90–95.
Kelley, M. A., Kviz, F., Richman, J. A., Kim, J. H., & Short, C. (1993). Development of a scale to measuregender-role attitudes toward breastfeeding among primiparas. Women and Health, 20, 47–68.
Kelly, B. N., Huckabee, M-L., Jones, R. D., & Frampton, C. M. A. (2007). The early impact of feeding on
breathing-swallowing
coordination.
Respiratory Physiology and Neurobiology,© infant
Jones& Bartlett Learning,
LLC© Jones 156,
& Bartlett Learnin
147–153.
NOT FOR SALE OR DISTRNOT FOR SALE OR DISTRIBUTION
Kent, J. C., Mitoulas, L. R., Cregan, M. D., Geddes, D. T., Larsson, M., Doherty, D. A., & Hartmann, P. E.
(2008). Importance of vacuum for breastmilk expression. Breastfeeding Medicine, 3, 11–19.
Kent, J. C., Ramsay, D. T., Doherty, D., Larsson, M., & Hartmann, P. E. (2003). Response of breasts todifferent stimulation patterns of an electric breast pump. Journal of Human Lactation, 19, 179–186.
Kotlow, L. (2004a). Oral diagnosis of abnormal frenum attachments in neonates and infants: Evaluation© Jones &andBartlett
Learning, LLC© Jones & Bartlett Learning, LLC
treatment of the maxillary and lingual frenum using the Erbium: YAG laser. Journal of Pediatric
NOT FOR Dental
SALECare,
OR10,DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
11–14.
Kotlow, L. (2004b). Oral diagnosis of abnormal frenum attachments in neonates and infants. Journal of
Pediatric Dental Care, 10, 26–28.
Kotlow, L. A. (2004c). Using the Erbium: YAG laser to correct an abnormal lingual frenum attachment in
newborns. Journal of the Academy of Laser Dentistry, 12, 22–23.
Kotlow, L. (2011a).
Diagnosis and treatment of ankyloglossia
maxillaryfraenum in infantsnes & Bartlett Learning,
LLC© Jonesand& tiedBartlett
Learning,
LLCusing
Er:YAG and 1064 diode lasers. European Archives in Paediatric Dentistry, 12, 106–112.
FOR SALE ORKotlow,
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
L. (2011b). Infant reflux and aerophagia associated with the maxillary lip-tie and ankyloglossia(tongue-tie). Clinical Lactation, 2, 25–29.
Kron, R. E., & Litt, M. (1971). Fluid mechanics of nutritive sucking behaviour: The suckling infant’s oral
apparatus analysed as a hydraulic pump. Medical and Biological Engineering, 9, 45–60.
Kumar, M., & Kalke, E. (2012). Tongue-tie, breastfeeding difficulties and the role of frenotomy. Acta
© Jones&ofBartlett
Learning, LLC© Jones & Bartlett Learnin­Paediatrica[Aheadprint].
Kumar, S.NOT
P., Mooney,
Wieser, L.
J., &DISTRIBUTION
Havstad, S. (2006). The LATCH scoring systemand prediction
NOT
FOR SALE OR DISTR
FORR.,SALE
OR
of breastfeeding duration. Journal of Human Lactation, 22, 391–397.
Lau, C., Sheena, H. R., Shulman, R. J., & Schanler, R. J. (1997). Oral feeding in low birth weight infants.
Journal of Pediatrics, 130, 561–569.
Leff, E., Jeffries, S., Gagne, M. (1994). The development of the Maternal Breastfeeding Evaluation Scale.
of Human
Lactation, LLC
10, 105–111.
© Jones &Journal
Bartlett
Learning,© Jones & Bartlett Learning, LLC
Marmet, C., & Shell, E. (1993). Lactation forms: A guide to lactation consultant charting (pp. 4–7). Encino,
NOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
CA: Lactation Institute and Breastfeeding Clinic.

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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9781449694654_CH03_131.indd
182
FOR SALE
OR DISTRIBUTION© Jones & Bartlett Learning, LLC
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nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
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References  183

Marmet, C., Shell, E., & Marmet, R. (1990). Neonatal frenotomy may be necessary to correct breastfeed© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
ing problems. Journal of Human Lactation, 6, 117–121.
NOT
SALE OR DISTRFOR
SALEA.,OR
Masarei, NOT
A. G., Sell,
D., Habel,Mars,DISTRIBUTION
M., Sommerlad, B. C., & Wade, A. (2007). The
natureFORof feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants. Cleft
Palate-Craniofacial Journal, 44, 321–328.
Mathew, O. P. (1988). Respiratory control during nipple feeding in preterm infants. Pediatric Pulmonology, 5, 220–224.
Mathew,
O. P. (1991a).
Science of bottle
feeding. Journal of Pediatrics,©119,
511–519. & Bartlett Learning, LLC© Jones& Bartlett
Learning,
LLC
Jones
Mathew,
O.
P.
(1991b).
Breathingpatterns
ofpreterm
infants
duringbottlefeeding:Role ofOR
milkDISTRIBUTIONflow.
NOT FOR SALE OR DISTRIBUTIONNOT FOR
SALE
Journal of Pediatrics, 119, 960–965.
Mathew, O. P., & Bhatia, J. (1989). Sucking and breathing patterns during breast- and bottle-feeding interm neonates. American Journal of Diseases in Childhood, 143, 588–592.
Matthews, M. K. (1988). Developing an instrument to assess infant breastfeeding behaviour in the earlyneonatal period. Midwifery, 4, 154–165.
nes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
Matthews, M. K. (1991). Mothers’ satisfaction with their neonates’ breastfeeding behaviors. Journal of
FOR SALE OR DISTRIBUTIONNOTFOR SALE OR DISTRIBUTION
Obstetric, Gynecologic, and Neonatal Nursing,20, 49–55.
Matthews, M. K. (1993). Assessments and suggested interventions to assist newborn breastfeeding behavior. Journal of Human Lactation, 9, 243–248.
McClellan, H. L., Geddes, D. T., Kent, J. C., Garbin, C. P., Mitoulas, L. R., & Hartmann, P. E. (2008).
Infants of mothers with persistent nipple pain exert strong sucking vacuums. Acta Paediatrica, 97,
1205–1209.
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
McClellan,
H. L.,FOR
Sakalidis,
V. S., Hepworth,
A. R., Hartmann, P. E., & Geddes, D. T. (2010).
Validation
NOT
FOR ofSALE OR DISTRNOTSALEOR DISTRIBUTION
nipple diameter and tongue movement measurements with B-mode ultrasound during breastfeeding. Ultrasound in Medicine and Biology, 36, 1197–1807.
Medeiros, A. P. M., Ferreira, J. T. L., & de Felicio, C. M. (2009). Correlation between feeding methods,
non-nutritive sucking and orofacial behaviors. Pro-fono Revista de Atualizacao Cientifica, 21,
315–319.
© Jones& Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
Meier, P. P. (1988). Bottle and breastfeeding: Effects on transcutaneous oxygen pressure and temperature
NOT FOR in
SALE
ORDISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
preterm infants. Nursing Research, 37, 36–41.
Meier, P. P. (1996). Suck-breathe patterning during bottle and breastfeeding for preterm infants. In J. J.
David (Ed.), Major controversies in infant nutrition (pp. 9–20). International Congress and Symposium Series 215. London: Royal Society of Medicine Press.
Meier, P. P. (2001). Breastfeeding in the special care nursery: Prematures and infants with medical problems. Pediatricnes & Bartlett Learning,
LLCClinics of North America, 48,©425–442.
Jones & Bartlett Learning, LLC
Meier, P. P. (2003). Supporting lactation in mothers with very low birth weight infants. Pediatric Annals,
FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
32, 317–325.
Meier, P. P., Lysakowski, T. Y., Engstrom, J. L., Kavanaugh, K. L., & Mangurten, H. H. (1990). The accuracy of test-weighing for preterm infants. Journal of Pediatric Gastroenterology and Nutrition, 10,
62–65.
Messner, A. H., Lalakea, L., Aby, J., Macmahon, J., & Bair, E. (2000). Ankyloglossia: Incidence and associJones& Bartlett
Learning,
LLC and Neck Surgery, 126, 36–39.
© Jones & Bartlett Learnin
ated ©
feedingdifficulties.
Archives of
Otolaryngology—HeadMiller, M.NOTJ., Martin,
R. J.,SALE
Carlo, W.
A., Fouke,
J. M., Strohl, K. P., & Fanaroff, A. A. (1985).
Oral breathing
NOT
FOR SALE OR DISTR
FOR
OR
DISTRIBUTION
in newborn infants. Journal of Pediatrics, 107, 465–469.
Mizuno, K, Ueda, A., & Takeuchi, T. (2002). Effects of different fluids on the relationship between swallowing and breathing during nutritive sucking in neonates. Biology of the Neonate, 81, 45–50.
Monaci, G., & Woolridge, M. (2011, September). Ultrasound video analysis for understanding of infantInternational Conference
Belgium.& Bartlett Learning, LLC© Jones &breastfeeding.
Bartlett Learning,
LLC on Signal Processing. IEEE,© JonesMoral, A., Bolibar, I., Seguranyes, G., Ustrell, J. M., Sebastia, G., Martinez-Barba, C., & Rios, J. (2010).
NOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Mechanics of sucking: Comparison between bottle feeding and breastfeeding. BMC Pediatrics, 10, 6.

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

nes & Bartlett Learning, LLC
9781449694654_CH03_131.indd
183
FOR SALE
OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

3/7/13 5:52 PM

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

184  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime develop© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
ment (2nd ed). San Antonio, TX: Therapy Skill Builders.
NOTandFOR
SALE OR DISTR
NOTFOR
DISTRIBUTION
Mukai, S.,
Mukai,
C., &SALE
Asaoka, OR
K. (1991).
Ankyloglossia with deviation of the epiglottis
larynx.
Annals of Otology, Rhinology, and Laryngology, 100, 3–20.
Mulder, P. J., & Johnson, T. S. (2010). The Beginning Breastfeeding Survey: Measuring mothers’ perceptions of breastfeeding effectiveness during postpartum hospitalization. Research in Nursing Health,33, 329–344.
Mulford,C. (1992).Learning,
The Mother-Baby
Assessment (MBA): An “Apgar©score”
for breastfeeding.
of© Jones& Bartlett
LLC
Jones
& BartlettJournal
Learning,
LLC
Human
Lactation,
8,
79–82.
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Nommsen-Rivers, L. (2003). Research Spotlight. Identifying mothers at risk for early abandonment ofbreastfeeding. Journal of Human Lactation, 19, 217–218.
Notestine, G. E. (1990). The importance of the identification of ankyloglossia (short lingual frenulum) as acause of breastfeeding problems. Journal of Human Lactation, 6, 113–115.
Nyqvist, K. H., Ewald, U., & Sjoden, P.-O. (1996). Supporting a preterm infant’s behaviour during breastnes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
feeding: A case report. Journal of Human Lactation, 12, 221–228.
FOR SALE ORNyqvist,
DISTRIBUTION
NOTP.-O.
FOR
SALE
OR DISTRIBUTION
K. H., Rubertsson, C., Ewald, U., & Sjoden,(1996).
Developmentof the Preterm Infant
Breastfeeding Behavior Scale (PIBBS): A study of nurse–mother agreement. Journal of Human­Lactation, 12, 207–219.
Nyqvist, K. H., Sjoden, P.-O., & Ewald, U. (1999). The development of preterm infants’ breastfeeding
behavior. Early Human Development, 55, 247–264.
Page, D. ©
C. Jones(2001). Breastfeeding
andLearning,
early functional
jaw orthopedics (an introduction).
Functional& Bartlett
LLC© Jones& Bartlett Learnin
Orthodontist,
18, 24–27.
NOT FOR SALE OR DISTRNOT FORSALE OR DISTRIBUTION
Palmer, B. (1998). The influence of breastfeeding on the development of the oral cavity: A commentary.
Journal of Human Lactation, 14, 93–98.
Palmer, M. M. (1993). Identification and management of the transitional suck pattern in prematureinfants. Journal of Perinatal and Neonatal Nursing, 7, 66–75.
Palmer, M. M. (2002). Recognizing and resolving infant suck difficulties. Journal of Human Lactation, 18,© Jones &166–167.
Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
NOT FORSALE
OR
DISTRIBUTIONNOTAssessment
FOR SALEOR
DISTRIBUTION
Palmer, M. M., Crawley, K., & Blanco, I. (1993). The Neonatal Oral-Motor
Scale: A
reliability
study. Journal of Perinatology, 13, 28–35.
Palmer, M. M., & Heyman, M. B. (1999). Developmental outcome for neonates with dysfunctional anddisorganized sucking patterns: Preliminary findings. Infant-Toddler Intervention: Transdisciplinary
Journal, 9, 299–308.
Peitsch, W. K.,LLC
Keefer, C. H., LaBrie, R. A., & ©
Mulliken,
J. B.
Incidenceof cranial LLC
asymmetrynes & Bartlett Learning,
Jones&(2002).
Bartlett
Learning,
in healthy newborns. Pediatrics, 110(6). Retrieved from http://www.pediatrics.org/cgi/content/
FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
full/110/6/e72
Peterson, A., & Harmer, M. (2010). Balancing breast and bottle: Reaching your breastfeeding goals. Amarillo, TX: Hale Publishing.
Pressler, J. L., Hepworth, J. T., LaMontagne, L. L., Sevcik, R. H., & Hesselink, L. F. (1999). Behavioral
responses of newborns of insulin-dependent and nondiabetic healthy mothers. Clinical Nursing© Jones& Bartlett Learning, LLC© Jones & Bartlett Learnin
Research,
8, 103–118.
Prieto, C.NOT
R., Cardenas,
Salvatierra,M., Boza, C., Montes, C. G., & Croxatto, H. B.NOT(1996).FOR
Sucking
SALE OR DISTR
FOR H.,SALE
OR A.
DISTRIBUTION
pressure and its relationship to milk transfer during breastfeeding in humans. Journal of Reproductive Fertility, 108, 69–74.
Ramsay, D. T., Kent, J. C., Owens, R. A., & Hartmann, P. E. (2001, September). Ultrasound imaging of milk
ejection in the human lactating breast (Abstract 30). Society for Reproductive Biology, Proceedings
the Thirty-Second
Annual LLC
Conference, Gold Coast, Queensland.
© Jones &ofBartlett
Learning,© Jones & Bartlett Learning, LLC
Ramsay, M., & Gisel, E. G. (1996). Neonatal sucking and maternal feeding practices. Developmental
NOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION­Medicine and Child Neurology, 38, 34–47.

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

nes & Bartlett Learning, LLC
9781449694654_CH03_131.indd
184
FOR SALE
OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

3/7/13 5:52 PM

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION
References  185

Reid, J., Kilpatrick, N., & Reilly, S. (2006). A prospective, longitudinal study of feeding skills in a cohort of© Jones & Bartlett Learning, LLC© Jones & Bartlett Learninbabies with cleft conditions. Cleft Palate-Craniofacial Journal, 43, 702–709.
FOR
SALE OR DISTR
NOTS.,FOR
SALE N.
OR
DISTRIBUTION
Reid, J., Reilly,& Kilpatrick,(2007).
Sucking performance of babies with cleft NOT
conditions.
Cleft­Palate-Craniofacial Journal, 44, 312–320.
Reiter, R., Brosch, S., Ludeke, M., Fischbein, E., Haase, S., Pickhard, A., . . . Maier, C. (2012). Genetic andenvironmental risk factors for submucous cleft palate. European Journal of Oral Science, 120, 97–103.
Riordan, J. (1998). Predicting breastfeeding problems. AWHONN Lifelines, 2, 31–33.
Riordan,J., Bibb, D.,
Miller, M., & Rawlins,
durationusing the LATCH© Jones& Bartlett
Learning,
LLC T. (2001). Predicting breastfeeding© Jones& Bartlett
Learning, LLC
breastfeeding
assessment
tool.
Journalof
Human
Lactation,
17,
20–23.
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Riordan, J. M., & Koehn, M. (1997). Reliability and validity testing of three breastfeeding assessment
tools. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26, 181–187.
Riordan, J., & Riordan, S. (2000). The effect of labor epidurals on breastfeeding. Unit 4/Lactation Consultant Series Two. Schaumburg, IL: La Leche League International.
Riordan, J. M., Woodley, G., & Heaton, K. (1994). Testing validity and reliability of an instrument whichnes & Bartlett Learning,
LLC© Jones & Bartlett Learning, LLC
measures maternal evaluation of breastfeeding. Journal of Human Lactation, 10, 231–235.
FOR SALE ORSakalidis,
DISTRIBUTIONSALEDISTRIBUTION
V. S., McClellan, H. L., Hepworth, A. NOT
R., Kent,FOR
J. C., Lai,
C. T., OR
Hartmann,
P. E., & Geddes, D.
T. (2012b). Oxygen saturation and suck-swallow-breathe coordination of term infants during breastfeeding and feeding from a teat releasing milk only with vacuum. Internatinal Journal of Pediatrics,
2012, Article ID 130769, doi:10.1155/2012/130769.
Sakalidis, V. S., Williams, T. M., Garbin, C. P., Hepworth, A. R., Hartmann, P. E., Paech, M. J., & Geddes,
D. T.©
(2012a).
UltrasoundimagingLearning,of infant sucking
dynamics during the establishmentof lactation.
Jones& Bartlett
LLC© Jones& Bartlett Learnin
Journalof Humanahead of print.]
NOT FOR SALE OR DISTRNOT
FORLactation
SALE [Epub
OR DISTRIBUTION
Sanchez-Molins, M., Carbo, J. G., Gaig, C. L., & Torrent, J. M. U. (2010). Comparative study of the craniofacial growth depending on the type of lactation received. European Journal of Paediatric Dentistry,
11, 87–92.
Schlomer, J. A., Kemmerer, J., & Twiss, J. J. (1999). Evaluating the association of two breastfeeding assessment tools with breastfeeding problems and breastfeeding satisfaction. Journal of Human Lactation,© Jones &15,Bartlett
Learning, LLC© Jones & Bartlett Learning, LLC
35–39.
NOT FORSALE
OR
DISTRIBUTIONNOT FORSALE
ORduring
DISTRIBUTION
Segami, Y., Mizuno, K., Taki, M., & Itabashi, K. (2012). Perioral movements
and sucking
patternbottle feeding with a novel, experimental teat are similar to breastfeeding. Journal of Perinatology[Epub ahead of print]
Shawker, T. H., Sonies, B., Stone, M., & Baum, B. J. (1983). Real-time ultrasound visualization of tongue
movement during swallowing. Journal of Clinical Ultrasound, 11, 485–490.
Shrago, L., & Bocar,
to breastfeeding.
of Obstetric,
Gynecones & Bartlett Learning,
LLCD. (1990). The infant’s contribution© Jones& BartlettJournal
Learning,
LLC
logic, and Neonatal Nursing, 19, 209–215.
FOR SALE ORSmith,
DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
L. J. (2004). Physics, forces, and mechanical effects of birth on breastfeeding. In L. J. Smith & M.
Kroeger (Eds.), Impact of birthing practices on breastfeeding (pp. 119–145). Sudbury, MA: Jones andBartlett.
Smith, W. L., Erenberg, A., & Nowak, A. (1988). Imaging evaluation of the human nipple during breastfeeding. American Journal of Diseases in Childhood, 142, 76–78.
LLC& Bartlett Learnin
Smith, W.©L.,Jones
Erenberg,&
A.,Bartlett
Nowak, A., Learning,& Franken, E. A.
(1985). Physiology of sucking in©
theJones
normal term
infantusing FOR
real-time
US. Radiology,
156, 379–381.
NOT FOR SALE OR DISTRNOTSALEOR DISTRIBUTION
Snyder, J. B. (1995). Variation in infant palatal structure and breastfeeding. A project submitted in partial
fulfillment of the requirements for the degree master of arts in human development specialization inlactation. Encino, CA: Lactation Institute.
Snyder, J. B. (1997). Bubble palate and failure to thrive: A case report. Journal of Human Lactation, 13, 139–143.
Sonies,B. C., Wang,
C., & Sapper, LLC
D. J. (1996). Evaluation of normal©
andJones
abnormal&hyoidbone movement© Jones& Bartlett
Learning,
Bartlett
Learning, LLC
during swallowing by use of ultrasound duplex-Doppler imaging. Ultrasound in Medicine and BiolNOT FOR SALE
OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
ogy, 22, 1169–1175.

1ST PAGES© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

nes & Bartlett Learning, LLC
9781449694654_CH03_131.indd
185
FOR SALE
OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

3/7/13 5:52 PM

nes & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION

186  Chapter 3: Influence of the Infant’s Anatomy and Physiology

Stellwagen, L., Hubbard, E., & Vaux, K. (2004). Look for the “stuck baby” to identify congenital torticollis.
© Jones & Bartlett Learning, LLC© Jones & Bartlett Learnin
Contemporary Pediatrics, 21, 55.
FOR
SALE OR DISTR
FORY.,SALE
ORS. DISTRIBUTION
Tamura, NOT
Y., Horikawa,& Yoshida,(1996). Coordination of tongue movements andNOT
peri-oral
muscleactivities during nutritive sucking. Developmental Medicine and Child Neurology, 38, 503–510.
Tornese, G., Ronfani, L., Pavan, C., Demarini, S., Monasta, L., & Davanzo, R. (2012). Does the LATCH
score assessed in the first 24 hours after delivery predict non-exclusive breastfeeding at hospital discharge? Breastfeeding Medicine, 7, 423–430.
Torres,M. M., Torres,
R. R. D., Rodriguez,(2003).
Translationand validationof© Jones& Bartlett
Learning,
LLC A. M. P., & Dennis, C.-L. ©
Jones& Bartlett
Learning,
LLC
the Breastfeeding Self-Efficacy Scale into Spanish: Data from a Puerto Rican population. Journal of
NOT FOR SALE OR DISTRIBUTIONNOT FOR SALE OR DISTRIBUTION
Human Lactation, 19, 35–42.
Vice, F. L., Heinz, J. M., Giuriati, G., Hood, M., & Bosma, J. F. (1990). Cervical auscultation of suckle feeding in newborn infants. Developmental Medicine and Child Neurology, 32, 760–768.
Walker, M. (1989). Functional assessment of infant breastfeeding patterns. Birth, 16, 140–147.
Wall, V., & Glass, R. (2006). Mandibular asymmetry and breastfeeding problems: Experience fromnes & Bartlett Learning,
LLC of Human Lactation, 22, 328–334.
© Jones & Bartlett Learning, LLC
11 cases. Journal
FOR SALE ORWambach,
DISTRIBUTION
FOR ASALE
OR
DISTRIBUTION
K. A. (1997). Breastfeeding intentionNOT
and outcome:test of thetheoryof planned behavior.
Research in Nursing Health, 20, 51–59.
Weber, F., Woolridge, M. W., & Baum, J. D. (1986). An ultrasonographic study of the organisation of sucking and swallowing by newborn infants. Developmental Medicine and Child Neurology, 28, 19–24.
Wiessinger, D., & Miller, M. (1995). Breastfeeding difficulties as a result of tight lingual and labial frena: A
case©
report.
JournalHuman Lactation,
11, 313–316.
Jones&ofBartlett
Learning,
LLC© Jones & Bartlett Learnin
Wilson-Clay, B., & Hoover, K. (2002). The breastfeeding atlas (2nd ed.). Austin, TX: LactNews Press.
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Wolf, L. S., & Glass, R. P. (1992). Feeding and swallowing disorders in infancy: Assessment and management. Tucson, AZ: Therapy Skill Builders.
Woolridge, M. W. (1986). The “anatomy” of infant sucking. Midwifery, 2, 164–171.
Woolridge, M. (2011). The mechanisms of breastfeeding revised-new insights into how babies feed provided by a fresh ultrasound studies of breastfeeding. Abstract. 5th Europaediatrics Congress.
© Jones& Bartlett
Learning,
LLC of infant feeding revisited:©Fresh
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LLC
Woolridge,
M. (2012,
July). The mechanics
ultrasoundstudies ofLearning,breastNOT FOR feeding
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Do babies extract milk from the breast
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combination of both? International Lactation Consultant Association conference. Orlando, Florida.
Woolridge, M., & Drewett, R. (1986). Sucking rates of human babies on the breast: A study using direct
observation and intraoral pressure measurements. Journal of Reproductive and Infant Psychology, 4,
69–75.
Woolridge, M. W., How, T. V., Drewett, R. F., Rolfe, P., & Baum, J. D. (1982). The continuous measurementnes & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC
of milk intake at a feed in breastfed babies. Early Human Development, 6, 365–373.

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