It is interesting to discuss what is going on with the nipple inside the
baby's mouth, and (like Diane) I really like thinking about relative sizes
and fits of things. And I submit that we should be doing more than just
thinking about it, we need to be collecting normative data on it.
The earlier ultrasound or radiographic work looking at nipples in the mouths
of babies may have methodologic flaws, who knows? Perhaps the views provided
by those studies ARE off given that positioning may not have been optimal or
maybe the wands were placed in some manner that interfered with normal
sucking.. However, Hartmann's ultrasonographer, D. Ramsey, has video that
seems to support the fact that the teat (formed from breast and nipple
tissue) does rest at or close to the palatal junction during apparantly
normal sucking. I think the benefit of work emerging from Hartmann's lab is
their great familiarity with normal breastfeeding. This increases the
likelihood that we are seeing stuff that is actually happening. If
positioning is good, I suspect that the baby may not need to work very hard
to pull the teat to the right spot to stimulate the sucking reflex. Maybe
some of the Australians can comment.
It can be confusing (to me anyway) to think about where things are happening
in the infant's mouth (like where the palatal junction is) because I tend to
visualize thinking about my own mouth, and really, the infant mouth is not
(in normal full term babies) a cavity and it is shaped quite differently
than it will be even at 4 months postpartum. All the structures (tongue,
soft palate, cheek fat pads) are in very close approximation. In infants,
the soft palate is large and rests on the tongue. As the infant skull
matures, the hard palate lengthens, the mandible pulls forward and the
intra-oral space increases to create an actual "cavity".
It is my observation (to add more confounding factors) that there is
great variety in nipple shapes and sizes. I agree with a statement made by
Mavis Gunther, MD in the 50's that it should be possible (to some extent) to
predict the baby's breastfeeding experience by looking at the mother's
breast. If a baby is presented with a flat, non-elastic nipple that doesn't
easily stimulate the baby's mouth, then some babies have difficulty latching
on and feeding and are what Gunther referred to as "apathetic" feeders. If
the nipple is too long, it triggers the gag reflex, which is elicited at a
shallower depth in newborns (mid-tongue area) moving back toward the
(retreating) pharyngeal wall or posterior tongue only as baby matures.
(Ref: Wolf & Glass, Feeding and Swallowing Disorders in Infancy, pg. 108.)
So where the baby positions things may change over time as sucking becomes
volitional, not just reflexive, and as the oral structures change. Some
must have to either pull a bit on the nipple to shape it in the case of the
"short" nipple. In the case of a too-long nipple, the baby may need to grow
a bit to accommodate it, and need help feeding in the meantime.
None the less, whenever the nipple shaft is distorted in the sucking process
to resemble a nuk-shaped nipple, tube of lipstick, or takes on a "pinched"
shape (whatever descriptive terminology paints the clearest picture), that
shape is diagnostic of the lower jaw compressing the wrong spot. Why this
miss-placed compression is occuring may be related to positioning and latch
problems, the length of the nipple, the length of the infant's palate or
jaw,etc.
Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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