Tongue movement and intra-oral vacuum in breastfeeding infants

Methodological procedures for ultrasonographic assessment of the tongue during sucking in full-term infants: A scoping review

BACKGROUND

This scoping review aimed to identify methodological procedures for acquiring and analyzing ultrasound images of the tongue during sucking in full-term infants. The Participants, Concept, and Context strategy was used to define the inclusion criteria: population (full-term infants); concept (ultrasound assessment); and context (assessment of tongue movements during sucking).

METHODS

It included observational, experimental, descriptive, and analytical studies, and excluded those unavailable in full, with premature infants, babies with craniofacial changes and syndromes, studies on animals, in vitro, letters to the editor, errata, and using ultrasound for other purposes. There were no language or time restrictions. Two blinded professionals independently selected 20 articles that met the inclusion criteria from different databases.

RESULTS

The most evaluated parameters were related to the morphometric and kinematic aspects of the tongue, considering the physical behavior of the nipple and bottle nipple; sucking, swallowing, and breathing; distance from the tip of the nipple to the hard-soft palate junction; and milk flow. An endocavity transducer was positioned in the submental region at 5 MHz to 8 MHz.  CONCLUSIONS: The studies present the acquisition and static analysis of ultrasound images of the tongue, hard and soft palate, nipple, and bottle nipple, and of kinematic measurements of the tongue, nipple, bottle nipple, and hyoid bone. They evaluated quantitative and qualitative parameters. Frequency adjustment depended on the child's age (the B mode was the most used), with babies reclined on the mother's lap to feed from the mother's breast and/or bottle.

Promoting Accurate Language on Lactation from Prenatal to Postpartum

ABSTRACT

Lactation is a vital function of reproduction and population dynamics as human milk supports infant survival and development. Although the physiological processes of lactation have largely remained unchanged throughout human history, contemporary practices in human milk provision have expanded the original lexicon, resulting in ambiguity and potential misrepresentations in lactation-related language. We provide an overview of the anatomy and physiology of lactation to emphasize the importance of precise and consistent language as most nurses and health care professionals receive little to no education in their programs of study about lactation and breastfeeding. Concrete definitions and explanations on how to use the science of human milk and the physiology of lactation are crucial for evidence-based lactation education, support, and intervention. LactaPedia, an online comprehensive human lactation glossary, is freely accessible to nurses and the public to remain updated on lactation-related language as well as offer feedback on the relevancy and usability of any fundamental terminology. Precise and consistent use of lactation-related language will overall improve communication between nurses and multidisciplinary teams and thereby enhance care and outcomes for families.

Effectiveness of Watching a Kumagai Method Video for Long-Nipple Bottle-Feeding for Children with Cleft Lip and Palate: A Pilot Experimental Before-After Trial Study

AIM

This study aimed to determine whether the Kumagai method could be followed by watching an instructional video and to compare the feeding actions of specialists and the general population.

MATERIALS AND METHODS

Eleven adults from diverse backgrounds were recruited and asked to feed a baby doll using a bottle feeder with a long nipple, and their actions were recorded. Then, they watched a 2.5-min instructional video of the Kumagai method and were asked to bottle-feed again. Video recordings of the participants were used to evaluate whether their actions followed the Kumagai method. Differences in the feeding actions of the specialists and participants were determined from still images in the videos. The McNemar test was used to analyze the differences between the participants' actions before and after. The Kruskal-Wallis test was also used to determine differences between the actions of participants and specialists.

RESULTS

Feeding movements significantly improved after watching the video. Participants' actions, which differed significantly from those of the specialists, were evident in "the angle of the nipple at the moment the nipple was brought close to the lips" and "the angle change of the nipple from the lip to the mouth".

CONCLUSIONS

Watching our short instructional video was effective in improving the technique of the Kumagai method; however, it is insufficient for feeding a real child with cleft lip and palate. Including the rationale of each action in the video and adding direct instruction as a supplement is required.

A Ducted, Biomimetic Nipple Improves Aspects of Infant Feeding Physiology and Performance in an Animal Model

Breastfeeding is widely regarded as the optimal form of feeding infants, as it provides both nutritional and physiological benefits. For example, breastfed infants generate greater intraoral suction and have higher amplitude muscle activities compared to bottle-fed infants, with downstream implications for motor function, development, and health. One mechanism that might explain these physiological differences is the structure of the nipple an infant is feeding on. Breasts in most mammals are ducted soft-tissue structures that require suction to be generated for milk to be released, whereas bottle nipples are hollow and allow milk to be acquired by compression of the nipple. We used a validated animal model (pigs) to test how being raised on a novel ducted nipple impacted feeding physiology and performance compared to infants raised on a standard (cisternic) nipple. At the end of infancy, we fed both groups with both nipple types and used high-speed videofluoroscopy synchronized with intraoral pressure measurements to evaluate feeding function. Nipple type did not have a profound impact on sucking or swallowing rates. However, when feeding on a ducted nipple, infant pigs raised on a ducted nipple generated more suction, consumed milk at a faster rate, swallowed larger boluses of milk, and had decreased likelihood of penetration and aspiration than those raised on a cisternic nipple. These data replicate those found when comparing breast- and bottle-fed infants, suggesting that a ducted, biomimetic nipple may provide bottle-fed infants with the physiologic benefits of breastfeeding.

Posterior tongue tie: that is a thing?

PURPOSE OF REVIEW

The purpose of this review is to examine the current research of the posterior tongue tie and how it relates to breast feeding, solid feeding, and speech.

RECENT FINDINGS

Recent findings show that the posterior tongue tie may play a role in effective breast feeding.

SUMMARY

Ankyloglossia is the term used for the restriction of the movement of the tongue that impairs certain functions such as breastfeeding or bottle feeding, feeding with solids, and speech. Cadaver studies have shown that there can be a restriction of the tongue and oral tissues in some people relative to others. In some breast-feeding studies, releasing the posterior tie has been shown to improve certain aspects of tongue movement. There is little evidence for or against posterior tongue ties contributing to other problems such as speech and solid feeding. This article goes into depth about the current studies on posterior ankyloglossia.

Infant Suck Strength Exam: Introduction of an Accessible Clinical Technique for Measuring Infant Suck at the Breast

One of the core skills required in lactation support is understanding and correcting ineffective or painful breastfeeding. The behavior being corrected, however, occurs inside the infant's mouth, making it difficult to see and assess. When providing care in the field, we use standardized tools and digital suck exams. In research, instruments have been developed to measure infant suck strength with a pacifier, bottle, or at the breast using ultrasound. The aim of this article is to introduce a simple manual clinical technique to identify areas of weakness in an infant's suck and describe one treatment option that can be used to reduce weakness in the identified area. During the Infant Suck Strength Exam, the lactation support provider places a finger on the breast 2 to 4 cm from the edge of the infant's mouth at the upper and lower lip and then at both corners of the mouth, testing the strength of the suck in each of these four areas. To address any specific areas of weakness, the nursing parent can be taught to apply light skin traction back toward the chest wall at the affected area. This engages the suckling reflex and amplifies the strength of the infant's suck in that particular area. The traction applied should not indent the breast but rather just pull back on the skin. It should be applied with enough strength to challenge the infant without pulling the breast out. This is a teaching tool, and is typically only needed for a few weeks before the infant improves their nursing habits.

Breastfeeding Success With Use of Electric Breast Pump Versus Inverted Syringe Technique in Lactating Women With Inverted Nipple: Open Labelled Randomized Control Trial

Background Inverted nipple is a commonly encountered impediment to proper attachment and latch establishment. Correction of inversion using a disposable syringe represents the conventional method of management. However, it is understudied, cumbersome, and inconvenient. Using electric breast pump represents a more physiological method to achieve correction of inversion. This open-label, randomized control trial investigated syringing versus electric breast pump both in terms of effectiveness in achieving correction of inversion of nipple and patient satisfaction with the use of the assigned intervention. Objectives The primary objective of this study was to compare breastfeeding success by Day 3 postnatal age (achieving correction of inversion of nipple and establishment of direct breastfeeding) in syringing versus electric breast pump in mothers with inverted or flat nipples. The secondary objective was to compare the two methods for the pain experienced by the mother while using syringing versus an electric breast pump. Methodology/Design This was a single-center, open-label randomized control trial performed at a tertiary care neonatal unit in Eastern India, from December 2022 to September 2023. 60 healthy mothers with inverted nipples were randomly allocated to one of two interventions: Group A (n=30, syringing); or Group B (n=30, electric breast pump). Both groups were compared for the establishment of breastfeeding by Day 3 postnatal age and daily maximum pain scores till Day 3 (visual analogue scale). Multivariable logistic regression was used to look for factors independently associated with establishment of breast feeding by Day 3 postnatal period. Chi square test was used to compare the proportions of different outcomes between the groups. Results The primary outcome of establishment of breastfeeding by Day 3 postnatal period was achieved in 18 (60%) mothers in syringe group vs. 17 (56.67%) in the breast pump group, with no statistically significant difference (p=0.793). In the first two days the pain score differences were not statistically significant, but on Day 3, 28 (93.99%) mothers in the electric breast pump group had no/mild pain compared to 22 (73.33%) mothers in the syringe usage group. This difference was statistically significant (p= 0.038). Conclusion In hospital settings where electric breast pump is easily available, the same may be preferred over inverted syringe technique for achieving establishment of breastfeeding by Day 3 postnatal period with minimal nipple pain in mothers. However, further large scale studies will be required to confirm these findings.

Characterization of parameters for the analysis of objective measures of non-nutritive sucking of newborns

PURPOSE

To propose a methodology for analyzing data generated by an instrument measuring non-nutritive sucking pressure in newborns.

METHODS

An analytical observational study was developed, with a cross-sectional design, considering the data collected from 24 full-term newborns without complications. Three collections from each neonate were analyzed, with duration of 2 minutes and a 2-minute interval between them. The defined parameters were extracted using a program developed in Matlab®. The results were obtained by analyzing and comparing 12 variables at a 5% confidence level. Comparison of manual and computerized analyzes was also carried out using the intraclass correlation coefficient.

RESULTS

The multiple comparison between the three collection moments showed that the significant statistical differences occurred between collections one and two and two and three. When analyzing and comparing each variable separately, it was noted that the second collection showed: greater number of sucking groups, greater number of suctions, less time to start the sucking groups, longer time of sucking groups, less number of sporadic suctions, higher mean pressure values and with less standard deviation, more number of pauses with shorter time of pauses. The intraclass correlation coefficient revealed almost perfect agreement for the 12 evaluated parameters.

CONCLUSION

The 12 variables analyzed are relevant, especially in the second collection. The Matlab® program proved to be viable and effective in extracting and analyzing parameters, showing high agreement when compared to manual evaluation.

Application of Statistical Analysis and Machine Learning to Identify Infants' Abnormal Suckling Behavior

OBJECTIVE

Identify infants with abnormal suckling behavior from simple non-nutritive suckling devices.

BACKGROUND

While it is well known breastfeeding is beneficial to the health of both mothers and infants, breastfeeding ceases in 75 percent of mother-child dyads by 6 months. The current standard of care lacks objective measurements to screen infant suckling abnormalities within the first few days of life, a critical time to establish milk supply and successful breastfeeding practices.

MATERIALS AND METHODS

A non-nutritive suckling vacuum measurement system, previously developed by the authors, is used to gather data from 91 healthy full-term infants under thirty days old. Non-nutritive suckling was recorded for a duration of sixty seconds. We establish normative data for the mean suck vacuum, maximum suck vacuum, suckling frequency, burst duration, sucks per burst, and vacuum signal shape. We then apply computational methods (Mahalanobis distance, KNN) to detect anomalies in the data to identify infants with abnormal suckling. We finally provide case studies of healthy newborn infants and infants diagnosed with ankyloglossia.

RESULTS

In a series of case evaluations, we demonstrate the ability to detect abnormal suckling behavior using statistical analysis and machine learning. We evaluate cases of ankyloglossia to determine how oral dysfunction and surgical interventions affect non-nutritive suckling measurements.

CONCLUSIONS

Statistical analysis (Mahalanobis Distance) and machine learning [K nearest neighbor (KNN)] can be viable approaches to rapidly interpret infant suckling measurements. Particularly in practices using the digital suck assessment with a gloved finger, it can provide a more objective, early stage screening method to identify abnormal infant suckling vacuum. This approach for identifying those at risk for breastfeeding complications is crucial to complement complex emerging clinical evaluation technology.

CLINICAL IMPACT

By analyzing non-nutritive suckling using computational methods, we demonstrate the ability to detect abnormal and normal behavior in infant suckling that can inform breastfeeding intervention pathways in clinic.Clinical and Translational Impact Statement: The work serves to shed light on the lack of consensus for determining appropriate intervention pathways for infant oral dysfunction. We demonstrate using statistical analysis and machine learning that normal and abnormal infant suckling can be identified and used in determining if surgical intervention is a necessary solution to resolve infant feeding difficulties.

Analysis of the Influence of Breastfeeding and Bottle-Feeding upon the Origin of Posterior Crossbites

(1) Introduction. An analysis was made of posterior crossbites in deciduous dentition and their relation to the type of feeding received by the child, with the objective of determining the influence of the way in which the child is fed in the early stages of life on the development of posterior crossbites. (2) Material and methods. A total of 1401 preschool children between 3 and 6 years of age from Seville (Spain) were included in the study. An intraoral exploration was carried out to assess the presence of crossbites (uni- or bilateral, and functional or not). The study was completed with a parent or legal guardian questionnaire exploring the type of feeding received by the child in the first stages of life, as well as the presence of bad oral habits and their duration. (3) Results. A total of 276 children (19.7%) presented posterior crossbite in occlusion. Uponn centering the midlines, 197 were maintained, indicating that 79 were due to premature contacts (functional crossbites). There were no significant differences in crossbites among the children who had received breastfeeding, though bottle-feeding was seen to favor crossbite. (4) Conclusions. No statistically significant relationship was found between posterior crossbites and breastfeeding, though an association between posterior crossbites and bottle-feeding was observed, with the number of crossbites increasing with the duration of bottle-feeding.

Differences in the swallowing process of newborns and healthy preterm infants: first results with a non-invasive bioimpedance and electromyography measurement system

PURPOSE

Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently understood. The aim of this study was to test a novel measurement device to measure breathing and pharyngeal processes involved in swallowing externally in everyday life to identify possible differences in neonates (NB) and PI.

METHODS

Forty healthy NB were studied at 4-8 weeks of age (mean: 6.7 weeks) and 20 healthy PI (mean gestational age 30.5 weeks) at postmenstrual age (PMA) 34/35 weeks (mean PMA 35.1 weeks) during a single feeding. Surface electrodes were used to measure bioimpedance and electromyography reflecting swallow-related changes in the pharynx and muscle activation of the tongue and submental muscles. A respiratory belt was combined with recording of the depth of chest movements and the occurrence of pauses in breathing.

RESULTS

Velocity and extent of pharyngeal closure did not differ significantly across the feeding period (velocity: p=0.09, closure: p=0.17), but during the first two suck-swallow bursts PI had greater velocity (p<0.001*) and extent of pharyngeal closure (p=0.004*) than NB. The duration of swallowing phases was significantly longer in PIs (p<0.001*), their muscle activation decreased faster (p<0.001*), and they had more pauses in breathing than NBs.

CONCLUSIONS

The novel measurement device allowed, for the first time in everyday life, the measurement of factors influencing swallowing and breath-swallow coordination in NBs and PIs. PIs showed differences from NBs most likely due to differences in muscle strength and condition.

Advancing the assessment of pacifier effects with a novel computational method

BACKGROUND

Numerous studies have demonstrated a high likelihood of malocclusions resulting from non-nutritive sucking. Consequently, quantifying the impact of pacifiers can potentially aid in preventing the development or exacerbation of malocclusions and guide the design of improved performance pacifiers.

METHODS

This work proposes and assesses a computational methodology that can effectively gather crucial information and provide more precise data regarding the consequences of non-nutritive pacifier sucking. The computational framework utilized is based on solids4Foam [1, 2], a collection of numerical solvers developed within the OpenFOAM® computational library [3]. The computational model focuses on the palate of a six-month-old baby and incorporates various components such as palate tissues, pacifier and tongue, and considers the negative intraoral pressure generated and the tongue displacement. Different models were tested, each offering varying levels of detail in representing the palate structure. These models range from a simplified approach, with one tissue, to a more intricate representation, involving up to five different tissues, offering a more comprehensive palate model compared to existing literature.

RESULTS

The analysis of results involved examining the distribution of stress on the palate surface, as well as the displacement and forces exerted on the dental crowns. By comparing the obtained results, it was possible to evaluate the precision of the approaches previously described in the literature. The findings revealed that the predictions were less accurate when using the simplified model with a single tissue for the palate, which is the most common approach proposed in the literature. In contrast, the results demonstrated that the palate model with the most intricate structure, incorporating five different tissues, yielded distinct outcomes compared to all other combinations.

CONCLUSIONS

The computational methodology proposed, employing the most detailed palate model, has demonstrated its effectiveness and necessity in obtaining accurate data on the impact of non-nutritive sucking habits, which are recognized as a primary contributor to the development of dental malocclusions. In the future, this approach could be extended to conduct similar studies encompassing diverse pacifier designs, sizes, and age groups. This would foster the design of innovative pacifiers that mitigate the adverse effects of non-nutritive sucking on orofacial structures.

Evolution, diversification and function of the maternal-infant dyad in mammalian feeding

The evolution of the mother/infant dyad providing a source of nutrition for infants is essential for the origin and subsequent diversification of mammals. Despite the importance of this dyad, research on maternal and infant function is often treated independently. Our goal is to synthesize the work on maternal and infant function, discuss our own studies of suckling, and compare the origins of lactation and suckling with their ensuing diversification. Our central premise is that while extensive work has demonstrated variation across mammals in the maternal aspect of this system, very little has been done to address how this relates to infant function. We start with a discussion of the fundamental anatomy and physiology of both mother and infant. We next discuss the origin of mammary glands and milk, and infant suckling, which is distinct from their subsequent diversification. We then discuss the diversification of maternal and infant function, highlighting the evolutionary diversity present in maternal function (both anatomically and physiologically), before arguing that the diversity of infant function is unexplored, and needs to be better studied in the future. We end by discussing some of the holes in our understanding, and suggestions for future work that can address these lacunae. This article is part of the theme issue 'Food processing and nutritional assimilation in animals'.

[Latest Findings on the Suck-Swallow-Breathe Mechanism of Direct Breastfeeding From the Breast to an Infant]

A mother's breast milk is the best nourishing food for infants. No only does it provide sufficient nutrition, but it is also well suited to infants' immature digestive function, thus promoting their growth and organ maturation. A 6-month period of breastfeeding can provide infants with the necessary nutrients, energy, and fluids. The best feeding method is direct breastfeeding from the breast to an infant, yet the difficulties involved in breastfeeding should not be overlooked. Approximately 1/3 the mothers who are performing direct breastfeeding from the breast to an infant experience moderate or higher levels of feeding difficulties. Difficulties in direct breastfeeding from the breast to an infant can lead to decreased feeding efficiency, hamper the growth and development of infants, and affect the emotional communication between mothers and infants. At present, many relevant studies have focused on topics such as the mothers' psychology, family and social support, and the immature development of infants. However, little research has been done to investigate suck-swallow-breathe, a physiological mechanism that infants undertake during the process of direct breastfeeding from the breast to an infant. In this paper, we summarized published literature, research parameters, measurement instruments, and physical intervention methods of the suck-swallow-breathe mechanism in infants, aiming to facilitate the early identification of breastfeeding difficulties and the subsequently provision of early intervention measures and to promote the early identification of neurodevelopmental abnormalities and other developmental abnormalities in infants.

Evaluation of the Breastfeeding Dynamics of Neonates with Ankyloglossia via a Novel Ultrasonographic Technique

To effectively address breastfeeding issues for neonates and mothers, one must understand the physiology of breastfeeding and the anatomical components involved in sucking, swallowing, and respiration. This study compared the tongue position and movement of neonates with tongue ties versus healthy controls during sucking. A new objective ultrasonography diagnostic approach was also introduced for the orofacial region. This retrospective study evaluated B-mode and M-mode ultrasonography images from 30 neonates clinically diagnosed with tongue tie, and a control group of 30 neonates. B-mode ultrasound images were used to examine several characteristics to locate the nipple in the oral cavity during breastfeeding. Anatomic M-mode ultrasound images were used to assess tongue movement during sucking. The nipple moved farther from the intersection of the hard and soft palates during the sucking cycle in the ankyloglossia group than in the control group (p < 0.05). Compared to the control group, neonates with ankyloglossia have a lower capacity to lift the anterior tongue toward the palate when sucking (p < 0.05). There was no significant difference in tongue movement metrics between the two groups (p > 0.05). Our findings were consistent with earlier research. The novel measurement method will offer a new perspective on breastfeeding.

Nipple properties affect sensorimotor integration during bottle feeding in an infant pig model

Infant feeding is a critical neurological milestone in development defined by the coordination of muscles, peripheral nerves, and brainstem nuclei. In infants, milk flow rate is often limited to improve feeding performance without treating the underlying deficiencies in the sucking and swallowing processes. Modification of the neuromotor response via sensory information from the nipple during bottle feeding is an unexplored avenue for physiology-based interventions. In this study, we assessed how differences in nipple hole size and nipple stiffness affect sucking muscle activation and subsequent movement. We fabricated four bottle nipples of varying hole size and stiffness to determine how variation in nipple properties affects the sucking behavior of infant pigs. Our results demonstrate that sensory information from the nipple affects sucking motor output. Nipple hole sizes and stiffnesses with a larger milk flow rate resulted in greater muscle activity and kinematic movement. Additionally, our results suggest that sensorimotor interventions are better directed toward modulating tongue function rather than the mandible movements due to a greater response to sensory information. Understanding how sensory information influences infant feeding is instrumental in promoting effective infant feeding.

The Function of the Mammal Extrinsic Tongue Musculature in the Transition from Suckling to Drinking

The transition from suckling to drinking is a developmental pathway that all mammals take. In both behaviors, the tongue is the primary structure involved in acquiring, transporting, and swallowing the liquid. However, the two processes are fundamentally different: during suckling, the tongue must function as a pump to generate suction to move milk, whereas during drinking, the tongue moves backwards and forwards through the mouth to acquire and move water. Despite these fundamental differences, we have little understanding of how tongues role varies between these behaviors. We used an infant pig model to investigate the relationships between anatomy, physiology, and function of the tongue to examine how lingual function is modulated in the transition from infancy to adulthood. We found that while some muscles were proportionally largest at birth, others were proportionally larger at the time of weaning. Furthermore, we found variation in tongue movements between suckling and drinking along both the mediolateral and anteroposterior axes, resulting in differences in tongue deformation between the two behaviors. The extrinsic tongue muscles also changed in function differently between drinking and suckling. Genioglossus increased its activity and turned on and off earlier in the cycle during drinking, whereas hyoglossus fired at lower amplitudes during drinking, and turned on and off later in the cycle. Together, the data highlight the significant need for high neuroplasticity in the control of the tongue at a young age in mammals and suggest that the ability to do so is key in the ontogeny and evolution of feeding in these animals.

SmartLact8: A Bio-Inspired Robotic Breast Pump for Customized and Comfort Milk Expression

According to the 2018 National Immunization Survey conducted by the Center for Disease Control and Prevention (CDC), 83.9% of the breastfeeding mothers in the United States have used a breast pump at least once. However, the majority of existing products use a vacuum-only mechanism to extract milk. This causes common breast injuries such as nipple soreness, breast-tissue damage, and lactation complications after pumping. The objective of this work was to develop a bio-inspired breast pump prototype, named as SmartLac8, that can mimic infant suckling patterns. The input vacuum pressure pattern and compression forces are inspired from term infants' natural oral suckling dynamics captured in prior clinical experiments. Open-loop input-output data are used to perform system identification for two different pumping stages that facilitates controller design for closed-loop stability and control. A physical breast pump prototype with soft pneumatic actuators and custom piezoelectric sensors was successfully developed, calibrated, and tested in dry lab experiments. Compression and vacuum pressure dynamics were successfully coordinated to mimic the infant's feeding mechanism. Experimental data on sucking frequency and pressure on the breast phantom were consistent with clinical findings.

Retracted: A preliminary study on the quantification of soft palate movement using ultrasonography

Retraction: [Kumiko Fujiwara, Satoru Saitou, Naomi Nakamichi, Kei Tomihara, Hideyuki Hasegawa and Makoto Noguchi, A preliminary study on the quantification of soft palate movement using ultrasonography, Congenital Anomalies, in Early View: https://doi.org/10.1111/cga.12446]. The above article, published online on 7 October 2021 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, Toshihisa Hatta, and John Wiley & Sons Ltd. The retraction has been agreed as it has been reported by a partner in the collaboration that this research had not been reviewed/approved by their research ethics committee.

Infant factors that impact the ecology of human milk secretion and composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 3

Infants drive many lactation processes and contribute to the changing composition of human milk through multiple mechanisms. This review addresses the major topics of milk removal; chemosensory ecology for the parent-infant dyad; the infant's inputs into the composition of the human milk microbiome; and the impact of disruptions in gestation on the ecology of fetal and infant phenotypes, milk composition, and lactation. Milk removal, which is essential for adequate infant intake and continued milk synthesis through multiple hormonal and autocrine/paracrine mechanisms, should be effective, efficient, and comfortable for both the lactating parent and the infant. All 3 components should be included in the evaluation of milk removal. Breastmilk "bridges" flavor experiences in utero with postweaning foods, and the flavors become familiar and preferred. Infants can detect flavor changes in human milk resulting from parental lifestyle choices, including recreational drug use, and early experiences with the sensory properties of these recreational drugs impact subsequent behavioral responses. Interactions between the infant's own developing microbiome, that of the milk, and the multiple environmental factors that are drivers-both modifiable and nonmodifiable-in the microbial ecology of human milk are explored. Disruptions in gestation, especially preterm birth and fetal growth restriction or excess, impact the milk composition and lactation processes such as the timing of secretory activation, adequacy of milk volume and milk removal, and duration of lactation. Research gaps are identified in each of these areas. To assure a sustained and robust breastfeeding ecology, these myriad infant inputs must be systematically considered.

Breastfeeding Symptoms with Tongue- and Lip-Tie

PURPOSE

The aims of this study were to describe maternal and infant symptoms relative to tongue- and lip-tie severity and describe changes in symptoms and feeding efficiency from pre- to post-frenotomy.

STUDY DESIGN AND METHODS

A one-group pre- and post-intervention study design was used. Data from a dental practice were collected from medical records of infants less than 1 year old who underwent a frenotomy procedure for tongue- and/or lip-tie. Infant and maternal symptoms were compared with severity of tongue- and lip-tie using binary logistic regression. Wilcoxon Signed Rank test compared pain scores and feeding duration pre- and post-frenotomy. Linear regression compared total number of symptoms reported pre-frenotomy with tongue- and lip-tie severity.

RESULTS

N = 121 dyads were included. More severe classifications of tongue- and lip-tie were significantly associated with certain infant and maternal symptoms pre-frenotomy. Improvements were noted in all reported infant symptoms post-frenotomy. Feeding duration times significantly decreased post-frenotomy.

CLINICAL IMPLICATIONS

Infants and mothers experience problematic symptoms with feeding associated with tongue- and lip-tie. Nurses are the primary care providers during postpartum and should be alert to signs and symptoms that may suggest oral restrictions. Early evaluation and involvement of feeding experts may improve the breastfeeding experience of the dyad.

Non-Nutritive Suckling System for Real-Time Characterization of Intraoral Vacuum Profile in Full Term Neonates

Infant breastfeeding diagnostics remain subjective due to the absence of instrumentation to objectively measure and understand infant oral motor skills and suckling characteristics. Qualitative diagnostic exams, such as the digital suck assessment which relies upon a clinician's gloved finger inserted into the infant's mouth, produce a diversity of diagnoses and intervention pathways due to their subjective nature. In this paper, we report on the design of a non-nutritive suckling (NNS) system which quantifies and analyzes quantitative intraoral vacuum and sucking patterns of full-term neonates in real time. In our study, we evaluate thirty neonate suckling profiles to demonstrate the technical and clinical feasibility of the system. We successfully extract the mean suck vacuum, maximum suck vacuum, frequency, burst duration, number of sucks per burst, number of sucks per minute, and number of bursts per minute. In addition, we highlight the discovery of three intraoral vacuum profile shapes that are found to be correlated to different levels of suckling characteristics. These results establish a framework for future studies to evaluate oromotor dysfunction that affect the appearance of these signals based on established normal profiles. Ultimately, with the ability to easily and quickly capture intraoral vacuum data, clinicians can more accurately perform suckling assessments to provide timely intervention and assist mothers and infants towards successful breastfeeding outcomes.

Pierre Robin and breathing: What to do and when?

Robin sequence is characterized by mandibular retrognathia, airway obstruction, and glossoptosis; 80%-90% also have a cleft palate. Various treatment approaches exist, and although controlled studies are rare, objective assessment of treatment outcomes that address the leading clinical issues, namely obstructive sleep apnea and failure to thrive, are essential. Sleep-disordered breathing may be detected using cardiorespiratory polygraphy or polysomnography. Pulse oximetry alone may miss infants with frequent obstructive apneas, yet no intermittent hypoxia. Among conservative treatment options, the Tubingen Palatal Plate with a velar extension shifting the tongue base forward is the only approach that corrects the underlying anatomy and that has undergone appropriate evaluation. Of the surgical treatment options, which are not necessarily the first line of therapy, mandibular distraction osteogenesis (MDO) is effective and has been most extensively adopted. Notwithstanding, it is puzzling that MDO is frequently used in some countries, yet hardly ever in others, despite similar tracheostomy rates. Thus, prospective multicenter studies with side-by-side comparisons aimed at identifying an optimal treatment paradigm for this potentially life-threatening condition are urgently needed.

Oropharyngeal Capsaicin Exposure Improves Infant Feeding Performance in an Animal Model of Superior Laryngeal Nerve Damage

Sensorimotor feedback is critical to safe and effective swallowing. Because of this, sensory interventions have the potential to treat dysphagia. One such treatment may be found in capsaicin, which activates the internal branch of the superior laryngeal nerve (iSLN). The iSLN initiates the pharyngeal swallow, and a more sensitive iSLN should more readily elicit swallowing and improve swallow safety. We explored the neurophysiological mechanism by which capsaicin improves swallow performance using an infant pig model with a unilateral iSLN lesion. Using high-speed videofluoroscopy, we collected oropharyngeal kinematic data while pigs suckled on bottles, before and after applying capsaicin to the posterior tongue and valleculae. We found that capsaicin application decreased maximal bolus sizes, which improved swallow safety. Furthermore, capsaicin improved performance when infant pigs swallowed more moderately sized boluses. However, capsaicin did not change swallow frequency, the number of sucks prior to each swallow, nor total pharyngeal transit time (TPT). Similarly, excursions of the hyoid, thyroid, and posterior tongue were unchanged. TPT and hyoid and thyroid excursions maintained relationships with bolus size post-capsaicin, suggesting that these variables are less sensitive to sensory intervention. The timing and extent of posterior tongue movement were only correlated with bolus size pre-capsaicin, which could imply that capsaicin fundamentally changes in relationships between tongue movements and bolus size. Our results provide insight into the neural control of swallowing and capsaicin's mechanism of action, and suggest that capsaicin may be beneficial in treating acute infant dysphagia.

Galactagogues and Lactation: Considerations for Counseling Breastfeeding Mothers

ABSTRACT

Development of a milk supply is a complex process that is not always understood by women who are breastfeeding. Galactagogues are substances commonly used by breastfeeding women who perceive that they have an insufficient milk supply. They can be herbal substances or pharmaceuticals. Herbal galactagogues are advertised and sold to women as capsules, cookies, milk shakes, and teas, as well as other forms of herbal supplements. Herbal galactagogues are classified as dietary supplements and not reviewed or regulated by the U.S. Food and Drug Administration. There are limited data on their safety and efficacy. Women experiencing problems with their milk supply should receive a thorough and thoughtful assessment of the situation. There are many factors that should be considered when counseling breastfeeding women about use of galactagogues. The physiology of lactation, process of milk supply development, and the evidence for use of galactagogues are reviewed to add to the knowledge of nurses and other health care providers working with women who are breastfeeding.

Ankyloglossia and Tethered Oral Tissue: An Evidence-Based Review

Tethered oral tissue may represent anatomic variation or true pathology with functional limitations. The most prevalent functional limitation is impaired feeding due to ankyloglossia. Treatment options include conservative management with feeding support versus intervention such as frenotomy or frenuloplasty. The benefits of intervention have yet to be fully elucidated. Many can agree that intervention may improve maternal pain during breastfeeding, but the impact of these procedures on feeding efficiency and intake is debated. Alternate ties such as posterior ankyloglossia and lip tie have been proposed as pathologic oral ties, but their true impact on feeding and speech articulation remains unclear.

A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series

BACKGROUND

Lactation consultants frequently advise adjustments to fit and hold (or positioning and attachment) with the aim of optimising intra-oral nipple placement. However, approaches to fit and hold vary widely, with limited evidence of benefits, and effects of fit and hold on infant tongue movement have not been examined. The aim of this preliminary study was to investigate whether a gestalt breastfeeding intervention alters tongue movement, using measurements from ultrasound imaging to determine nipple placement and intra-oral nipple and breast tissue dimensions.

METHODS

Ultrasound measurements were conducted in five breastfeeding dyads, infants aged 4-20 weeks, while feeding in their usual or 'standard' position and again after brief application of gestalt principles of fit and hold. Four of the mother-baby pairs, who had received comprehensive lactation support, reported persisting nipple pain. Three of these infants had difficulty latching and fussed at the breast; three had been diagnosed with oral ties. A fifth pair was breastfeeding successfully.

RESULTS

Ultrasound demonstrated that the distance from nipple tip to junction of the hard and soft palate decreased, intra-oral nipple and breast tissue dimensions increased, and nipple slide decreased after a brief gestalt intervention.

CONCLUSION

These preliminary findings suggest that changes in fit and hold impact on infant tongue movement and contour. Further research investigating short- and long-term outcomes of a gestalt breastfeeding intervention in larger cohorts is required.

Breast Pumps and Mastitis in Breastfeeding Women: Clarifying the Relationship

Mastitis is a debilitating condition that can impact around 20% of mothers and is characterized by fever, flu-like symptoms and tender, swollen areas of the breasts. Despite the emerging evidence that breast milk dysbiosis is an underlying cause of mastitis, breast pumps have been implicated as a predisposing risk factor in the pathophysiology of mastitis in breastfeeding mothers. Previous studies have suggested that the use of a breast pump increases a mother's risk for developing mastitis, however, incidence rates of mastitis over the stages of lactation do not match breast pump usage rates. Furthermore, breast pumps, even when used at low vacuum, still promote some breast drainage, thus avoiding milk stasis, which is considered a key factor in the development of mastitis. As a consequence, these data suggest that the literature association of breast pumps with mastitis is more a case of reverse causation and not direct association. Moreover, it is important to note that breast pumps are actually a part of the conservative management of mastitis. In combination, these data show that the breast pump should not be considered a driver in the pathophysiology of mastitis in women.

A Review of Quantitative Instruments for Understanding Breastfeeding Dynamics

Breastfeeding, as a unique behavior of the postpartum period and an ideal source of nourishment, is profoundly impacted by the physiology and behavior of both mothers and infants. For more than three-quarters of a century, there has been an ongoing advancement of instruments that permit insight into the complex process of latching during breastfeeding, which includes coordinating sucking, swallowing, and breathing. Despite the available methodologies for understanding latching dynamics, there continues to be a large void in the understanding of infant latching and feeding. The causes for many breastfeeding difficulties remain unclear, and until a clearer understanding of the mechanics involved is achieved, the struggle will continue in the attempts to aid infants and mothers who struggle to breastfeed. In this review, the history of development for the most prominent tools employed to analyze breastfeeding dynamics is presented. Additionally, the importance of the most advanced instruments and systems used to understand latching dynamics is highlighted and how medical practitioners utilize them is reported. Finally, a controversial argument amongst pediatric otolaryngolo gists concerning breastfeeding difficulties is reviewed and the urgent need for quantification of latching dynamics in conjunction with milk removal rate through prospective controlled studies is discussed.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Tongue movements and teat compression during bottle feeding: A pilot study of a quantitative ultrasound approach

Nutritive sucking is a complex process, essential to proper growth and development. The complexity of this oral sensorimotor activity includes movements of the tongue and jaw. Tongue movements during nutritive sucking can only be visualized with instrumented methods such as ultrasound. Until now, studies using ultrasound during nutritive sucking performed measurements on each individual ultrasound image frame, which was quite time-consuming. The aim of this pilot study was to automatically process ultrasound video recordings in healthy infants during bottle feeding to measure teat compression and tongue movements. Tongue movements and teat compression during bottle feeding were visualized and recorded using 2D dynamic ultrasound imaging. A custom-made semi-automated analysis-routine was developed. Teat compression was expressed as the median difference in teat diameter during the recording. Tongue movements were expressed as the displacement of the tongue along four evenly distributed image lines and the corresponding time-shifts between those lines. The recordings of 12 out of 14 participants were adequate for the analysis of tongue movements. Teat compression could be analysed in the recordings of 6 participants. The reliability of our analysis-routine was considered to be good, and the analysis-routine was more time-efficient than manual frame-by-frame analysis. This quantitative analysis-routine is a promising tool, that can be used efficiently and accurately in the future to collect normative data that can serve as reference values to distinguish normal from abnormal tongue movements in infants with feeding difficulties.

Position of lips and tongue in rest in newborns with and without ankyloglossia

PURPOSE

Verify the position of lips and tongue at rest in newborns with and without ankyloglossia.

METHODS

Cross-sectional study, carried out with 130 newborns in University Hospital. Data collection was performed by the researcher and speech-language pathologists from the Hospital. Information on gestational age, sex, weight, height and days of life was collected. The position of the lips and tongue at rest was evaluated through visual inspection with the newborns asleep. After the newborns were awakened, Neonatal Screening of the validated Protocol for the evaluation of the lingual frenulum for infants was performed to detect the alteration of the lingual frenulum. The data obtained were described and submitted to statistical analysis using the Chi-Square test to verify the association between the position of the lips with the tongue and to compare the position of the lips and tongue with and without ankyloglossia. The Mann-Whitney test was used to verify the behavior of the variables the differed between newborns with and without ankyloglossia. The significance level of 5% was adopted.

RESULTS

When comparing the data, a significant difference was found between: weight and height with and without ankyloglossia; position of lips and tongue. An association between the position of the tongue and lips with and without ankyloglossia was also found.

CONCLUSION

Newborns without alteration of the lingual frenulum have a tendency to remain with their lips closed and their tongue elevated during rest and newborns with ankyloglossia have a tendency to keep their lips parted and their tongue low during rest.

Nipple shield use does not impact sucking dynamics in breastfeeding infants of mothers with nipple pain

Nipple shields (shield) may reduce pain during breastfeeding, but the impact on infant sucking dynamics is not known. We examined the effects of shield use on sucking dynamics, milk removal and nipple pain in two groups of breastfeeding dyads: pain group (PG): shield used for nipple pain; comparison group (CG): no breastfeeding difficulties. Twenty PG (6 ± 4 weeks postnatal) and 28 CG dyads (8 ± 6 weeks postnatal) attended 2 monitored breastfeeding sessions with shield use randomised. Within-subject outcomes were compared. PG: shield use did not affect intra-oral vacuum (peak p = 0.17, baseline p = 0.59), sucking frequency (p = 0.20) or milk transfer (40 mL vs 48 mL, p = 0.80; percentage of available milk removed (PAMR) 55% vs 57%, p = 0.88), and reduced McGill pain scores (p = 0.012). CG: shield use increased non-nutritive sucking (10% more, p = 0.049), and reduced nutritive sucking (18% less, p = 0.017) and milk transfer (63 mL vs 31 mL p < 0.001, PAMR 65% vs 36% p < 0.001). For both groups, feeding duration increased by 2 min (p < 0.0001) and non-nutritive portions of the feed increased with shield use.Conclusion: Nipple shield use improved maternal comfort and did not impact milk removal or sucking strength in PG, but significantly reduced milk transfer and nutritive sucking in CG. What is Known: • Mothers report that nipple shields reduce nipple pain and enable continued breastfeeding. • Concerns that nipple shield use may reduce milk transfer and alter infant sucking patterns are based on limited published evidence. What is New: • Nipple shield use is associated with a 25% reduction in pain scores in breastfeeding mothers with chronic nipple pain. • Milk transfer is not reduced in dyads that regularly use a shield for chronic nipple pain. • Intra-oral vacuums are not impacted by nipple shield use in mothers experiencing pain.

Increased viscosity of milk during infant feeding improves swallow safety through modifying sucking in an animal model

Infants experiencing frequent aspiration, the entry of milk into the airway, are often prescribed thickened fluids to improve swallow safety. However, research on the outcomes of thickened milk on infant feeding have been limited to documenting rates of aspiration and the rheologic properties of milk following thickening. As a result, we have little insight into the physiologic and behavioral mechanisms driving differences in performance during feeding on high viscosity milk. Understanding the physiologic and behavioral mechanisms driving variation in performance at different viscosities is especially critical, because the structures involved in feeding respond differently to sensory stimulation. We used infant pigs, a validated animal model for infant feeding, to test how the tongue, soft palate, and hyoid respond to changes in viscosity during sucking and swallowing, in addition to measuring swallow safety and bolus size. We found that the tongue exhibited substantive changes in its movements associated with thickened fluids during sucking and swallowing, but that pharyngeal transit time as well as hyoid and soft palate movements during swallowing were unaffected. This work demonstrates the integrated nature of infant feeding and that behaviors associated with sucking are more sensitive to sensorimotor feedback associated with changes in milk viscosity than those associated with the pharyngeal swallow, likely due to its reflexive nature.

Impact of Nipple Shield Use on Milk Transfer and Maternal Nipple Pain

Background: Nipple pain is a common cause of early cessation of breastfeeding. A nipple shield (shield) is often used to improve breastfeeding comfort. There are concerns that shield use may limit milk transfer. The aims of this study were to determine whether shield use reduces milk transfer and maternal nipple pain. Methods: A within-subject study of two groups of breastfeeding dyads (infants <6 months) was conducted; Control Group (CG): no breastfeeding difficulties; Pain Group (PG) shield used for nipple pain. There were two monitored sessions where shield use was randomized. Test weights and pain questionnaires were completed, and percentage of available milk removed (PAMR) was calculated. Results: Twenty-five PG (6 ± 4 postnatal weeks) and 34 CG (9 ± 6 postnatal weeks) had similar 24-hour milk production (PG: 676 ± 239 mL, CG: 775 ± 162 mL, p = 0.083). PG mean milk transfer volume and PAMR did not differ with shield use (no shield: 46 mL, 59%; shield: 40 mL, 53%, volume p = 0.38, PAMR p = 0.64). CG mean volume and PAMR were reduced with shield use (no shield: 65 mL, 64%; shield: 31 mL, 33%, volume p < 0.001, PAMR p < 0.001). PG pain scores were similar with and without shield use (Visual Analog Scale p = 0.44, McGill p = 0.97). Conclusions: Shield use did not impact either milk production or milk transfer in breastfeeding women experiencing nipple pain.

Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns

Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.

Effects of newborn intraoral pressure on colostrum intake

ABSTRACT Objective To explore the effects of intraoral pressure on colostrum intake. Methods Healthy women with full-term infants were admitted in the study after birth. Intraoral pressure was detected before and after the mothers’ onset of lactation by a pressure sensor during a breastfeeding session. Colostrum intake was measured by weighting the infant before and after breastfeeding. The onset of lactation was confirmed by the mothers’ perceptions of sudden breast fullness. Results The newborns’ peak sucking pressure was 19.89±7.67kPa before the onset of lactation, dropping to 11.54±4.49kPa after mothers’ onset of lactation (p<0.01). The colostrum intake was 4.02±4.26g before the onset of lactation, and 11.09±9.43g after the onset of lactation. Sucking pressure was correlated with the amount of colostrum intake before and after the onset of lactation after adjusting the confounding factors. Conclusions The newborns’ intraoral pressure at early stage played a predominant role in colostrum intake. It is recommended to initiate breastfeeding immediately after the birth to take advantages of the active and robust sucking response. It is valuable to understand the importance that the sucking pressure plays in the colostrum intake and active immunity achievement during the first several days after birth.

Sucking versus swallowing coordination, integration, and performance in preterm and term infants

Mammalian infants must be able to integrate the acquisition, transport, and swallowing of food to effectively feed. Understanding how these processes are coordinated is critical, as they have differences in neural control and sensitivity to perturbation. Despite this, most studies of infant feeding focus on isolated processes, resulting in a limited understanding of the role of sensorimotor integration in the different processes involved in infant feeding. This is especially problematic in the context of preterm infants, as they are considered to have pathophysiological brain development and often experience feeding difficulties. Here, we use an animal model to study how the different properties of food acquisition, transport, and swallowing differ between term and preterm infants longitudinally through infancy to understand which processes are sensitive to variation in the bolus being swallowed. We found that term infants are better able to acquire milk than preterm infants, and that properties of acquisition are strongly correlated with the size of the bolus being swallowed. In contrast, behaviors occurring during the pharyngeal swallow, such as hyoid and soft palate movements, show little to no correlation with bolus size. These results highlight the pathophysiological nature of the preterm brain and also demonstrate that behaviors occurring during oral transport are much more likely to respond to sensory intervention than those occurring during the "pharyngeal phase."NEW & NOTEWORTHY Physiological maturation of infant feeding is clinically and developmentally significant, but seldom examined as an integrated function. Using longitudinal high-speed videofluoroscopic data, we found that properties of sucking, such as the length of the suck, are more sensitive to swallow physiology than those associated with the pharyngeal swallow itself, such as hyoid excursion. Prematurity impacted the function and maturation of the feeding system, resulting in a physiology that fundamentally differs from term infants by weaning.

Estimates of Preterm Infants' Breastfeeding Transfer Volumes Are Not Reliably Accurate

BACKGROUND

Adequate human milk nutrition is critical for infant growth and neurodevelopment; however, low milk transfer volumes are common when establishing preterm breastfeeding. Despite clinical assessments of milk transfer volumes at the breast being inaccurate, measurement of feed volume via test weighing is rarely carried out either routinely or in cases where infant weight gain is inadequate.

PURPOSE

To assess the accuracy of the Preterm Breastfeeding Assessment Tool (PBAT) in determining transfer volumes and examine factors associated with PBAT accuracy.

METHODS

Pre/postfeed weights were performed using electronic scales and PBAT scores recorded for 1186 breastfeeds in 60 preterm infants born less than 33/40 and 33 to 39/40 postmenstrual age. Measured milk intake volumes were converted to percent prescribed feed volume and compared with PBAT estimates of milk transfer.

RESULTS

The PBAT is accurate in identifying when no milk is transferred at the breast but not in estimating transfer of half or the full prescribed volume (accuracy 26% and 47%, respectively). Wide ranges of transfer volumes (11-75 mL) were observed within and between infants, and for 20% of breastfeeds, no milk was transferred. Preterm Breastfeeding Assessment Tool accuracy decreased with each 1-week increase in birth gestation (odds ratio = 0.82; 95% confidence interval, 0.71-0.94; P = .004).

IMPLICATIONS FOR PRACTICE

When establishing breastfeeding, test weighing facilitates adequate nutrition by guiding appropriate complementary feeding. For mothers breastfeeding several times per day in preparation for discharge home, test weighing may offer a useful tool for developing maternal confidence in assessing milk transfer. Preterm Breastfeeding Assessment Tool is inaccurate in assessing preterm infants' milk transfer volumes when breastfeeding.

IMPLICATIONS FOR RESEARCH

While studies have typically focused on medically stable infants, test weighing offers a useful tool to examine breastfeeding efficacy and inform nutritional management of preterm infants with complications such as chronic lung and cardiac disease.

Altered sucking dynamics in a breastfed infant with Down syndrome: a case report

BACKGROUND

The health and developmental advantages of human milk and breastfeeding are particularly important for infants with Down syndrome. However, they typically have shorter breastfeeding duration due to sucking issues that are not well understood. This case report describes serial measures of milk transfer volumes, sucking dynamics and tongue movement in a breastfeeding infant with Down syndrome. Management of maternal milk production enabled feeding of only breast milk until maturation of breastfeeding skills and the achievement of full breastfeeding by 6 months.

CASE PRESENTATION

The mother of a term infant with Down syndrome and no associated health complications presented with concerns regarding adequacy of milk removal at the breast and low milk supply. We monitored sucking dynamics during breastfeeding by measuring intraoral vacuum strength, nutritive and non-nutritive suck rates and burst durations, and tongue movement using submental ultrasound. Breastfeeds were monitored at 4, 10, 14, 19 and 24 weeks, and maternal 24 h milk production was measured at 4, 10 and 24 weeks postpartum. We observed a weaker suck strength and shorter nutritive suck duration, and atypical tongue movement up to 19 weeks, with low milk transfer volumes. Regular breast expression was effective in increasing maternal milk production, providing expressed milk for all complementary feeds. Full breastfeeding was achieved by 6 months when reference sucking values were observed.

CONCLUSIONS

This case report illustrates that infants with Down syndrome may have low intraoral vacuum and limited nutritive sucking that persists for several months, likely due to delayed oro-motor development. In the absence of effective sucking human milk feeding can continue when milk production is stimulated with frequent and adequate breast expression. It is possible for infants with Down syndrome and no associated health complications to eventually establish full breastfeeding. Mothers that wish to breastfeed their infant with Down syndrome require anticipatory guidance and continuing lactation and family support.

Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery

Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad range of indications from birth through adulthood. This study utilizes histology to define the structure and tissue composition of the lingual frenulum and floor of mouth (FOM) fascia. En bloc specimens of anterior tongue, lingual frenulum, and FOM tissues were harvested from ten embalmed adult cadavers. An additional three fresh tissue cadaveric specimens were frozen with the tongue supported in an elevated position, to enable harvesting and paraffin embedding of the elevated lingual frenulum as a discrete specimen. All 13 specimens were prepared as ten-micron coronal sections using stains to determine the general morphology of the lingual frenulum, its relationship to neighbouring structures (Mason's Trichrome), presence of elastin fibers (Verhoeff-van Gieson), and collagen typing (Picrosirius Red). Our results have shown a submucosal layer of fascia spanning horizontally across the FOM was present in all specimens, with variability in fascial thickness and histologic composition. This FOM fascia suspends the sublingual glands, vessels, and genioglossus from its deep surface. The elevated lingual frenulum is formed by a central fold of this FOM fascia together with the overlying oral mucosa with variability in fascial thickness and composition. With tongue elevation, the fascia mobilizes to a variable extent into the fold forming the frenulum, providing a structural explanation for the individual variability in lingual frenulum morphology seen in clinical practice.

Imaging the breastfeeding swallow: Pilot study utilizing real-time MRI

OBJECTIVE

Knowledge of the breastfeeding swallow is limited by practical challenges. Radiation exposure to both mother and infant and the radiolucent properties of breastmilk make videofluoroscopy an unsuitable imaging modality. Furthermore, ultrasound is not ideal for capturing the complex 3-dimensional functional anatomy of swallowing. In this study we explore the feasibility of using real-time MRI to capture the breastfeeding swallow.

METHODS

Prospective observational study: Review of imaging from 12 normal infants (<5 months of age) and their mothers while breastfeeding using real-time MRI.

RESULTS

Static images were successfully captured in 11 infants and dynamic images in nine infants. This imaging modality confirms the dorsal surface of the infant's tongue elevates the maternal nipple to the hard palate, closing the space around the nipple with no air visible in the oral cavity during sucking and swallowing. We obtained dynamic imaging of mandibular movement with sucking, palatal elevation and pharyngeal constriction with swallowing, diaphragm movement with breathing and milk entering the stomach. Breastmilk was easily visualized, being high intensity on T2 sequences. Technical challenges were encountered secondary to infant movement and difficulties acquiring and maintaining midsagittal orientation. The similarity in tissue densities of the lips, tongue, nipple and hard palate limited definition between these structures.

CONCLUSION

Real-time MRI imaging was successful in capturing dynamic images of the breastfeeding swallow. However, technical and practical challenges make real-time MRI unlikely at present to be suitable for swallow assessment in clinical practice. Advances in technology and expertise in dynamic image capture may improve the feasibility of using MRI to understand and assess the breastfeeding swallow in the near future.

LEVEL OF EVIDENCE

4.

Feeding and Swallowing Difficulties in Neonates: Developmental Physiology and Pathophysiology

Development of enteral and oral feeding milestones in infants is intricately linked to physiologic maturation of the gastrointestinal tract and its complex interplay with cardiorespiratory and central nervous system control and coordination. Assessment of an infant's developmental skills and maturation can guide us with targeted management approaches and prediction of feeding outcomes. In this article, we review and summarize the developmental aspects of oral feeding and swallowing physiology, and current understanding of the pathophysiological changes associated with feeding difficulties in infants.

Bio-Inspired Breastfeeding Simulator (BIBS): A Tool for Studying the Infant Feeding Mechanism

OBJECTIVE

This work introduces a bio-inspired breastfeeding simulator (BIBS), an experimental apparatus that mimics infant oral behavior and milk extraction, with the application of studying the breastfeeding mechanism in vitro.

METHODS

The construction of the apparatus follows a clinical study by the authors that collects measurements of natural intra-oral vacuum, the pressure from infant's jaw, tongue and upper palate, as well as nipple deformation on the breast areola area. The infant feeding mechanism simulator consists of a self-programmed vacuum pump assembly simulating the infant's oral vacuum, two linear actuators mimicking the oral compressive forces, and a motor-driven gear representing the tongue motion. A flexible, transparent and tissue-like breast phantom with bifurcated milk duct structure is designed and developed to work as the lactating human breast model. Bifurcated ducts are connected with a four-outlet manifold under a reservoir filled with milk-mimicking liquid. Piezoelectric sensors and a CCD (charge-coupled device) camera are used to record and measure the in vitro dynamics of the apparatus.

RESULTS

All mechanisms are successfully coordinated to mimic the infant's feeding mechanism. Suckling frequency and pressure values on the breast phantom from the experimental apparatus are in good agreement with the clinical data. Also, the change in nipple deformation captured by BIBS matches with those from in vivo clinical ultrasound images.

SIGNIFICANCE

The fully-developed breastfeeding simulator provides a powerful tool for understanding the bio-mechanics of breastfeeding and formulates a foundation for future breastfeeding device development.

Comparison of Continuous positive airway pressure versus High flow nasal cannula for Oral feeding Preterm infants (CHOmP): randomized pilot study

Objective: To assess the feasibility of conducting a study comparing nasal continuous positive airway pressure (nCPAP) or heated, humidified, high flow nasal cannula (HHHFNC) on oral feeding in preterm infants.Study design: Randomized controlled pilot study in a level III NICU, of infants' born ≤28°^/7weeks who at 34°^/7weeks post menstrual age (PMA) were dependent on noninvasive ventilation (NIV). Infants were randomized evenly to nCPAP or HHHFNC groups and orally fed on low-flow oxygen. The primary outcomes of enrollment and retention were assessed.Results: We enrolled 40 infants and 12 completed the study in the nCPAP group versus 13 in the HHHFNC group. Using our respiratory and feeding protocols, we showed overall enrollment and retention rates (95%CI) at 0.66 (0.54, 0.77) and 0.63 (0.48, 0.78), respectively. Breastfeeding rates were 82% in the nCPAP group and 76% in the HHHFNC group. Infants in the HHHFNC group reached full feeds 7 days earlier than those in the nCPAP groupConclusions: Based on our retention rate, an adequately powered randomized controlled trial can be performed to confirm or refute that HHHFNC is associated with achieving oral feeds earlier.Trial registration: United States National Library of Medicine (www.clinicaltrials.gov) Identifier: NCT02055339. First posted 2/5/2014.

Nipple Deformation and Peripheral Pressure on the Areola During Breastfeeding

Breastfeeding is a complex process where the infant utilizes two forms of pressure during suckling, vacuum and compression. Infant applied compression, or positive oral pressure, to the breast has not been previously studied in vivo. The goal of this study is to use a methodology to capture the positive oral pressure values exerted by infants' maxilla (upper jaw) and mandible (lower jaw) on the breast areola during breastfeeding. In this study, the positive and negative (vacuum) pressure values are obtained simultaneously on six lactating mothers. Parallel to the pressure data measurements, ultrasound images are captured and processed to reveal the nipple deformations and the displacements of infants' tongues and jaw movements during breastfeeding. Motivated by the significant differences in composition between the tissue of the breast and the nipple-areola complex, the strain ratio values of the lactating nipples are obtained using these deformation measurements along with pre- and postfeed three-dimensional (3D) scans of the breast. The findings show an oscillatory positive pressure profile on the breast under both maxilla and mandible, which differs from clinical indications that only the mandible of an infant moves during breastfeeding. The strain ratio varies between mothers, which indicates volume changes in the nipple during feeding and suggests that previous assumptions regarding strain ratio for nonlactating breasts will not accurately apply to breast tissue during lactation.