Weight Gain is Not the Only Marker of Successful Breastfeeding

by Bobby Ghaheri

Where I practice in Portland, Oregon, I'm very fortunate to have a great network of ancillary services supporting breastfeeding moms, making it a great breastfeeding environment. On the more frustrating side, however, is that some insurance companies refuse to authorize releasing a tongue-tie or lip-tie for breastfeeding. Among the many reasons cited is: "Baby's weight gain has not suffered".

This post will detail many of the potential problems a baby can have when breastfeeding is not optimal, and will show you why weight gain is only part of the picture. The assumption here is that our common goal is to keep the baby on the breast as long as possible (there are numerous studies showing improved long-term health benefits when babies breastfeed compared to formula feed). There are cost advantages to breastfeeding as well. A 2009 cost analysis study in Pediatrics found that low breastfeeding rates cost the United States $13 billion. Additionally, a study by the USDA showed that $3.6 billion could be saved each year if 50% of children were breastfed for at least 6 months.Therefore, anything that lessens breastfeeding duration will cost the insurance company (and society) a greater financial burden.  

  • Falling asleep while nursing - This is one of the most common symptoms that I encounter with tongue-tied babies. The most plausible explanation for why this occurs is that babies with tongue-tie have to exert much more effort to attempt to breastfeed than babies who can nurse normally. When it's combined with frequent nursing sessions (when they aren't fully satiated after the previous feedings), stamina becomes a problem. Why the insurance company should care: this symptom can lead to cessation of breastfeeding because of frustration or fatigue on mom's part.
  • Poor quality latch - Obviously, if the baby's oral anatomy prevents them from performing the necessary movements to latch on to the breast, the latch can be visibly abnormal. Babies with tongue-tie or lip-tie aren't able to widely open their mouths. (Try this yourself - first, open your mouth as wide as you can and then close it. Next, roll your upper lip inwards against your gumline, hold it there, and then open your mouth again. You will feel significant tension that will limit your ability to open your mouth). Even if the baby starts out opening widely and gets on to the breast appropriately, it's not typically a sustainable motion so they slide down on to the end of the nipple, which affects their efficiency of nursing. Why the insurance company should care: an inappropriate latch is the root cause of many other breastfeeding problems, all of which threaten the success of long-term breastfeeding.
  • Reflux and colic symptoms - I am not going to claim that all infantile reflux and colic is caused by tongue-tie and lip-tie. However, babies who have tongue-tie and lip-tie commonly take in significant amounts of air. With an inability to flange out the upper lip and an inability to appropriately cup the breast with the tongue comes a shallower, more bottle-like latch. This allows these babies to take in a significant amount of air. Sometimes, an audible clicking or gulping sound is heard. Parents can often feel or hear air in their child's stomach, and burping doesn't always work to get it out. This air can act as propellant, causing silent reflux, spitting up or even projectile vomiting. The baby can have significant abdominal discomfort as a result. Why the insurance company should care: infant reflux is often medicated. While generic Zantac is often a first-line medication, many go on to use more costly medications like Prevacid.
  • Gumming or chewing the nipple - While some may describe this as a lazy latch, babies with tongue-tie or lip-tie are sometimes physically unable to avoid using their gums or to chew. If the upper lip doesn't flange out, the depth of the latch suffers. If the tongue cannot elevate and cup the breast while cushioning the lower gumline, what results is the baby using the lower gums and the outside of the upper lip to hold on to the nipple. Why the insurance company should care: this is one of the primary causes of nipple pain. Moms who experience pain are much more likely to wean prematurely, again causing long-term health problems (and subsequently, costs).
  • Lip blisters - When an easy, classic breastfeeding latch isn't attainable because of anatomy, some very determined babies will do anything they can to hold on to the nipple. This includes using both lips, like a sucker fish. The most common manifestation of inappropriate reliance on the lips to hold on is a central upper lip blister. While common in the first few weeks of life because of the delicate upper lip skin, I feel that the persistence of blisters beyond the first few months of life is indicative of an upper lip tie. When examining children, it's important to analyze both lips for swelling. Any degree of swelling of the lower lip is cause for suspicion of underlying tongue-tie or lip-tie. Swelling along the sides of the upper lip (outside of the central blisters) is also cause for concern. Rarely, as pictured here, lip blistering can be extremely severe. Why the insurance company should care: trauma to the baby's lips can prevent the baby from continuing to breastfeed. It can be painful for the baby and can occur in the setting of severe trauma to the nipples.

Upper lip blisters can be indicative of a baby's inability to flange outward.

A severe case of upper and lower lip blistering. This severity is quite uncommon.

  • Short sleep episodes - Certainly, there are a multitude of reasons for a baby to have frequent nocturnal awakenings. I'll be the first to tell you that there aren't data to support this claim. All I can say is that my experience has shown me that babies sleep better when they're satiated and when they aren't refluxing. When they're hungry, they wake up. When they're uncomfortable from acid going up, they wake up. When babies wake up frequently, moms sleep less. While sleep duration occasionally increases following a tongue or lip procedure, this should never be the sole reason why someone pursues revision. Why the insurance company should care: disrupted sleep cycles jeopardize the duration of breastfeeding. In some cases, poor sleep can exacerbate postpartum depression as well. Both can cost insurers money.
  • Inability to hold a pacifier in - I'm not going to address the pro's and con's of pacifier use. It is quite common for a baby with a tongue-tie or lip-tie to have an inability to hold in a pacifier, regardless of pacifier shape. This often improves with revision. This has little to do with insurance companies.
This child was treated at 6 months of age. Prior to the treatment, the child had been dropping percentiles in weight. Despite having reattachment that needed a secondary procedure 3 months later, this child nearly immediately began to gain weight. This change in weight post-procedure is common for children who can't gain weight because of a tongue-tie or lip-tie.

This child was treated at 6 months of age. Prior to the treatment, the child had been dropping percentiles in weight. Despite having reattachment that needed a secondary procedure 3 months later, this child nearly immediately began to gain weight. This change in weight post-procedure is common for children who can't gain weight because of a tongue-tie or lip-tie.

  • Poor weight gain - This symptom is the most concerning to parents and the baby's doctor. It's the symptom that convinces doctors to act, either by treating the baby or referring them to a specialist. It is also the symptom that insurance companies seem to focus on. This can manifest as losing significant amount of weight immediately after birth (many cite 10% of weight loss as a concerning amount). It can also take the form of a prolonged time period until the baby returns to birth weight. Why an insurance company should care: Weight loss often undermines a mother's attempt at exclusively feeding their children breast milk. Reliance on formula to bolster a baby's weight increases the chances that the mother will stop nursing and/or pumping altogether, resulting in long-term costs to the insurance company.

Finally, I think we must analyze the various reasons how a baby can gain weight when they have a tongue-tie and/or lip-tie. Early on, a mom's supply can be strong enough where it allows the baby to drink rather than nurse. This is especially true at letdown or in situations where mom has oversupply. When their caloric demands are lower, this drinking is sufficient to maintain growth. The insurance company may deny treatment if presented with a request during this period of life. But as the baby grows and caloric demands increase, weight gain can definitely fall off later. Secondly, supplementation with either pumped milk, donor milk or formula can be needed to keep the baby's weight up. An insurance company will look at the raw numbers but doesn't focus on how that weight was sustained. I will contend that babies who are exclusively breastfed have a better chance at long-term breastfeeding than babies dependent on pumped milk. Finally, a determined mother can power through all of the negative consequences of poor breastfeeding quality in an effort to keep her child healthy. That does not mean that the relationship is a healthy one. Looking at weight alone does not give the insurance company the whole picture.

As I will show you in future posts, there are distinct advantages to breastfeeding when compared to bottle feeding. I think it's overly simplistic to think of breastfeeding as just nourishment for the baby. Ignoring the symptoms that can complicate getting a baby to latch appropriately and feed normally can have detrimental long-term effects. We need to broaden our understanding of breastfeeding problems so that we may address what we can to improve the success of the dyad.