Beyond First Latch: the role of dentists in ensuring proper growth of the cranio-facial-respiratory complex from infancy

Drs. Lynda Dean-Duru and Krystle Dean-Duru explain the importance of early diagnosis and intervention

The connection between breastfeeding and craniofacial development begins remarkably early, setting the foundation for proper sleep and breathing patterns throughout life.

Many babies have restrictions that make it difficult, sometimes impossible, to breastfeed. Typically, these situations involve anatomic, functional, and sometimes neurological issues with the baby. The tongue acts as a natural pump while breastfeeding and drives the development of the face, jaws, and airway, and when tongue function is compromised, breastfeeding, breathing, sleep, and the growth of the face and jaws are adversely affected.

Where does it all start?

At 4 weeks gestation, the neural tube is specializing, mesoderm growing the vascular system and seeding the skeletal, and endoderm invaginating into the gut tube. The endoderm is also forming the pharyngeal pouches, which contain the neuro/meso/skeletal blueprints for the face, mouth, and throat. Neural crest cells are migrating through all tissues, illuminating cranial nerve sprouts and roots and wiring underlying autonomic brainstem circuits (Courtesy of Neurovascular Institute, Inc.©2019). Before week four, the tongue is functional/peristaltic. This core principle, Rhythmic Integration, begins early in the embryo, gains sophistication during fetal development, facilitates recovery perinatally, and continues throughout life, unless interrupted by unresolved trauma or toxic exposure (Dr. Darick Nordstrom). At 8 weeks gestation, genetic blueprints are established, the embryo transitions to fetus, continues to grow and develop for another 32 weeks.

The brainstem and its critical functions

The brainstem has three main functions: as a signal conduit between body and brain, as “home base” for our cranial nerve function, and as an integrative switchboard for signals transmitting between the body and the brain (Courtesy of Neurovascular Institute, Inc. ©2019).

The brainstem is a stalk-like projection of the brain extending caudally from the base of the cerebrum, bridging communication between the cerebrum with the cerebellum and spinal cord.^1,2 It has three sections: midbrain, pons, and medulla oblongata, combining to maintain functions necessary for life, such as breathing, consciousness, maintaining blood pressure, heart rate, and sleep regulation.

The brainstem contains both collections of white and grey matter: The grey matter consists of nerve cell bodies and includes important brainstem nuclei; for example, 10 of the 12 cranial nerves’ nuclei originate there. The white matter tracts involve neuron axons traveling between the cerebrum, cerebellum, and spinal cord to the peripheral nervous system. These tracts carry information to the brain (afferent pathways, such as the somatosensory pathways) and from the brain (efferent pathways such as the corticospinal tract).³

State of ideal development

People are born obligate nose breathers. For survival, the baby needs to be able to suck-swallow and breathe. The important steps include: first breath, breast crawl, and breastfeeding, which all help decompress the cranium, setting the stage for graceful transition of the autonomic nervous system as well as loosening the fascia connections. The healthy swallow is most critical in re-igniting and maintaining rhythmic motion and, with breathing, coordinates fascia, visceral motion, and the brainstem.

Birth trauma and developmental challenges

It follows then, that intrauterine factors, birth trauma, and intervention could affect these important areas and compromise function and structure. These include the normal process of descent through the birth canal, abnormal position of the baby, and interventions such as epidural and pitocin, which increase compressive forces via stronger contractions. Others are caesarean births, vacuum, and/or forceps-assisted deliveries. These can lead to somatic dysfunction, notably, occipital condylar compression/dysfunction.⁵

With extra compressive forces, the skull bones and the surrounding fascia can affect the function of the nerves and muscles. The occipital bone, which at this stage is in four parts, is in close proximity to the vagus and hypoglossal nerves, which partially control tongue function, breathing, rest, and digestion. Cranial nerves IX (glossopharyngeal and XI (accessory nerve) are in close proximity as well.

Symptoms of occipital condylar compression

Occipital condylar compression manifests through various interconnected symptoms affecting multiple bodily functions. Common manifestations include difficulties with nursing, sucking, and swallowing, often accompanied by digestive issues such as reflux, vomiting, and colic. Respiratory challenges frequently arise, and patients may experience constipation and bloating. Physical manifestations can include torticollis, and many infants display notable irritability as a result of these combined challenges.

Where it goes wrong

Somatic function, early cranial nerve mapping, and integration are most critical for successful breastfeeding, and problems are best detected and treated within 24-48 hours after birth. Breastfeeding is a baby’s innate function and should be effortless. Suck, swallow, and nasal breathing set the foundation of good function and flow throughout the body.

Infant symptoms for compromised tongue function and breastfeeding

Infants experiencing compromised tongue function display a complex array of feeding-related symptoms. During breastfeeding, they often exhibit clicking sounds, chomping or gumming behaviors, and struggle to maintain proper flange formation. The latch is typically shallow and frequently slides off the nipple, leading to extended feeding times and frequent sleep episodes at the breast. These babies commonly show signs of acid reflux, notably clicking sounds and air swallowing during nursing, accompanied by frequent feeding sessions and excessive spit-up.

Digestive issues manifest through gassiness and hiccups, while nursing blisters may develop. The inadequate milk transfer often results in slow weight gain and, in severe cases, failure to thrive. Physical manifestations include a preference for feeding on one side and development of a high vaulted palate. Breathing difficulties become apparent through open mouth posture, heavy breathing patterns, and inability to retain a pacifier. Sleep disturbances often present as congestion upon waking, along with snoring. Skin manifestations such as baby acne or rash may also occur.

Maternal symptoms during breastfeeding

Mothers experiencing breastfeeding challenges due to infant tongue dysfunction face a range of physical and emotional difficulties. Physical symptoms predominantly affect the breast and nipple area, including soreness and discomfort, creased or lipstick-shaped nipples, and flattened nipples. More severe complications can develop, such as plugged ducts, open wounds, and mastitis. Many mothers struggle with low milk supply and may need to resort to using nipple shields. The presence of inverted nipples can further complicate the feeding process. The persistent physical challenges, including ongoing nipple pain and repeated episodes of mastitis, often contribute to low milk supply and can lead to depression.

Differential diagnosis for difficulty breastfeeding

The challenges in breastfeeding can stem from various underlying conditions and factors that require careful consideration for proper diagnosis. Primary physical factors include fascial restrictions resulting from in-utero positioning or traumatic birth experiences, along with occipital condylar compression. Oral structure issues such as restrictive tethered oral tissues, which can be either functional or structural in nature, play a significant role. Additionally, conditions like hypotonia, laryngomalacia, and Pierre Robin sequence can impact feeding ability. Structural abnormalities such as cleft palate and/or cleft lip must be considered, as well as complications related to prematurity. Maternal metabolic issues can also contribute to breastfeeding difficulties, highlighting the importance of examining both infant and maternal factors in the diagnostic process.

The importance of early intervention and proper diagnosis is foundational in a child’s lifelong, overall health. It’s critical that healthcare providers, particularly dentists, understand these developmental processes as they directly impact craniofacial development for the children we treat, so we can set them up for a healthy and happy life.