Resources. Resources (end) Objectives. Importance for the LC 3/25/2017. Dr Evelyne Ruf

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Resources Dr Evelyne Ruf MD, Dipl. Fam. Med.

LMTP Dubai 2017 Supporting Sucking Skills Catherine Watson Genna, 2 nd Ed.

Wambach 5 th Edition (2016) Core Curriculum ILCA 3rd Edition (2013) 2 Resources (end)

2 nd edition BF, An illustrated Guide to Diagnosis and Rx Denise Both & Kerri

describe the different components of the infant oral and facial anatomy involved in

Identify the reference, as well as common variations or abnormalities Describe their

1 Resources Dr Evelyne Ruf MD, Dipl. Fam. Med., IBCLC (since 1993) Head of Lactation Clinic Family Health Promotion Center, Sharjah LMTP Dubai 2017 Supporting Sucking Skills Catherine Watson Genna, 2 nd Ed. (2013) BF and Human Lactation Jan Riordan & K. Wambach 5 th Edition (2016) Core Curriculum ILCA 3rd Edition (2013) 2 Resources (end) The BF Atlas Wilson-Clay & Hoover, 4 th Edition (2008), 5 th Edition (2013) and CD from 2 nd edition BF, An illustrated Guide to Diagnosis and Rx Denise Both & Kerri Frischknecht 2008 Cases from Sharjah MCH Lactation Clinic Objectives Locate, name and describe the different components of the infant oral and facial anatomy involved in breastfeeding: lips, cheeks, jaws, tongue, palate, nose, epiglottis, larynx, pharynx Identify the reference, as well as common variations or abnormalities Describe their potential impact on breastfeeding 3 4 Importance for the LC Oral and Facial Anatomy: basis for understanding Normal structure Function in infant feeding * for analyzing and correcting breastfeeding problems 5 6 1

Most common example, greatest representation of a population Less judgmental than norm Necessary to distinguish between normal

process: constant adaptation to a changing anatomy Far more than simply obtaining food: principal interaction with the environment

sucking (often used interchangeably) Common to all mammals 7 8 9 10 7-month fetus (midsagittal section) Oral Anatomy of Infant and

2 Most common example, greatest representation of a population Less judgmental than norm Necessary to distinguish between normal variations and abnormalities (both of them might cause breastfeeding problems) Aim of oral anatomy: suckling Suckling is a dynamic process: constant adaptation to a changing anatomy Far more than simply obtaining food: principal interaction with the environment Suckling vs. sucking (often used interchangeably) Common to all mammals month fetus (midsagittal section) Oral Anatomy of Infant and Adult 11 A: Smaller oral cavity, flatter tongue and palate. Epiglottis almost attached to soft palate. Airway and food way separated. B: Larynx lower in the neck. 2 ways cross in pharynx. Matsuo (2008)

Main characteristics Newborn mouth (vertically short):

(large in relation to the size) touching gums and roof of the

Variations and Abnormalities 13 14 Lips: Soft and flexible

swellings on the inner surface (eminences of the pars

Lower lip: flanged outward Upper lip: neutral position Lips:

) Good lip tone: well defined philtrum and closed mouth

Labial frenulum/frenae: Inferior Superior (maxillary)

3 Main characteristics Newborn mouth (vertically short): particularly well designed for sucking When closed: tongue (large in relation to the size) touching gums and roof of the palate When feeding: tongue and breast fill almost all space Variations and Abnormalities Lips: Soft and flexible Partially everted: oral mucosa slightly externally Tiny swellings on the inner surface (eminences of the pars villosa) Well adapted for airtight closure around the breast Lower lip: flanged outward Upper lip: neutral position Lips: reference (cont.) Good lip tone: well defined philtrum and closed mouth posture while sleeping Lips: Muscles and Innervation Labial frenulum/frenae: Inferior Superior (maxillary) Muscles: orbicularis oris (closes the lips) and mentalis (elevates center of lower lip) Innervation: facial nerve (VII) withealth.net Dr Kotlow

Poor lip tone (and facial tone) Variations and

Opened mouth breathing 19 20 Poor lip tone Poor lip (and

pressure Intermittent breaks in suction: Clicking or

Tiring, incomplete feeding poor weight gain, down

4 Poor lip tone (and facial tone) Variations and Abnormalities! Opened mouth breathing Poor lip tone Poor lip (and facial) tone Poor lip seal impairs amount of negative pressure Intermittent breaks in suction: Clicking or smacking sounds Milk leaking Needs constant re-latching: Tiring, incomplete feeding poor weight gain, down regulation of milk supply 17 day-old, still under birth weight Milk leaking Lip retraction (compensation for low tone)

Lip retraction (compensation for low tone) Hypertonic,

able to breastfeed 25 26 Sucking blister(s) sign of

) SHJ MCH LC 21-05-2015 27 28 Tight labial frenulum

5 Lip retraction (compensation for low tone) Hypertonic, purse string lips (due to excessive tone) 14 day-old, not able to breastfeed Sucking blister(s) sign of frictional trauma Suckling blisters (cont.) SHJ MCH LC Tight labial frenulum Difficult latch Cleft lip Poor gape Sore nipples Tooth decay Space between incisive teeth

Infant with unilateral cleft lip Haemangioma 31

Structural support for oral and pharyngeal

while suckling Cheek stability influences lip

) Muscle: buccinators Compress the cheeks to

6 Infant with unilateral cleft lip Haemangioma Variations Cheeks: Subcutaneous fat deposits Structural support for oral and pharyngeal function Thick wall: prevents collapse of cheeks while suckling Cheek stability influences lip seal Cheeks: (cont.) Muscle: buccinators Compress the cheeks to maintain contact with the breast Innervation: facial nerve (VII) Variations

cheeks ( dimpling ) CD BF Atlas, Chapter 17 11-Cheek dimpling 17 day-old, not latching 6-week old, after CST 37 38 Jaws:

Normal lower jaw movements are rhythmic and graded (not too wide or too narrow) important role in milk removal.

7 Thin cheeks Thin vs. Fatty cheeks Thin cheeks (lack of adequate fat deposits) Cheek instability Difficulty to create vacuum Collapsing of the cheeks ( dimpling ) CD BF Atlas, Chapter Cheek dimpling 17 day-old, not latching 6-week old, after CST Jaws: Variations Provide stability for the tongue, lips and cheeks. Normal lower jaw movements are rhythmic and graded (not too wide or too narrow) important role in milk removal. Muscles: Masseter : depresses and elevates the mandible (lower jaw) Temporalis: closes mandible during suckling Innervation: Trigeminal (V) Mandible usually short in newborns (< 40% complete at birth); forward growth until 3 years Jaws: Muscles and Nerves Variations and abnormalities

(breech) Specific chromosomal disorders (Pierre

chin on breastfeeding Poorly positioned jaw sore

dysfunctional sucking ability 46 Jaw Asymmetry

8 Receding Chin (retrognathia) vs. Receding chin Familial Intrauterine positioning (breech) Specific chromosomal disorders (Pierre Robin Syndrome) Consequences of receding chin on breastfeeding Poorly positioned jaw sore nipples poor milk transfer 45 Jaw Asymmetry Due to: asymmetrical muscle tone, injury or paralysis, torticollis or abnormal jaw development. Consequences: Asymmetrical jaw movements dysfunctional sucking ability 46 Jaw Asymmetry (cont.) /PositionalJaw1.html /PositionalJaw2.html

Natal Teeth http://newborns.stanford.edu/photogallery/positionaljaw3.

html http://mchoralhealth.org/ flvarnish/mod3_2_4.

Role in: latching (draws the nipple/breast in) sustaining the latch

channeling fluid towards the pharynx (central groove) preparing the

rounded tip, lies on the bottom of the mouth with a slight central

9 Natal Teeth allery/teeth1.html flvarnish/mod3_2_4.html Natal Teeth Variations SHJ MCH LC Tongue: Role in: latching (draws the nipple/breast in) sustaining the latch (stabilizes the breast) milk removal (positive and negative pressure) channeling fluid towards the pharynx (central groove) preparing the bolus (in valeculae) for swallowing : soft, thin, excellent tone, rounded tip, lies on the bottom of the mouth with a slight central groove. Complex muscular structure Genioglossus Superior longitudinal Inferior longitudinals Vertical muscles Transverse muscles

10 Tongue: muscle and nerves Tongue: Extension Valeculae Fig Tongue: Elevation Tongue: Elevation (cont.) Figure 2 SHJ MCH Lact. Clinic SHJ MCH Lact. Clinic Tongue: Lateralization Lingual frenulum Should allow free movements of the tongue

Whole range of disorders Variations and anomalies Short tongue: restricts ability to attach to the breast Long tongue: held on the palate, poor

(structural or from neurological cause) Tongue protruding (poor muscle tone) Enlarged tongue or macroglossia (hypothyroidism, chromosomal syndromes)

25-07-2013 65 Constellation of feeding challenges If the tongue cannot move properly, a whole range of consequences can occur: Latching Maintenance of

11 Whole range of disorders Variations and anomalies Short tongue: restricts ability to attach to the breast Long tongue: held on the palate, poor coordination Flat tongue (low tone or severe tongue-tie) Humped tongue (antero-posterior direction) Bunched tongue (lateral direction) Asymmetrical (structural or from neurological cause) Tongue protruding (poor muscle tone) Enlarged tongue or macroglossia (hypothyroidism, chromosomal syndromes) Tongue-tie or ankyloglossia (tight lingual frenulum) Macroglossia Tongue-tie: whole range of tongue disorders Tongue-tie (cont) SHJ MCH LC Constellation of feeding challenges If the tongue cannot move properly, a whole range of consequences can occur: Latching Maintenance of latch Milk removal Swallowing Jaws compensate by extra pressure nipple pain++ Conversely, sometimes babies compensate other problems with abnormal tongue movements

Palate: Variations and anomalies 67 68 Palate: (cont.

Assists with positioning Soft palate (with uvula): Works with the

Palate: Intact Length 1 inch (newborn) Smoothly contoured

in utero and after birth) 69 http://newborns.stanford.

/EpsteinPearl1.html 2017 70 Hard Palate: (cont.

12 Palate: Variations and anomalies Palate: (cont.) Hard palate: passive role Stability for the oral structures Assists with positioning Soft palate (with uvula): Works with the tongue to create the posterior seal of the oral cavity Hard Palate: Intact Length 1 inch (newborn) Smoothly contoured (moderate angle of the slope) Plastic (shaped by tongue movements, in utero and after birth) 69 Dr Evelyne Ruf_Infant oral anatomy_lmtp /EpsteinPearl1.html Hard Palate: (cont.) Palatine rugae SHJ MCH LC Transverse folds, assisting for holding the breast Excellent tongue elevation reference palate

sucking). 73 http://newborns.stanford.edu/photogallery/epsteinpearl2.

palatal fusion. Very common and benign finding.

74 Soft Palate (Velum): Intact Muscular flap, moving in coordination with

Variations and anomalies 75 76 Shapes of hard palate Short palate Long

13 Epstein pearls (cont.) Firm papules that can be felt by the examiner s finger (during infant s sucking) Epstein pearls Epithelial tissue that becomes trapped during the palatal fusion. Very common and benign finding. Very often misdiagnosed as thrush. 74 Soft Palate (Velum): Intact Muscular flap, moving in coordination with tongue (up during swallowing, down during suckling) symmetrical movement Variations and anomalies Shapes of hard palate Short palate Long palate High palate (arched) Channel palate (grooved) Bubble Sloped V-shaped Wide or flat palate (reduced arch) Influence on the latch (tip of the nipple) Abnormal palate shape reflect abnormal tongue movements

14 Clefts of the Hard Palate Bilateral Cleft Palate /CleftPalate1.html Bilateral Cleft Palate Complete unilateral cleft of lip and palate Discovered in MCH Lactation Clinic (2013) Cleft of the Soft Palate (Velum)

Cleft of the soft palate Submucosal Cleft Palate When the palate appears to be

in 36% of children with cleft lip Discovered in MCH Lactation Clinic (2013) 85 http://face.

) Possible associated signs: bifid uvula (cleft of the uvula), notching at junction of

zone (bluish or white line) in the middle of the soft palate (muscular Dr diastasis)

) Complete or partial cleft of the uvula http://elementsofmorpholo gy.nih.gov/index.cgi?

15 Cleft of the soft palate Submucosal Cleft Palate When the palate appears to be structurally intact, but there are bony and/or muscular abnormalities underlying the skin's surface. Called the invisible cleft Diagnosis by direct palpation only Uncommon in general Present in 36% of children with cleft lip Discovered in MCH Lactation Clinic (2013) Submucosal Cleft Palate (cont.) Possible associated signs: bifid uvula (cleft of the uvula), notching at junction of hard/soft palate, bony defect in the hard palate (it looks dented ) midline translucent zone (bluish or white line) in the middle of the soft palate (muscular Dr diastasis) Evelyne Ruf_Infant oral anatomy_lmtp Submucosal cleft palate (cont.) Complete or partial cleft of the uvula gy.nih.gov/index.cgi?tid=30 b9e9da9758d9d7 missinglink.ucsf.edu PhotoGallery/BifidUvula1.html 88 Velopharyngeal Inadequacy Inability of the soft palate and pharyngeal muscles to close off the nasopharynx. Caused by a submucosal cleft of the palate or by neurological mechanisms (poor coordination) Consequences of velopharyngeal inadequacy: Paranasal bulging Nasal regurgitation (during or after feeds) Poor milk transfer Ear problems (glue ear) Speech problems Signs of velopharyngeal inadequacy Paranasal bulges and mild gull wing upper lip. Nasal regurgitation during a breastfeed

Nose: Infants are nose-breathers: they will prioritize

flaring Not congested (no noisy breathing).

93 94 Newborn: Unique Airway Protection Adult versus infant

Upper airway very short Reduced risk of aspiration Reduced

16 Nose: Infants are nose-breathers: they will prioritize breathing over eating Nostrils should be symmetrical, Without flaring Not congested (no noisy breathing) Anomaly: Small nasal passages Variations and anomalies Newborn: Unique Airway Protection Adult versus infant (both swallowing) Epiglottis and soft palate touch at rest Upper airway very short Reduced risk of aspiration Reduced resistance to airflow when extending the neck Soft Palate Epiglottis Larynx Esophagus

Epiglottis: Infant s epiglottis: just below the soft palate. Role: closing off the pathway to the lungs during swallowing.

Epiglottis and Larynx False vocal folds Vocal folds Arytenoid cartilages: open the airway during breathing close the airway

Adult) Higher in the oral cavity Occupies larger space Short and funnel-shaped During swallowing: larynx is high and elevated

muscles and ligaments To the hyoid bone To the cervical vertebrae 99 100 Abnormalities of the Airway Variations and anomalies

17 Epiglottis: Infant s epiglottis: just below the soft palate. Role: closing off the pathway to the lungs during swallowing. Milk moves laterally on the outside of the epiglottis into the esophagus. Epiglottis and Larynx False vocal folds Vocal folds Arytenoid cartilages: open the airway during breathing close the airway during swallowing alexanderglenfield.blogspot.com Larynx: (Infant vs. Adult) Higher in the oral cavity Occupies larger space Short and funnel-shaped During swallowing: larynx is high and elevated Depends much less on epiglottis and closure of vocal folds for airway protection Larynx: suspended Cartilage suspended by muscles and ligaments To the hyoid bone To the cervical vertebrae Abnormalities of the Airway Variations and anomalies Laryngomalacia: epiglottis small and curled on itself; most common cause of neonatal stridor Tracheomalacia: less common Vocal fold (Cord) paralysis Subglottic stenosis Laryngomalacia

18 Pharynx: Soft muscular tube at the back of the throat Dual role: Swallowing Breathing Divided in: Nasopharynx Oropharynx Laryngopharynx

Infant Anatomy and Physiology for Feeding

CHAPTER 3 Infant Anatomy and Physiology for Feeding Nina Isaac Elizabeth Choi OBJECTIVES Describe and assess infant orofacial structures and identify abnormal presentations. Jones & Bartlett Learning,