Nipple Pliability: A Tale of Two Sisters

IBCLC Janine was looking forward to the birth of her third baby.  She had breastfed her previous two children without difficulty for over one year and was planning the same for this baby.  But you know how third babies can be!   They tend to surprise us in various ways.  Janine's third baby, Emma, was no exception.   Born at term, Emma went skin-to-skin immediately following an uncomplicated vaginal birth, but breastfeeding was instantly painful for Janine despite adjustments of position and latch.  It also appeared and felt as though the baby was very “chompy” at the breast. Janine’s mother, Christine (also an IBCLC!) was present for the birth, and could see right away that there was a “posterior tongue-tie.”  

A posterior tongue-tie, sometimes called a “hidden” tongue-tie, is less common than the classic anterior tongue-tie.  It sits further back in the floor of the mouth making it more difficult to see and treat. Although there has been an increase in diagnosis of tongue-tie over the past two decades there remains no universally agreed upon definition or standard treatment and some medical professionals remain skeptical about the validity of frenotomy and its effect on breastfeeding and maternal nipple pain. 

Being in the lactation field, Janine was well aware of the controversy around posterior tongue-tie.  Like a lot of lactation consultants, Janine herself was somewhat "on the fence," about how to discuss posterior tongue-tie with clients and providers.   But one thing was sure, she was not going to be able to continue breastfeeding without something being done.   She tried a nipple shield to lessen the nipple pain, but she did not experience any improvement in her comfort level.  Her nipples were becoming increasingly damaged and a fissure was forming at the nipple-areola junction.  In addition, she heard no audible swallowing with feedings.  Janine decided to begin pumping and feeding Emma her milk via bottle. Although she had an ample milk supply, she was becoming very disheartened as she began to wonder if she might have to  exclusively pump, not something she had ever imagined she would be doing for her third baby.

Christine had an interesting thought.   Her younger daughter, Olivia, had recently had a baby, now just seven weeks old.  Christine had worked closely with both of her daughters throughout their breastfeeding journeys, and she knew that the sisters had very different nipples.   Janine's nipples were short and not very pliable, while Olivia's nipples were very pliable, soft and stretchy.  

Pliability is the stretchiness or malleability of the nipple.   Density of the areola, length and width of the nipple are other ways of describing and  measuring nipples, but there are few standards in this area.  Studies are just beginning to emerge which take these factors in to consideration. 

Christine wondered if baby Emma would be able to move milk from Auntie Olivia (with pliable nipples), and also if Auntie Olivia would experience nipple pain if she breastfed niece Emma.   The sisters agreed to the little experiment, and Janine brought her baby to Olivia for a feeding.   Little Emma with her posterior tongue-tie, easily latched deeply on to Auntie Olivia and demonstrated a strong, coordinated suck with much audible swallowing - something she had not been able to do with Janine, despite the fact that Janine had plenty of milk.   And Auntie Olivia experienced no pain at all when breastfeeding niece Emma.   The posterior tongue-tie had no consequence whatsoever on the nipple that was pliable, but was a huge problem for the mom with the short firm, less-pliable nipple.   It was a bit of a “wow,” moment for all.  

Since the sisters decided not trade babies (hahaha) - Janine was still in a quandary.  She couldn’t tolerate the nipple pain she was experiencing with breastfeeding, but also didn’t want to be tied to exclusive pumping.   She knew of the option of frenotomy, but wasn’t sure if there was anyone who would support a revision due to the high level of controversy surrounding posterior tongue-ties.   Because she worked in the lactation field, Janine did have a connection with a local and well-respected Ear, Nose and Throat (ENT) specialist, Dr. Conlon.   Janine reached out to her for an appointment, and was able to have Emma seen within a few days.  Emma was just six days old when she went to her appointment and  I was fortunate to be able to attend this appointment with her and mother and grandmother.  Dr. Conlon spoke with us about her experience with posterior tongue-ties, about the exceedingly specialized tool she would use to clip the tongue-tie and about how she would do the procedure.  Janine was on-board and signed the standard consent.   Emma was placed supine on grandma Christine's lap.  Dr. Conlon had her headlight in place, her surgical scissors and a small guaze pad ready to go.  She quickly and easily clipped Emma’s posterior tongue-tie, applied pressure to the area with a small gauze pad for two minutes and then Emma went right to mom’s breast.  Janine used a nipple shield for this first feeding because she already had nipple damage and was too anxious to breastfeed without it due to her nipple pain.  Emma latched on with the shield, and within minutes moved into sustained nursing with swallowing, and Janine was comfortable enough to continue.  Hooray!! Within one week Janine was nursing comfortably without a nipple shield, and Emma was feeding effectively at the breast. 

I love the insight that this case brings! While it doesn’t necessarily change our practice, it does serve as an explanation for why some mothers who have a baby with a tongue-tie can feed comfortably and without complications.  Healthcare providers may misinterpret such situations to support their belief that tongue-ties don’t interfere with breastfeeding.   But it’s important for all of us to remember not to apply individual findings to the population as a whole.  We need to remember that each mother-baby dyad brings a completely different set of circumstances to the table.   So, we shouldn’t apply an “always-or-never,” mindset to these tongue-tie situations.  The “look,” of the tongue-tie is not enough to form the basis of a treatment plan.   Emma’s tongue-tie did not “look” bad – but in fact it was a big problem for this mother and baby.   And on the opposite side, the tongue-ties that “look” bad, do not necessarily have to be corrected if things are going smoothly for the dyad.   Providing information on how tongue-ties may interfere with breastfeeding, and options for support and treatment is always the right thing to do.   As are keeping an open mind, and listening to the mother’s experience and supporting her goals. 

A special thanks to all the women here who allowed me to be a part of their story and to share it with you.   I hope you found this case review helpful and relevant to your practice. 

(names have been changed to protect privacy)

Becker S, Brizuela M, Mendez MD. Ankyloglossia (Tongue-Tie) [Updated 2023 Jun 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482295/

Ventura AK, Lore B, Mireles O. Associations Between Variations in Breast Anatomy and Early Breastfeeding Challenges. Journal of Human Lactation. 2021;37(2):403-413. doi:10.1177/0890334420931397