PERSPECTIVES
Tutorial
Assessing the Breastfeeding Dyad: A Guide
for Speech-Language Pathologists
Jamie Mahurin-Smitha and Catherine Watson Gennab
Purpose: More than 80% of U.S. mothers initiate
breastfeeding; for many of them, direct breastfeeding
is an important goal. Speech-language pathologists
(SLPs) who assess infants with feeding concerns, however,
are generally much more familiar with assessing bottle-
feeding. The purpose of this tutorial is to assist SLPs in
A
cross the past 20 years, breastfeeding rates in the
United States have risen steadily in response to
public health campaigns emphasizing the impor-
tance of human milk. According to the most recent data
available, more than 83% of mothers in the United States
initiate breastfeeding (Centers for Disease Control and Preven-
tion, 2018). Many of them have a goal in mind for breastfeed-
ing duration, and they may report a variety of strong negative
feelings (e.g., grief, regret, anger, or guilt) if they are unable
to meet it (Mozingo, Davis, Droppleman, & Merideth, 2000).
While speech-language pathologists (SLPs) are
trained to assess infant feeding disorders (American Speech-
Language-Hearing Association, 2016), few SLPs receive
breastfeeding-specific training (Blake, 2014; Fishbein, Flock,
& Benton, 2013) and may have limited understanding of the
differences between breastfeeding and bottle-feeding. If SLPs
cannot provide accurate information to families about their
infants’ breastfeeding abilities, their assessments will neces-
sarily be limited to other feeding modalities, most often
bottle-feeding. For a mother who wishes to breastfeed, this
approach can cause significant frustration. Given that
mothers are almost universally advised by public health
authorities and their pediatricians to breastfeed their babies,
it is important for SLPs to be able to provide them with
information to assist them in meeting their breastfeeding
goals. The purpose of this tutorial was to provide SLPs with
a
Communication Sciences & Disorders, Illinois State University,
Normal
b
Private Practice, Woodhaven, New York, NY
Correspondence to Jamie Mahurin-Smith: j.m.smith@ilstu.edu
Editor: Aneesha Virani
Received November 20, 2018
Revision received March 25, 2019
Accepted March 27, 2019
https://doi.org/10.1044/2019_PERS-SIG13-2018-0018
Perspectives of the ASHA Special Interest Groups • 1–5 • Copyright © 2019 American Speech-Language-Hearing Association
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SIG 13
building on their existing assessment skills in order to
provide effective, evidence-based options for mothers
who wish to breastfeed their infants.
Conclusion: SLPs can assist families in meeting their
breastfeeding goals through effective assessment of
breastfeeding dyads.
information to assist them in building on their existing
assessment skills, extending those skills to meet the needs of
the breastfeeding dyad.
Assessing the Breastfed Infant
The process of assessing a breastfeeding infant is sim-
ilar in many ways to the process of assessing a bottle-feeding
infant: The SLP must collect a history, observe the baby
at rest, observe the baby during a feeding, consider in-
strumental assessment, and make appropriate recommen-
dations in consultation with other professionals (cf. Arvedson,
2008; Rogers & Arvedson, 2005). The same training that
equips SLPs to complete feeding assessments with bottle-
feeding infants will provide a solid foundation for working
with breastfeeding dyads, but in each of these areas, some spe-
cialized knowledge will assist in developing a more complete
picture of the dyad’s strengths and needs. Further information
on assessment of the breastfed infant can be found in Genna
(2017) and Mannel, Martens, and Walker (2013).
Collect a History
The background information that informs an SLP’s
observations of a feeding is fairly similar regardless of
the preferred feeding method. For breastfeeding dyads, how-
ever, it may be useful to obtain some additional information,
and to bear in mind that a particular diagnosis may have
additional ramifications for breastfeeding dyads. A useful
clinical guideline to keep in mind is the principle of
reciprocity: The baby’s feeding difficulties can shape the
Disclosures
Financial: Jamie Mahurin-Smith has no relevant financial interests to disclose.
Catherine Watson Genna earns income as a lactation consultant in private practice
and as the author of two books on breastfeeding.
Nonfinancial: Jamie Mahurin-Smith has no relevant nonfinancial interests to
disclose. Catherine Watson Genna has no relevant nonfinancial interests to disclose.
1
SIG 13 Swallowing and Swallowing Disorders (Dysphagia)

mother’s lactation success, which can in turn affect out-
comes for the baby. For example, SLPs are accustomed
to seeing variations in muscle tone, both hypotonia and
hypertonia. Like a hypotonic bottle-fed baby, a hypotonic
breastfed baby may require support to maintain adequate
intake. Unlike a hypotonic bottle-fed baby, a hypotonic
breastfed baby with suboptimal milk transfer is down-
regulating the mother’s milk supply, potentially creating
future issues with milk flow rate and weight gain. Similarly,
a hypertonic bottle-fed baby who clenches the jaw at feeding
time may require careful handling and positioning, and
may create premature wear on the bottle nipples used by
caregivers. The hypertonic breastfed infant who clenches
may cause maternal nipple pain and trauma, creating ad-
ditional downstream problems. These and other situations
are addressed in Table 1.
Some of the additional information that is relevant
for breastfeeding dyads includes perinatal history. Deliv-
ery via cesarean section with attendant maternal–infant
separation can affect the onset of copious milk produc-
tion (Dewey, Nommsen-Rivers, Heinig, & Cohen, 2003),
with implications for milk flow rates and successful es-
tablishment of breastfeeding. Similarly, a late preterm in-
fant (born at 34–36 weeks gestation; Engle, 2006) with an
uncomplicated perinatal course is likely to be discharged
quickly from the hospital but may feed inefficiently due
to neurological immaturity (Nagulesapillai, McDonald,
Fenton, Mercader, & Tough, 2013). This situation can
easily influence maternal milk supply and milk flow
rate, and merits particular consideration for the SLP
in an outpatient setting. As a final example, although
SLPs routinely ask about a history of respiratory prob-
lems, long-term intubation can create breastfeeding-
specific problems if palatal grooving results (Enomoto
et al., 2017; Wilson-Clay, 2002). Because the human
nipple is richly innervated, variations in a baby’s oral
anatomy can create pain for a breastfeeding mother,
sometimes with serious repercussions for successful feed-
ing. Some of these variations are reviewed in the follow-
ing section.
Observe the Baby at Rest
Key elements of the assessment include muscle
tone, activity level, state stability, symmetry across the
midline, and resting respiratory effort. An oral exam is
particularly important for breastfeeding infants. It should
include the status of cheek fat pads, which are impor-
tant for stability; palate shape, height, and width; and
mobility of the tongue, lip, and jaw. It is important to
note that relatively minor anatomical differences such
as a high palate or a bubble palate may cause maternal
pain with breastfeeding and lead to slow weight gain
(see Snyder, 1997). Similarly, tongue mobility restric-
tions that would not cause conspicuous disruption of
bottle-feeding may interfere significantly with breastfeed-
ing (Berry, Griffiths, & Westcott, 2012; Buryk, Bloom, &
Shope, 2011; Dollberg, Botzer, Grunis, & Mimouni,
2006; Geddes et al., 2008; Hogan, Westcott, & Griffiths,
2005). Digital assessment of the baby’s suck will allow a
clinician to observe tongue movement. It is not typically
necessary to introduce an artificial nipple to assess suck-
ing skills in a breastfeeding infant, since nonnutritive

Table 1. Interdisciplinary problem-solving for the breastfeeding dyad.

Potential solutions
Problem observed
during assessment Referral for infant Referral for mother

Tight frenum restricts tongue
movement.
Inefficient feedings cause
slow weight gain.
Nutritive sucking appears
uncoordinated.
Cyanosis noted during
feedings.
Cleft lip or palate interferes
with direct breastfeeding.
Torticollis or similar asymmetry
noted.
Thrush (white patches in baby’s
mouth indicating yeast
overgrowth).
Atypical muscle tone
interferes with effective
latch and milk transfer.
Refer to otolaryngologist or pedodontist with
experience in ankyloglossia for possible revision.
Consult with IBCLC on optimal supplementation
methods; for babies with congenital cardiac
anomalies, consult with registered dietitian
regarding fortification of human milk.
Consider ultrasound assessment of at-breast tongue
movement patterns.
Consult with pediatrician/neonatologist and respiratory
therapist to measure oxygen saturation.
Refer to credentialed cleft team. For cleft lip, consult
with IBCLC or occupational/physical therapist for
positioning strategies. For cleft palate, discuss
supplementation methods with IBCLC.
Refer to physical therapist for assessment/treatment.
Refer to pediatrician for coordinated treatment, even
if baby does not seem to be bothered by the
condition.
Consider neurology referral to determine cause;
consult with IBCLC to optimize latch and milk
transfer.
Refer to IBCLC to address nipple trauma.
Consult with IBCLC to assess milk supply.
Consult with IBCLC to rule out overactive milk
ejection reflex.
Refer to IBCLC for assessment of milk flow.
For cleft palate, refer to IBCLC for long-term
management of milk supply.
Refer to IBCLC to address potential
nipple trauma.
Refer to PCP or obstetric provider for
coordinated treatment; refer to IBCLC
for management strategies.
Consult with IBCLC to prevent nipple trauma
and preserve milk supply.

Note. IBCLC = international board-certified lactation consultant; PCP = primary care provider.

2 Perspectives of the ASHA Special Interest Groups • 1–5

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suck can be observed via digital exam or at an “emptied”
breast.1
Observe the Baby During a Feeding
As with assessment of nonnutritive suck, it is not
typically necessary to introduce artificial nipples to evalu-
ate feeding skills. In fact, preterm babies at breast demon-
strate better body temperature regulation and oxygenation
than their bottle-fed peers (Lucas & Smith, 2015; Meier,
1988). A typical newborn will use the face (Smillie, 2012)
and hands (Genna & Barak, 2010) to locate the nipple, dig
the chin into the breast below the nipple (Cantrill, Creedy,
Cooke, & Dykes, 2014) and gape widely with the tongue
down, grasp the breast with the tongue, and move closer
to the breast for a stable latch with the mouth. The jaws
are wide open, the upper lip is relaxed, the chin and cheeks
are against the breast, and the nose is close to the breast
(Cadwell, 2007). Sucking is initially rapid, with the jaw open
and closed for equal intervals. Milk ejection is usually elicited
within seconds to a minute.2 Nutritive sucking slows to
about one suck per second and takes on a deep, drawing
property, with a distinct pause as the mandible drops.
Swallows are identified as soft plosive sounds produced
by velopharyngeal closure. The infant should be able to
stay fixed to the breast with the anterior tongue, without
overstressing the lip or cheek muscles. The tongue should
do the primary work of keeping the infant fixed to the
breast and creating subatmospheric pressure (suction; Elad
et al., 2014). Overuse of lip or cheek musculature can be
compensatory for shallow attachment, tongue restriction,
or oral weakness. Milk transfer can be objectively deter-
mined by weighing the infant immediately before and after
feeding in the same clothing on a scale precise to 2–5 g
(Meier, Engstrom, Patel, Jegier, & Bruns, 2010). Human
milk weighs about 1 g per 1 ml. Several neonatal scales are
designed for test weighing of breastfed infants; they save
prefeeding weights and calculate milk intake on reweighing.
Consider Instrumental Assessment
SLPs often place particular emphasis on video-
fluoroscopic swallowing studies (VFSSs); in breastfeeding
infants, however, alternative approaches to instrumental
assessment can be particularly valuable. Fiberoptic en-
doscopic evaluation of swallowing (FEES) is increas-
ingly used in breastfeeding infants (Carro et al., 2017;
Willette, Molinaro, Thompson, & Schroeder, 2016); it is
described as a safe and effective procedure that is typi-
cally tolerated well. During FEES, natural feeding posi-
tions are maintained, secretion management can be assessed,
and strategies to improve swallowing safety such as prone
feeding and reduction of milk flow from the breast can
be evaluated, without concerns about radiation exposure.
1
Even immediately after a pumping session, the breasts are not entirely
empty.
2
Milk ejection refers to the physiological response in which oxytocin
triggers contraction of the myoepithelial cells within the breast.
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SIG 13 Swallowing and Swallowing Disorders (Dysphagia)
Information on protocols and procedures for at-breast
FEES assessment can be found in Reynolds et al. (2016).
Additional instrumental assessment approaches
can provide information about swallowing safety and effi-
cacy. Submental ultrasound is being used experimentally
to examine tongue movements during sucking (Burton,
Deng, McDonald, & Fewtrell, 2013; Elad et al., 2014;
Geddes et al., 2008; Sakalidis et al., 2013). Cervical
auscultation may warrant consideration as an adjunct
to clinical feeding assessment in infants; this tactic can
help assess respiratory stability and the coordination of
swallowing with breathing (Cichero & Murdoch, 2002;
Comrie & Helm, 1997; Frakking et al., 2016, 2017a, 2017b).
VFSS is commonly used to identify aspiration, but
should be interpreted with caution in breastfeeding infants.
The positions, feeding equipment, and barium mixtures
used poorly reflect breastfeeding mechanics (Cichero,
Nicholson, & Dodrill, 2011), and there is evidence that
infants coordinate swallowing better with human milk
than formula or water (Mizuno, Ueda, & Takeuchi, 2002).
Although VFSS is highly regarded as a tool for assessing
the safety and efficacy of swallowing in bottle-feeding in-
fants, it may offer a limited picture of a baby’s perfor-
mance at breast, where modifications in positioning,
flow rate, and fluid dynamics can alter feeding outcomes
substantially.
Make Appropriate Recommendations in Consultation
With Other Professionals
While many aspects of assessing the breastfeeding
dyad will be familiar to SLPs, solving breastfeeding
problems is frequently an interdisciplinary undertaking.
Resolution of complex problems in breastfeeding dyads
may require collaboration across multiple specialties. The
infant’s nurse, for instance, can share information about
the infant’s reactions to stimuli, tolerance for handling,
current medical condition, and maternal–infant interac-
tions. Table 1 summarizes some of the referrals that may
be appropriate for problems frequently encountered in
the breastfeeding dyad. Teamwork enriches the information
that each member has to work with and fosters a coherent
strategy that can be easier for the parents to implement.
Counseling Considerations
Supporting the breastfeeding dyad is not merely a
matter of adjusting a baby’s latch or improving sucking
coordination. Breastfeeding can evoke strong emotions,
ranging from intense elation to intense distress (Palmér,
Carlsson, Mollberg, & Nyström, 2012). SLPs and other
providers who work with breastfeeding dyads must be
sensitive to this emotional climate and to the reality that
maternal decisions about breastfeeding may be driven by
factors invisible to providers, including a history of abuse
or trauma (Bohn & Holz, 1996). The SLP scope of prac-
tice includes counseling families “regarding acceptance,
adaptation, and decision making” (American Speech-
Language-Hearing Association, 2007), and thus, SLPs
Mahurin-Smith & Genna: Assessing the Breastfeeding Dyad 3
SIG 13 Swallowing and Swallowing Disorders (Dysphagia)
may need to respond to mothers experiencing uncer-
tainty and frustration related to breastfeeding. In this
situation, it is important to avoid two pitfalls. On the
one hand, health care providers who are narrowly focused
on the importance of human milk might underestimate
the costs of providing it. Repeated unsuccessful attempts
to breastfeed can be painful, exhausting, demoralizing,
and expensive, and the authors unequivocally support the
right of a mother to determine the best time to discontinue
breastfeeding. On the other hand, mothers who value
breastfeeding report that their health care providers are
too quick to recommend formula supplementation or
weaning as the best solutions to perceived distress (Dill-
away & Douma, 2004), even when the mothers remained
motivated to continue breastfeeding. In counseling breast-
feeding mothers, SLPs are advised to recall that grief is a
normal response to the loss of the hoped-for newborn expe-
rience, and that, by its nature, grief is impervious to simple
solutions. Listening attentively to a mother’s feelings
without attempting to resolve them is a basic counseling
principle that applies in this context as well. Asking care-
ful questions can clarify a mother’s wishes regarding the
continuation of breastfeeding attempts. Establishing a net-
work of skilled contacts can facilitate problem-solving for
SLPs whose own experience with breastfeeding is more
limited. Sharing accurate information with other family
members, particularly fathers, is important as well, since
mothers’ perceptions of paternal attitudes are a chief de-
terminant of breastfeeding duration (Arora, McJunkin,
Wehrer, & Kuhn, 2000). In sum, SLPs counseling breast-
feeding mothers must sometimes navigate carefully: They
must provide new ideas and evidence-based assistance to
the mother who wishes to continue breastfeeding attempts,
support and acceptance to the mother who elects to stop,
and a listening ear to the mother who is ambivalent about
how to proceed.
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