Breastfeeding the Child with Torticollis
In honor of World Breastfeeding Week, I decided to prioritize writing this piece. Torticollis is a common issue for infants and as I found personally, it can complicate breastfeeding considerably. Despite these factors, torticollis is often unrecognized and information on how to troubleshoot breastfeeding in this circumstance is limited. So this piece has information that I have gleaned from a few sources, my own OT background, and my recent experience with my son. 
Torticollis is a term to describe a "twisted neck." The etiology of congenital torticollis is not known, and can affect 1-2% of children. The newborn may present with a head preference, plagiocephaly, and/or asymmetries of the head and face. The slightly older infant may have any of these signs, and may resist certain position changes (especially tummy time), may not turn his head easily, and may have difficulty with feeding. (1,2,4,6,7) His jaw may look uncoordinated or have excess lateral movement (5). A doctor can easily screen a child for torticollis during a well-child visit, but OB & pediatric nurses, midwives, doulas, lactation consultants and of course early intervention therapists should be familiar with the signs and assess for torticollis if the child is having any of the above problems.
I think it's very important to stress to new moms that it is 1) not their fault, 2) easy to treat in a conservative fashion, and 3) will likely resolve without residual deficits in a short amount of time. The Virginia EI Providers site has an excellent, evidence-based entry on intervention strategies for the child with torticollis (I intend to make an entry here on a few further OT strategies in the future) but does not fully address feeding.
If a child has even a mild torticollis, such as my son, there can be a big impact on breastfeeding. What I first noticed was that though I was using the same hold on each side, he was not able to latch well on the left. Even though it was a short time that he exhibited this side preference, it had an effect on my milk supply and pain was also greater on this side. We had to use only the easiest positions (see chart) initially and continue to use these for the majority of our feeding sessions. This led to plugged ducts (and more pain!) and need to use a pump to fully express on the affected side.
For a child who has a poor latch, or is frequently coming off the breast (especially if only on one side) be sure to first try any latch suggestions from the lactation consultant or therapist (C-hold, scissor hold, pressing on the upper breast to bring nipple forward, etc (5). The lactation consultant or therapist should also assess for tongue-tie. A nipple shield may minimize the pain felt by mom when there is a poor latch, and can improve the baby's ability to get milk. (5) A pillow or positioner (such as a Boppy or My Brest Friend) can assist with holding the baby, which will allow your hands more flexibility to help hold the breast and baby's head. Stabilizing his head may be necessary to help him get a good suckling pattern.
In the straddle position, the baby straddles your leg and faces you while you are reclined. He may need chin support in this position. Prone position with baby directly on top of mom may be difficult on either side until the muscles are no longer tight. (2,8) Offering chin and cheek support may assist with harder positions, as your baby may not be able to make a tight seal on one side. (5) An OT or lactation consultant should be able to demonstrate how to support the chin and cheek, and may recommend non-nutritive sucking (pacifier, finger, etc) to work on strengthening his muscles.
Another consideration for feeding is the baby's fatigue level. If he is a sleepy feeder or falling asleep while eating frequently, the effort of feeding may be overly fatiguing. This is another good reason to use an easy position when baby is newborn and trying to regain his weight, and also for anytime that baby might be especially tired (first thing in morning, before bed, etc). Baby may need to take a break between sides, or may need a bottle if still hungry following 15-20 minutes at one breast.
An environmental factor that may also need to be addressed regarding breastfeeding is mom's attentiveness. I am guilty of being distracted during feedings with TV or phone or falling asleep. I also had multiple health professionals recommend that I spend the time feeding my baby also eating a snack, doing kegels, calling my friends, reading a book, or pumping the opposite side. But being watchful of your baby will let you know if he's having trouble making a seal, sucking at an appropriate pace, or getting frustrated. So give yourself permission to be fully present during feedings especially if they are difficult.
In my opinion, it is best to establish the breastfeeding relationship first and give the baby positive experiences and nutrition than to "therapy-ize" this time and work on head turn to the weak side. (2,5) Obviously, if your baby isn't getting enough nutrients (which may especially be the case with a premature infant or one who is not gaining weight quickly) he isn't going to have the energy or attitude to give effort to therapy-type activities. There are plenty of good suggestions for how to encourage active and passive range of motion at times outside of feeding. (4)
Once baby is displaying good active and passive ROM at other times during the day and feeding well, it can be a good time to work on adjusting to new positions. I started by trying a "harder" position during 2 feedings each day, during the first half of the feeding. As his endurance improved, we were able to take some feedings and try a harder position on each side. We continue (at 3 months) to have the last feeding of the day and any nighttime feedings be done strictly in the easier positions, but have been able to progress to a 50-50 split of easy and hard positions the rest of the day. This is after about a month of practice, after his neck was almost entirely corrected at 2 months.
Though my son's torticollis did make breastfeeding difficult and at times quite painful, I'm glad that we were able to persevere and correct the problem in a relatively short amount of time. We started bottles very early due to his fatigue but were able to get to breastfeed about 90% of the time before I returned to work. Bottles are not the enemy (and you can use expressed milk) but by using these strategies hopefully others will have an easier breastfeeding journey if they choose. There are lots of people who may be helpful during your journey, such as your pediatrician, lactation consultant, OT, or local La Leche League members.
Disclaimer: If the child's torticollis is more severe, the result of a neurological condition, or there are other comorbidities, it may take longer to resolve. No part of this piece should be taken as medical advice, and since each child is different you should discuss any potential treatment with your doctor or therapist. Remember that all states have provisions for free early-intervention services for children under 3, and if your child is having difficulties he can be assessed by a multidisciplinary team.
Resources/References (sorry, no APA formatting or proper numerical listing)
1) LLI Center for Breastfeeding Information- Journal Abstract of the Month for December 2006 “Mandibular asymmetry and breastfeeding problems: experience from 11 cases.”
2) ILCA's Inside Track - Helping your baby with torticollis (pdf) ***
3) Torticollis and Breastfeeding (personal story)
4) Strategies for working with children with torticollis -VEIPD ***
5) Supporting Sucking Skills in Breastfeeding Infants By Catherine Watson Genna (book)
6) UpToDate Literature Review- Congenital Muscular Torticollis
7) Torticollis wikipedia
8) Breastfeed.com Techniques Beyond the Basic Four Holds
10) Breastfeeding Basics ***
*** = awesome
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