Neonatal Back Arching During Breastfeeding
Back arching during breastfeeding is most commonly a sign of positional instability between mother and infant, indicating that the baby is struggling to achieve optimal positioning for effective milk transfer, rather than a medical condition requiring intervention. 1, 2
Primary Cause: Positional Instability
- Back-arching, along with difficulty latching or staying on the breast and fussing, are classic signs of infant positional instability during breastfeeding. 2
- These behaviors signal that the infant cannot achieve optimal intra-oral vacuum and breast tissue volumes needed for effective, pain-free milk transfer. 1
- The arching represents the infant's attempt to eliminate conflicting intra-oral vectors that interfere with proper sucking mechanics. 1
Common Misdiagnoses to Avoid
- These positional cues are frequently misdiagnosed as medical conditions or oral connective tissue abnormalities (such as tongue-tie), leading to unnecessary pharmaceutical interventions, surgical procedures like frenotomy, or manual therapy. 1, 2
- Over the past two decades, there has been an exponential increase in infants being treated with medications, laser or scissors frenotomy, and manual therapy for what is actually suboptimal positional instability. 1
When to Consider Gastroesophageal Reflux (GER)
While positional instability is the primary cause, GER should be considered in specific circumstances:
- Respiratory symptoms are more likely associated with GER when gross emesis occurs at the time of the episode, when episodes occur while the infant is awake and supine ("awake apnea"), and when obstructive apnea patterns are observed. 3
- Reflux-related laryngospasm has been temporally associated with 30% of brief resolved unexplained events (BRUEs) in infants. 3
- However, GER management should focus on nonpharmacologic measures: avoiding overfeeding, frequent burping during feeding, upright positioning in the caregiver's arms after feeding, and avoidance of secondhand smoke. 3
Recommended Management Approach
- Optimize mother-infant positional stability to eliminate conflicting intra-oral vectors and maximize intraoral breast tissue volume. 1, 2
- Address the underlying positional instability rather than pursuing medical workup or surgical intervention as first-line management. 2
- Focus on achieving pain-free, effective milk transfer through improved fit and hold techniques. 1, 2
- Breastfeeding is preferred over formula feeding, as the frequency of GER is decreased in breastfed compared with formula-fed infants. 3
Key Clinical Pitfall
The most important pitfall is attributing back-arching to medical conditions (reflux, tongue-tie, neurological issues) without first addressing positional instability, which leads to unnecessary interventions and does not resolve the underlying breastfeeding difficulty. 1, 2