Introduction

Breastfeeding provides substantial nutritional, immunological, and developmental benefits for infants and important health benefits for mothers.1 Despite these advantages, breastfeeding difficulties occur in approximately 25–45% of mother–infant dyads during the early postpartum period.2

One anatomical factor frequently associated with breastfeeding dysfunction is ankyloglossia, commonly referred to as tongue-tie. This condition involves a restrictive lingual frenulum that limits tongue mobility and may impair an infant’s ability to generate adequate intraoral vacuum or maintain an effective latch during breastfeeding.3 Prevalence estimates range from 4–11% of newborns.4

In addition to lingual restriction, infants may present with labial or buccal tethered oral tissues, which may further impair oral mechanics.5 Several assessment tools have been developed to evaluate lingual function, including the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF),6 Kotlow,2,3,5 and Bristol Tongue Assessment Tool (BTAT).2,5 While these tools primarily focus on oral anatomy and tongue function, the WING Method expands assessment beyond the oral cavity by evaluating whole-body biomechanical patterns—including lumbopelvic mobility, trunk rotation, cervical movement, shoulder mobility, and oral structures—to identify neuromuscular tension patterns that may influence feeding and infant regulation. In this way, the WING Method complements existing oral restriction assessments by providing a broader functional screening framework that integrates musculoskeletal and oral-motor factors involved in infant feeding.

Some clinicians have observed that infants with feeding dysfunction may also demonstrate patterns of musculoskeletal tension involving the cervical spine, thoracic cage, and pelvis.7 Proposed explanations include altered feeding mechanics, neuromotor compensation, and fascial continuity between craniofacial and cervical structures.8 However, there is no standardized system of evaluation that draws attention to how other parts of a system may affect the dynamic of another.

Tongue ties may lead to functional adaptations that alter biomechanical patterns. Similar to compensatory movement patterns observed following orthopedic injury (i.e. a broken foot requiring a boot), altered oral mechanics may lead to secondary adaptations in cervical, thoracic, and pelvic movement patterns. There are problems arising from the present issue (i.e. broken foot), altered biomechanics along artificially unbalanced motion planes (i.e. the use of boot while healing), as well aberrant lingering biomechanical artifacts associated with compensation even though the issue had attempt to be resolved (i.e. walking funny after boot is removed).

The WING Method was developed as a structured observational framework designed to document not only oral mobility but broader musculoskeletal tension patterns in infants that exist with any functional deficits such as feeding difficulties. Finding these patterns can be essential in assisting in proper diagnosis of aberrant movement patterns, assessment of individual or global interventions, and proper detection of lingering post-intervention biomechanics that must be addressed in order to see full or near full resolution.

The purpose of this case study is to describe the clinical presentation, interdisciplinary management, and observed musculoskeletal patterns of an infant with breastfeeding dysfunction and tethered oral tissues assessed using the WING Method observational framework.

Case Report

This paper discusses an infant with breastfeeding dysfunction and tethered oral tissues who underwent interdisciplinary evaluation and management in a private outpatient clinical setting. The baby was evaluated as part of routine clinical care for breastfeeding difficulties. Caregivers provided informed consent for clinical documentation and anonymized use of data for educational and research purposes. This report was prepared following the CARE reporting guidelines for case reports.

The infant was born at term without major perinatal complications. He had previously been evaluated by a lactation consultant and demonstrated some persistent feeding dysfunction despite initial lactation support. Lactation consult noted an infant at 4 weeks of age with lingual and lip ties, with clicking, poor latch and maternal nipple pain.

Common presenting symptoms included: Prolonged feeding sessions, Audible clicking during feeds, Difficulty maintaining latch, and Infant irritability during feeding. Intraoral examination identified lingual restriction and buccal tethering.

Wing Method Observational Findings

The baby had the following observed musculoskeletal patterns: cervical spine with reduced rotation symmetry, shoulders with elevated resting position, rib cage with limited expansion during inspiration, and a pelvis with increased hip flexor tone and limited extension.

Intervention

Management consisted of 3 coordinated components. The patients were seen for 2 combination visits prior to and 3 post-frenotomy9 (seeing both a lactation consultant and conservative manual therapy assessment and treatment)

Lactation Management

The infant continued lactation care with an International Board-Certified Lactation Consultant (IBCLC). Interventions included: Positioning adjustments, Latch optimization, and Post-frenotomy oral exercises.

Frenotomy

Lingual frenotomy was performed by a trained provider. Labial frenotomy was also performed when clinically indicated. Frenotomy has been shown in multiple studies to improve breastfeeding outcomes in infants with symptomatic ankyloglossia.10–12

Manual Therapy

Manual therapy was delivered over 5 visits (2 pre-frenotomy, 3 post-frenotomy), each lasting approximately 30 minutes and directed at cervical soft tissue restriction, thoracic excursion, diaphragmatic mechanics, inter and intraoral exercises and passive hip mobility. All (infant lead) interventions were in line with passive range-of-motion and low-force mobilization techniques appropriate for neonatal musculoskeletal care9,13 and consistent with commonly described paediatric manual therapy approaches. All manual therapy interventions were guided by findings from the WING assessment. Caregivers were additionally instructed in home exercises, positioning modifications, and interval symptom monitoring guided by serial WING assessments.

Outcomes

Improvements were observed in oral function, musculoskeletal patterns, and feeding behaviour.

  • Oral Findings included across interventions: Improved tongue elevation, improved lateral tongue movement, and improved lip eversion during latch.

  • Musculoskeletal Findings Post-Frenectomy Demonstrated: Improved cervical rotation symmetry, reduced shoulder girdle tension, increased rib cage expansion during breathing, and reduced hip flexor resistance (i.e. Improvement in WING scoring).

  • Functional Feeding Outcomes for Caregiver Reports Included: Shorter feeding duration, improved latch stability, reduced audible clicking, and reduced infant irritability.

Subject noted improved over 5 visits (2 pre and 3 post-frenectomy). Subject presented with a cumulative WING total score of 34 on initial presentation and was discharged at a 1.

Discussion

This case study describes an infant with breastfeeding dysfunction and tethered oral tissues who also demonstrated observable musculoskeletal tension patterns.

Ankyloglossia has been widely recognized as a contributor to breastfeeding difficulty. Restricted tongue mobility may impair the infant’s ability to generate intraoral vacuum and maintain effective latch mechanics.3 Frenotomy has been shown in several randomized and observational studies to improve breastfeeding outcomes.10–12,14

Beyond intraoral mechanics, some clinicians have proposed that feeding dysfunction may be associated with broader neuromusculoskeletal adaptations.15 Fascial continuity between craniofacial, cervical, and thoracic structures may contribute to compensatory movement patterns during feeding.8

Manual therapy directed at cervical and thoracic regions has been reported in several studies to improve breastfeeding function in infants with feeding difficulty.16,17

The WING Method was developed as an exploratory observational framework intended to document both oral mobility and broader musculoskeletal patterns during infant feeding assessment and placing them into a 0-3 scale and scoring it both orally and in whole bodied biomechanics. The WING Method is not a replacement for oral restriction classifications such as HATLFF, Kotlow, and BTAT but rather a complementary functional screening that contextualizes oral findings within whole-body neuromechanical patterns. A comparison chart is provided (Table 1).

The WING Method is a structured observational framework designed to evaluate both oral function and global musculoskeletal movement patterns in infants presenting with feeding dysfunction. The assessment integrates intraoral examination with passive and observational movement testing of cervical, thoracic, and pelvic regions.

The WING Method uses a structured 5-domain observational scoring system incorporating oral mobility, cervical motion, shoulder tone, thoracic expansion, and pelvic mobility. Each domain is scored using a 0–3 observational grading scale, with higher scores indicating increased restriction or tension.

For example: A score of 0 (normal) would be noted as Symmetric movement, relaxed tone, no observable distress, score of 1 (mild variation) would be noted as slight asymmetry, hesitation, or mild increase in tension during movement, score of 2 (moderate restriction) would be noted as clear resistance to movement, observable compensatory patterns, or guarding, and a score of 3 (significant finding) would be noted as defensive response, marked restriction, or inability to complete the assessed motion

A Note on scores: They are assigned based on observational assessment of movement quality, symmetry, tone, and infant response during passive or active motion testing. This scoring system is used within the Wing Method observational framework to document movement quality and musculoskeletal tension patterns across cervical, thoracic, and pelvic regions during infant assessment.

This report suggests that clinicians evaluating infants with breastfeeding dysfunction may benefit from incorporating broader musculoskeletal observation into clinical assessment. Recognition of cervical mobility restriction, rib cage motion asymmetry, and global tone patterns may assist in identifying infants who could benefit from interdisciplinary care including lactation consultation, medical evaluation, and conservative manual therapy.

Table 1.Comparative features of wing method and common infant feeding assessment tools
Feature WING Method™ Hazelbaker (HATLFF) Kotlow Classification BTAT
Primary focus Whole-body biomechanical and feeding assessment Tongue anatomy and function Tongue-tie severity grading Tongue-tie screening for breastfeeding
Assessment type Functional + movement-based Functional + anatomical oral assessment Structural / anatomical Focused oral functional screening
Primary clinical scope Oral function + global musculoskeletal mechanics Oral function and tongue mobility Lingual frenulum attachment severity Tongue appearance and mobility
Body regions evaluated Spine, pelvis, trunk, neck, shoulders, diaphragm, oral structures Tongue and limited oral function Lingual frenulum only Tongue and oral structures only
Assesses tongue mobility Yes Yes Limited Yes
Evaluates lip / buccal restrictions Yes Limited No Limited
Evaluates cervical mobility Yes No No No
Evaluates breathing mechanics Yes No No No
Evaluates global tone patterns Yes No No No
Scoring method Multi-domain functional scoring Numeric function + appearance score Distance-based classification Four-item numeric score
Clinical emphasis Feeding mechanics, posture, tone, and movement integration Tongue function during feeding Anatomical restriction severity Screening breastfeeding-related tongue dysfunction
Typical users DC, PT, OT, IBCLC, MD, Dentist, SLP IBCLC, SLP, MD, ENT Dentist, ENT, IBCLC IBCLC, MD, SLP

Additionally, future use and refining of WING method made aid in clinical best practices and establish order of effective clinical management and referral/co-treatment. For example, a score of 0-1 warranted minor to no intervention, 1-2 would monitor/treat/co-treat, and 2-3 would be very clinically relevant and should include treat/co-treat/refer for multidisciplinary intervention.

Limitations

This case study describes a single patient and lacks a control group. Multiple interventions, including lactation support, frenotomy, and manual therapy, were performed concurrently, making it difficult to determine the relative contribution of each component to observed outcomes. Additionally, outcome measures were primarily observational and based partly on caregiver report rather than standardized feeding assessment tools. Future studies should include validated feeding metrics, blinded examiners, and evaluation of inter-rater reliability scoring consistency across examiners for the WING Method scoring system.13

Conclusion

Infants presenting with tethered oral tissues and breastfeeding dysfunction may also demonstrate patterns of global musculoskeletal tension. The WING Method may provide a structured observational framework for documenting relationships between oral restriction and musculoskeletal patterns, along with global biomechanical dysfunction outside of just oral tethers. Further research is needed to determine the clinical relevance and reliability of this assessment approach. Additionally, improvements in feeding outcomes may reflect the combined effects of frenotomy, lactation support, and manual therapy rather than any single intervention, so future research using stepwise or controlled intervention designs may help clarify the relative contributions of each component of care.