Torticollis and Infant Feeding Explained

Torticollis and infant feeding: understanding head preference, neck movement and feeding function

Torticollis is a condition in which an infant's head tilts to one side, often with the chin turned towards the opposite side. It can be associated with restricted neck movement, muscular tightness or a preference for looking in one direction. Some infants with torticollis experience difficulties with breastfeeding or bottle feeding, particularly when a feeding position requires them to turn towards a less-preferred side.

Feeding involves more than the mouth. The head, neck, jaw, tongue, lips and cheeks work together with breathing, swallowing and postural control. When an infant has restricted movement or asymmetry, it may be helpful to consider how these factors interact during feeding.

However, torticollis does not automatically cause feeding difficulties, and feeding problems should not be attributed to head position alone. A thorough assessment considers the infant's movement, oral function, feeding method, milk transfer and the comfort of the feeding dyad.

What is torticollis?

The term torticollis describes an abnormal head position, usually involving a tilt to one side and rotation towards the opposite side. It is a clinical sign rather than a single diagnosis, and the underlying cause needs to be considered.

Congenital muscular torticollis is commonly identified during the first weeks or months of life. It involves tightness or shortening of the sternocleidomastoid muscle, which runs along each side of the neck. The muscle helps rotate and tilt the head, so differences in its length or function can affect the infant's range of movement.

Not every infant with a preferred head position has muscular torticollis. Some have a positional preference without clear muscle tightness or restricted passive movement. Other causes of an abnormal head position may also need consideration.

The Royal Children's Hospital Melbourne (2020a) describes both muscular and postural presentations and recommends assessment of head position, neck movement, craniofacial asymmetry and the infant's wider clinical presentation.

A head-turning preference may be noticeable during everyday activities, including being carried, lying on the floor, looking towards a caregiver or feeding. Some infants can turn comfortably in both directions but consistently choose one side; others have a more obvious restriction in movement.

The distinction matters because the appropriate management depends on the findings. A positional preference, muscular torticollis and an acquired or acute-onset head position should not automatically be treated as the same condition.

How can torticollis affect infant feeding?

An infant needs to bring their mouth comfortably towards the breast or bottle, open their mouth, establish an effective attachment and coordinate sucking, swallowing and breathing. Head and neck movement can influence how easily they achieve and maintain that position.

When an infant has restricted neck movement or a consistent head-turning preference, feeding may be easier in one position than another. This can be particularly noticeable during breastfeeding because the infant's approach to each breast differs according to the position used.

Watson Genna (2015) describes how muscular tension and associated craniofacial, spinal and hip asymmetries may contribute to breastfeeding difficulties in some infants with congenital torticollis. The article discusses positioning adaptations and support for comfortable movement as part of lactation care, alongside referral for physiotherapy when indicated.

These observations do not mean that every infant with torticollis will struggle to feed. Some feed effectively without additional support, while others may have difficulties that require a more detailed assessment.

Breastfeeding and chestfeeding

Breastfeeding requires the infant to achieve an effective attachment and coordinate tongue, jaw and other oral movements to remove milk. The position of the head and neck can influence how comfortably the infant approaches the breast and maintains that attachment.

An infant who consistently turns towards one side may find one breastfeeding position easier than another. Families may notice that the infant attaches readily to one breast but struggles on the other, repeatedly loses attachment, turns away or appears uncomfortable when positioned in a particular direction.

Some infants may feed well in one position but find another difficult. This can make the difference between positions a useful observation during assessment.

It is important not to assume that difficulty feeding from one breast means that the breast itself is the problem, or that the infant necessarily has a tongue-tie. The infant's head position, neck movement, oral function, latch, milk flow and the feeding parent's comfort all need to be considered.

My article on Breastfeeding Latch and Positioning discusses how the infant's position and freedom to move their head can influence attachment. How to Improve Infant Latch: Practical Breastfeeding Support also explores the factors that can affect an effective latch.

A feeding assessment can help establish whether changing the infant's position makes attachment easier, whether the infant can maintain a comfortable latch and whether milk transfer appears effective. Where there are ongoing difficulties, skilled breastfeeding support may be useful alongside assessment of neck movement.

Bottle feeding and torticollis

Bottle feeding also requires coordination between the infant's mouth, jaw, tongue, head and neck. Although the feeding method differs from breastfeeding, the infant still needs to maintain a comfortable position while sucking, swallowing and breathing.

An infant with restricted neck movement may find it difficult to maintain a comfortable head position during a bottle feed. Families might notice that the infant settles more readily when held on one side, turns their head away from the teat, struggles to maintain a seal or appears less comfortable in a particular feeding position.

These signs are not specific to torticollis. Similar behaviours may occur for several reasons, including difficulties with milk flow, teat characteristics, oral function, feeding coordination, discomfort or previous stressful feeding experiences.

The position used for bottle feeding is therefore worth considering as part of the assessment. The infant should be well supported, with their head and neck in a comfortable position that allows them to breathe and swallow without restriction. They should not be forced to turn their head against their preferred movement or held in a position that appears uncomfortable.

My article on Bottle Feeding Positions explains how positioning can be adapted while keeping the infant's comfort and feeding cues central to the feed. How to Pace Bottle Feeds: A Calm, Practical Guide discusses responsive pacing and recognising when an infant needs a pause.

The bottle and teat should also be considered. Teat shape, flow and the way the infant attaches can affect feeding mechanics, although no particular teat can correct torticollis or guarantee effective feeding. Choosing Bottles and Teats explores these considerations, while Choosing the Best Bottles for Tongue-tied Infants considers bottle-feeding choices where oral restriction is also being assessed.

Where tongue movement is restricted, an infant may have difficulty maintaining a seal or coordinating oral movements. Bottle Feeding With Tongue Restriction discusses these possible difficulties. Torticollis and tongue-tie may coexist, but neither diagnosis should be assumed from the other.

If an infant begins refusing a bottle, becomes increasingly distressed or accepts progressively less milk, it is important to consider the full feeding history rather than assuming that head position explains the behaviour. My article When Your Baby Suddenly Refuses the Bottle discusses possible reasons for a change in bottle-feeding behaviour.

Sucking, swallowing and breathing

Effective feeding requires coordination between sucking, swallowing and breathing. The infant must manage milk flow while maintaining a safe and sustainable pattern of oral movement and respiration.

Research into breastfeeding mechanics has used ultrasound and other methods to investigate tongue movement, intra-oral vacuum and milk transfer (Geddes and Sakalidis, 2016; Sakalidis and Geddes, 2016). These studies help explain the complexity of feeding, although findings from breastfeeding research should not automatically be applied to every bottle-feeding situation.

Head and neck position may be relevant to feeding comfort and coordination, but the presence of torticollis alone does not establish that an infant has a swallowing or respiratory problem.

During an observed feed, it may be useful to consider whether the infant maintains a comfortable position, attaches effectively, sustains sucking, pauses appropriately and appears able to coordinate breathing with swallowing. Persistent coughing, choking, colour changes, breathing difficulty or repeated episodes of distress during feeds require appropriate clinical assessment rather than simply changing the feeding position.

Bottle-feeding research also highlights that the feeding method involves interactions between the infant, the caregiver and the equipment used (Kotowski et al., 2020). A teat's flow characteristics, the way the bottle is held and the caregiver's response to the infant's cues may all influence the feeding experience.

Where an infant appears to swallow excessive air or needs frequent pauses, the cause should not automatically be attributed to torticollis. My article How to Wind a Baby During and After Feeds provides further information about winding, while Recognising Feeding Cues in Young Babies explores how infants communicate their readiness to feed, need for a pause and signs of having had enough.

The relationship between the head, neck and jaw

The jaw and the surrounding oral structures contribute to attachment, suction and milk transfer. The mandible, or lower jaw, needs to move in coordination with the tongue, lips and cheeks during feeding.

An infant with restricted neck movement may adopt compensatory positions to bring their mouth towards the breast or teat. In some cases, the head position may also influence the apparent alignment of the jaw or the ease with which the infant opens their mouth.

Wall and Glass (2006) described mandibular asymmetry in a small case series involving breastfeeding difficulties. Such reports can help clinicians recognise possible relationships between asymmetry and feeding, but a case series cannot establish that one feature causes another or that the same pattern occurs in every infant.

It is useful to observe how the infant's head, jaw and mouth move together during feeding rather than treating these structures as separate systems. However, an apparent asymmetry does not automatically indicate a structural abnormality, and it should be interpreted in the context of the infant's age, movement, feeding function and clinical assessment.

My articles Infant Oral Anatomy: Structure, Function and Feeding and A Guide to Understanding Your Baby’s Oral Function explore the relationship between oral structures and feeding mechanics.

Torticollis, head shape and positional asymmetry

Some infants with torticollis also develop positional plagiocephaly, which describes asymmetrical flattening of the skull. Brachycephaly describes a relatively broad, short head shape, often associated with flattening across the back of the head.

When an infant consistently rests or turns their head in one direction, pressure may be concentrated on the same area of the skull. Restricted neck movement and a preferred head position may therefore be relevant when considering head shape and movement together.

The Royal Children's Hospital Melbourne (2020a) includes craniofacial asymmetry among the features that may be seen in congenital muscular torticollis. The relationship between head shape, neck movement and feeding is not straightforward, however. Positional flattening does not, by itself, demonstrate that feeding is impaired, and feeding difficulties do not establish that skull shape is responsible.

My article Infant Skull Shape and Infant Feeding discusses how head shape, jaw position and feeding mechanics may be considered together without assuming a direct causal relationship.

Families should follow safer-sleep guidance and place infants on their backs for sleep, on a firm, flat surface. Advice about awake-time positioning, supervised tummy time and encouraging comfortable head movement should be appropriate to the infant's age and development and should not compromise safe sleep.

What might families notice?

The signs associated with torticollis vary. Some families notice a head-turning preference before feeding difficulties become apparent; others seek feeding support first and only later recognise that their infant consistently prefers one direction.

Observations that may be useful to discuss with a healthcare professional include:

• consistently turning the head towards one side;

• difficulty turning comfortably in the opposite direction;

• a persistent head tilt;

• finding one breastfeeding position easier than another;

• appearing less comfortable when bottle fed in a particular position;

• repeatedly losing attachment or struggling to maintain a seal;

• visible asymmetry of the head or face;

• difficulty settling into certain feeding positions.

None of these observations alone establishes a diagnosis or identifies the cause of a feeding difficulty. They are useful pieces of information to include in a wider assessment.

Families may find it helpful to note whether the infant's feeding changes with position, whether the same pattern occurs at the breast and bottle, and whether the infant appears comfortable between feeds. A short video of a typical feeding position may sometimes help a healthcare professional understand what the family is observing, provided it is recorded safely and does not delay assessment when there are urgent concerns.

Assessment and management

Assessment should consider the infant's head position, neck range of movement, muscle function, general movement, development and any associated asymmetry. The healthcare professional should also consider whether the presentation is consistent with congenital muscular torticollis or whether another cause needs to be investigated.

The Royal Children's Hospital Melbourne (2020a) recommends that infants with suspected congenital muscular torticollis receive appropriate clinical assessment. Physiotherapy referral may be indicated where movement is restricted, the presentation is more severe or improvement is limited. The management plan depends on the infant's clinical findings.

A feeding assessment is complementary to, rather than a replacement for, assessment of neck movement. It may involve observing a breast or bottle feed, considering the infant's position and attachment, and assessing sucking, swallowing, breathing, milk transfer and the comfort of the feeding dyad.

Where an infant has difficulty feeding, it is important to consider the impact on intake, hydration and growth. Concerns about poor milk transfer, reduced urine output, lethargy, persistent feeding distress or faltering weight gain require timely clinical review.

A sudden onset of torticollis, a head position associated with significant pain, fever, unusual drowsiness, neurological symptoms or other signs of acute illness should not be assumed to be congenital muscular torticollis. Such presentations need prompt medical assessment. The Royal Children's Hospital Melbourne (2020b) provides guidance on acquired torticollis and the importance of considering other causes.

Physiotherapy and body therapy

Physiotherapy can play an important role in the management of congenital muscular torticollis. Paediatric physiotherapists assess the infant's movement and may provide guidance on positioning, handling, appropriate exercises and opportunities to develop comfortable movement.

The 2024 evidence-based clinical practice guideline from the American Physical Therapy Association Academy of Pediatric Physical Therapy sets out recommendations for the assessment and management of congenital muscular torticollis (Sargent et al., 2024). Management should be guided by the infant's individual presentation and delivered by an appropriately qualified practitioner.

Families sometimes also explore other hands-on or body-based approaches when an infant has asymmetry, muscular tension or feeding difficulties. These approaches do not all have the same evidence base, scope of practice or proposed mechanism. Evidence for one intervention should not be treated as evidence for another, and a change in posture or perceived tension does not, by itself, demonstrate improved feeding function.

Any body-based approach should be considered in the context of the infant's clinical needs, with appropriate professional qualifications, clear consent and safe handling. It should not delay medical assessment or recommended physiotherapy. There is also no reason to assume that every infant with torticollis needs additional hands-on treatment.

Body therapy does not replace an assessment of feeding. Where a family is concerned about attachment, milk transfer, bottle acceptance or feeding comfort, these aspects need to be assessed directly.

The role of an infant feeding specialist and IBCLC

An infant feeding specialist can assess feeding mechanics and help identify whether the infant's head position or movement appears to affect feeding. Depending on the practitioner's qualifications and scope of practice, this may include observing breastfeeding or bottle feeding, considering attachment and positioning, assessing oral function and discussing responsive feeding strategies.

An International Board Certified Lactation Consultant (IBCLC) can provide specialist lactation care, including assessment of breastfeeding difficulties and support for families who are expressing milk or combining feeding methods. An IBCLC may also work alongside other healthcare professionals where an infant has torticollis or another condition affecting feeding.

A feeding assessment should not be limited to finding a position that appears easier. It should also consider whether the infant is transferring milk effectively, whether the feeding parent or caregiver is comfortable, and whether the feeding plan is sustainable for the family.

Further information is available in What Does an Infant Feeding Specialist Do?, What Is an IBCLC? Feeding Support Explained and Lactation Support: What Does a Lactation Consultant Do?.

Is tongue-tie related to torticollis?

Tongue-tie, or ankyloglossia, describes a lingual frenulum that restricts tongue movement and is associated with functional difficulty. It is a separate consideration from torticollis, which concerns head position and neck movement.

Some infants may have both conditions, and both may be relevant to feeding assessment. However, the presence of torticollis does not establish that an infant has tongue-tie, and tongue-tie should not be diagnosed solely because an infant has difficulty latching, prefers one feeding position or has facial asymmetry.

Where tongue restriction is suspected, assessment should consider the infant's tongue structure and function alongside a detailed feeding history and observation of feeding. The aim is to determine whether restricted tongue movement is contributing to the functional difficulty, rather than attributing all feeding problems to the appearance of the frenulum.

My article What Does a Tongue-tie Assessment Consider? explains the factors that may be considered during assessment. Where a division has been performed, Beyond a Tongue-tie Release: Why Aftercare Matters discusses follow-up and feeding support. The article Tongue-tie Release Exercises provides further information about exercises and oral movement.

A tongue-tie procedure does not treat torticollis. If restricted neck movement is present, it needs its own assessment and appropriate management. Similarly, addressing torticollis does not necessarily resolve feeding difficulties that have another contributing cause.

Supporting the feeding dyad

When an infant has torticollis alongside feeding difficulties, support is most useful when it responds to the needs of that individual feeding dyad. There is no single position or intervention that will suit every infant.

Practical support may include:

• identifying feeding positions that allow the infant to remain comfortable without forcing neck movement;

• observing attachment, sucking, swallowing and breathing during an actual feed;

• reviewing bottle-feeding position, pacing and teat characteristics where relevant;

• assessing oral function when feeding difficulties indicate that this is appropriate;

• arranging physiotherapy or medical assessment when neck movement is restricted or the clinical presentation warrants it;

• monitoring feeding effectiveness, milk intake and growth;

• coordinating care between the relevant healthcare professionals.

For some families, a small change in positioning may be enough to improve comfort. Others may need a combination of feeding support, physiotherapy and medical follow-up. The plan should be guided by assessment and reviewed in response to the infant's progress.

Where breastfeeding is difficult, families should not be left feeling that they must repeatedly try new positions without understanding why feeding is uncomfortable or ineffective. Where bottle feeding is difficult, the response should not automatically be to change the bottle or teat without considering the infant's movement, oral function, feeding cues and overall clinical presentation.

The aim is to understand what is happening during feeding and to identify support that is appropriate to the cause of the difficulty.

Conclusion

Torticollis and positional preference can be relevant to infant feeding because head and neck movement contribute to the position in which an infant attaches to the breast or teat. Some infants find feeding easier on one side or in one position, while others feed effectively despite an observable head preference.

The presence of torticollis does not automatically mean that feeding will be affected, and feeding difficulties should not be attributed to torticollis, tongue-tie or any other single factor without appropriate assessment.

Considering head and neck movement alongside oral function, feeding mechanics, milk transfer and the infant's wider clinical presentation can help families and practitioners understand what support may be needed. Where restricted neck movement is present, appropriate clinical assessment and physiotherapy may be important. Where feeding difficulties coexist, skilled infant-feeding support can help the feeding dyad work towards comfortable and effective feeding.

References

Geddes, D.T. and Sakalidis, V.S. (2016) ‘Ultrasound imaging of breastfeeding—a window to the inside: Methodology, normal appearances, and application’, Journal of Human Lactation, 32(2), pp. 340–349. Available at: https://doi.org/10.1177/0890334415626152.

Kotowski, J., Fowler, C., Hourigan, C. and Orr, F. (2020) ‘Bottle-feeding an infant feeding modality: An integrative literature review’, Maternal & Child Nutrition, 16(2), e12939. Available at: https://doi.org/10.1111/mcn.12939.

Royal Children's Hospital Melbourne (2020a) ‘Clinical practice guidelines: Congenital torticollis’. Available at: https://www.rch.org.au/clinicalguide/guidelineindex/CongenitalTorticollis/.

Royal Children's Hospital Melbourne (2020b) ‘Clinical practice guidelines: Acquired torticollis’. Available at: https://www.rch.org.au/clinicalguide/guidelineindex/Acquiredtorticollis/.

Sakalidis, V.S. and Geddes, D.T. (2016) ‘Suck-swallow-breathe dynamics in breastfed infants’, Journal of Human Lactation, 32(2), pp. 201–211. Available at: https://doi.org/10.1177/0890334415601093.

Sargent, B., Coulter, C., Cannoy, J. and Kaplan, S.L. (2024) ‘Physical therapy management of congenital muscular torticollis: A 2024 evidence-based clinical practice guideline from the American Physical Therapy Association Academy of Pediatric Physical Therapy’, Pediatric Physical Therapy, 36(4), pp. 370–421. Available at: https://doi.org/10.1097/PEP.0000000000001114.

Wall, V. and Glass, R. (2006) ‘Mandibular asymmetry and breastfeeding problems: Experience from 11 cases’, Journal of Human Lactation, 22(3), pp. 328–334. Available at: https://doi.org/10.1177/0890334406290096.

Watson Genna, C. (2015) ‘Breastfeeding infants with congenital torticollis’, Journal of Human Lactation, 31(2), pp. 216–220. Available at: https://doi.org/10.1177/0890334414568315.