THE MAMA ‘HOOD ON TONGUE TIE, April 2017

the mama ‘hood’s Lactation Team: We are International Board Certified Lactation Consultants The mama ‘hood’s expert lactation team delivers evidence-based lactation support to families who come to us from across the entire state of Colorado. Since opening our doors in 2012, we have had over 11,000 visits for breastfeeding support – either through our daily community-supported and expert led groups or in 1-to-1 consults.

What is Tongue Tie? According to the American Academy of Pediatrics, “Tongue Tie (ankyloglossia) is a condition in which the bottom of the tongue is tethered to the floor of the mouth by a membrane (frenulum) so that the tongue’s range of motion is unduly restricted. This may result in various oral development, feeding, speech, swallowing, and associated problems. Genetic factors are suspected, as tongue-tie is frequently familial. Tongue-ties can be divided into four types, according to how close to the tip of the tongue the leading edge of the frenulum is attached.” (AAP, 2003)

How do we Identify Tongue Tie? At the mama ’hood, we do not diagnose tongue tie. Our Breastfeeding providers are IBCLCs and our scope of practice allows us to examine the mother’s breasts and the infant’s mouth. If we feel a restriction and suspect a tether may be part of the feeding challenge, it is our duty to refer the family to a qualified provider (typically an ENT or Pediatric Dentist for diagnosis and treatment which is a quick procedure in office either with sterile scissors or a special laser.

Numbers Illuminate Trends There is an overwhelming body of medical literature that demonstrates the important role functional infant anatomy plays in successful breastfeeding. However, only after the mama ‘hood’s lactation team saw 1,000s of damaged nipples and babies who were not growing well did we become true believers in the direct correlation with tethered oral anatomy.

Furthermore, the outcomes following the release of a tether are overwhelmingly positive, as evidenced by the mama ‘hood’s Oral Anatomy Survey conducted in November, 2016. Once the tether has been released the mother’s pain was reduced or went away and baby’s feeding and weight gain got on track.

Tongue Tie is Genetic – it is Nothing New! When we see/feel a tethered tongue or lip, we explore family history – tethered oral anatomy is genetic and has likely been an issue since the days of the caveman/woman. Interestingly, tongue tie is also mentioned in The Bible. More often than not, we find that one or both of the parents also had issues related to their tether that was not understood to be caused by their tongue. A tongue that doesn’t move freely may cause speech issues, food texture preferences because the tongue protects the airway, sleep apnea, neck and back pain

Yes, Opinions Vary The difference of opinion regarding tongue tie appears to be closely tied to perspective and training. According to the American Academy of Breastfeeding Medicine (ABM) Tongue Tie forum in October 2016, “10% of pediatricians vs 70% of lactation consultants believe tongue tie causes feeding difficulties.”

The Breastfeeding Dyad : A holistic approach to breastfeeding is what a Lactation Consultant offers. Historically, neither obstetricians or pediatricians (the 2 medical specialties focused on birth and babies) looked at the breastfeeding dyad to find solutions to breastfeeding challenges. Historically, OBs and pediatricians look at the mother or the baby instead of the mother and the baby. However, as we know, breastfeeding is the physical connection between the mother’s breast and baby’s mouth - 2 equally important, complementary pieces of the puzzle. Consequently, it is understandable that the importance of the infant’s oral anatomy had not been explored as a result of this care gap. In the 1970s and 1980s, the field of lactation consulting emerged to fill that gap. Then in 1985, IBCLE® (International Board Certified Lactation Examiners®) was established to create standards for this budding profession.

Tongue Tie and Bottle Feeding “Tongue Tie does not necessarily cause challenges for a bottle feeding infant since an infant can often obtain milk from a bottle without the wide gape and consistent suction needed for a good breast latch. If the tongue-tied infant cannot maintain the tongue over the lower gum during sucking, the “phasic bite reflex” (chewing) is allows milk to drip into the mouth without effort, thus requiring less tongue muscle effort (such as tongue grooving, cupping and depression) than needed for breastfeeding (Hartman, P, oral communication, 2003). Breastfeeding requires well-defined peristalsis from the front to the back of the tongue as well as tongue–palate synchronization. Some tongue-tied infants cannot manage a bottle.” (AAP 2004) For decades, bottle-feeding was the predominant feeding method in the United States so tongue tie was less of an issue. However, as breastfeeding once again gains popularity, the role tongue tie plays in breastfeeding is coming to the fore.

How to Remedy Tongue or Lip Tie? The release of the frenulum which is a tiny piece of collagen that has very few nerves or blood vessels is a quick in office procedure. There is very little bleeding and the babies can feed immediately after the release. There are non-breastfeeding reasons to consider releasing a baby’s tethered tongue. In addition to increasing the chances of successful breastfeeding, releasing the tongue/lip/buccal tie can decrease the likelihood of cavities, the need for orthodontia and improve coordination of feeding, including bottle feeding. It may also decrease the likelihood of apneic events.

Common Myths

Myth: If a baby can protrude the tongue beyond the gum line, there is no tie. Not true, to assess the function of the tongue, we must make sure the tongue can lift and move freely in the mouth. Myth: A tether will stretch. Not true, it is collagen and will only stretch 3%. In fact, over time the tight frenulum becomes thicker and more tenacious.

Myth: The data has shown no benefit from tongue tie release. That study was one where ENTs were doing a very conservative release with sterile scissors and not a full release.

Myth: Damaged nipple are a normal part of breastfeeding. Not true, because Lactation consultants did not understand the importance of infant oral anatomy, we thought the mom and baby just weren't “doing it right”. Damaged and bloody nipples are never normal.

Myth: Some moms just don’t make enough milk. Not true, most mothers with babies who have normal oral anatomy will make plenty of milk.

Summary

Not correcting a baby’s tongue increases the likelihood that mom will stop breastfeeding if the pain is too great or if the mother’s milk supply decreases because the baby is not good at removing milk, the baby will give up on breastfeeding. The risks of not breastfeeding are well known.

Learn More About Tongue Tie

Dr. James Bieneman DDS has a wonderful website describing symptoms for baby and mother. http://yourcoloradodentist.com/lip-and-tongue-ties/breastfeeding-infant-and-mother-symptoms/

Dr. Kotlow are nationally-recognized expert in tethered oral tissues www.kiddsteeth.com

Dr. Boback Ghaheri: “Breastfeeding Improvement Following Tongue-Tie and Lip-Tie Release: A Prospective Cohort Study” https://static1.squarespace.com/static/52ee7826e4b07fbe8885e2ab/t/57e8ca2ff7e0ab5e258a2910/1474873905104/Ghaheri.pdf is worth reading

Amanda Ogden RN, BSN, IBCLC Co-Founder & Director of Lactation Services