When a new mom and baby come to see me in the office, I always ask them if they were referred by someone or if they did their own research and came on their own. Specifically, I ask them about the attitudes of their pediatrician, midwife or family practitioner with respect to breastfeeding. I also ask what they think about them coming to my office to try and get a better sense of the idealogical hurdles that exist in my medical community.
One of the most frequent things I hear is that primary care providers say something to the effect of "Oh, diagnosing tongue-tie is just a fad" or "This tongue-tie business is just something new that some people are doing".
While that sentiment is frustrating, I think it is important to address the various reasons why we may be seeing and hearing more about tongue-tie and lip-tie as a cause of breastfeeding problems. As is the case with any new paradigm shift in medicine, the initial response is almost always one of conservatism and doubt.
Why the surge in babies who are felt to have tongue-tie and/or lip-tie as potential causes of breastfeeding problems?
- Genetics: There are several studies that examine the potential inheritance patterns of ankyloglossia (tongue-tie).
- Acevedo et al in 2010 identified a Brazilian family that had both ankyloglossia and dental abnormalities. While it only looked at 12 patients, the study demonstrated an autosomal dominant pattern of inheritance. (For clarification, an autosomal gene is located on one of the 22 chromosomes that is NOT an X or Y chromosome. A dominant gene needs only one of the two copies to be passed to cause a specific effect - a 50/50 chance of getting the gene.)
- Trying to answer the question why males are more affected by ankyloglossia than females, a Korean study by Han et al in 2012 identified potential X-linked patterns of inheritance.
- Klockars in 2009 identified that the prevalence of ankyloglossia in the population is approximately 4-5% and that inheritance is also passed in an autosomal dominant fashion (like Acevedo).
What these studies demonstrate to us is that there is likely some genetic predisposition towards ankyloglossia. My own observation in my patients is that greater than 50% of babies have a relative who also has ankyloglossia. As is the case with many genetic disorders, if a gene is passed from generation to generation, and that gene is potentially passed in a dominant fashion, more and more babies will be affected by that gene with each new generation and with increasing population size (assuming those affected will be able to have kids of their own).
- More moms are breastfeeding now than they were previously. As rates of breastfeeding increase, the number of moms who have difficulty with breastfeeding is bound to increase. Before the formula revolution, doctors would routinely check a baby for ankyloglossia in the newborn nursery and perform a frenotomy if the frenulum looked tight. There are historical reports of midwives using a long and sharp pinky nail to lance the frenulum in newborns who had difficulty at the breast. Was it a fad then too?
- A major argument I make is that I am attributing a baby's breastfeeding problems to a specific set of anatomical problems. A doctor who doesn't know about these correlations may simply pass along what was taught to them in residency. If their mentors taught them common myths about difficulty breastfeeding, babies would be described as "lazy" or having a "small mouth or small tongue" as potential excuses for problems. If those excuses didn't seem to hold, the mom would also be blamed for not making enough milk or having nipples that weren't conducive to breastfeeding. I don't think these excuses are evolutionarily plausible explanations for why babies have problems breastfeeding. You would never hear a doctor explain away a patient's low oxygen level by saying "You just have lazy lungs." I feel that we must find the anatomical reason why some babies can't breastfeed and I will make the argument that many of these babies have problems because of restrictions at the tongue or upper lip.
Future posts will look at the evidence in favor of releasing tongue-ties when those ties are the cause of breastfeeding problems. Ironically, there are no data that argue against treating tongue-tie for babies having breastfeeding problems. When people describe this focus on ankyloglossia and how it relates to breastfeeding as a fad, it is insulting as it doesn't acknowledge the struggles of the mom or the baby. It minimizes the frustrations felt by the dyad and does nothing to help solve the actual problem at hand.
I am asking the doctors and lactation consultants to approach this problem analytically rather than passing old dogma on to their patients.