April 3, 2014

How To Choose Your Provider: Does Laser vs Scissors Matter?

Families frequently ask me whether they should go to a particular tongue tie provider because they use a laser for their procedures. I always respond that the tool that the provider is using for the procedure is far less important than their skill and understanding of how tongue tie affects breastfeeding. Anyone can buy a laser, so that cannot be the deciding factor for how a doctor or dentist should be chosen.

This post will serve to answer two major questions. I will show you the questions you should ask before a potential procedure in addition to the advantages and disadvantages of using laser vs scissors.

How can a family know whether or not a provider will do a complete job when treating tongue tie? This isn't an easy question to answer, but there are certain questions you should ask if you're unsure of their expertise:

How many tongue tie procedures do you perform per month? There isn't a magic number that is necessary. This is more for you as parents to gauge whether a provider embraces the concept that tongue tie affects breastfeeding or not. If the answer is "1 or 2" vs "10 or 20", that tells you something.
Do you treat posterior tongue tie as well? If the provider gives you a blank stare, then I can almost guarantee you that their tongue tie procedure will be incomplete. Going back to the concept that all tongue ties have a posterior, submucosal component, if a provider isn't aware of the anatomy, the result will be suboptimal. You will also know this is a problem if your baby has a posterior tongue tie (confirmed by your IBCLC or your own homework) and the provider tells you that no tongue tie exists.
Do you require general anesthesia? This doesn't necessarily prevent you from seeking treatment from a provider because it may be your only option for treatment. If you have to choose between the principle of avoiding GA or improving your breastfeeding relationship, you will hopefully choose the latter, because the only other feasible alternative is to travel to another provider. Unfortunately, most providers don't realize that the procedure can be done safely in the office.
What is your post-procedure stretching routine? Again, if you get a blank stare here, it's a tipoff that they aren't familiar with the concept of reattachment of the wounds. Alternatively, if the provider says something to the effect of "the baby's tongue moves so much that scar tissue can't develop", I would recommend you look elsewhere because this sort of advice frequently accompanies an incompletely done procedure.

Additionally, if you go to a provider and hear some of the myths many of us have been told about tongue tie and breastfeeding, I would recommend looking elsewhere. While it may seem excessive, if you live somewhere where no one makes you feel comfortable with proceeding, you need to consider traveling to someone who knows more.

Does it matter whether a provider uses laser or scissors for the procedure? This is one of the most frequently asked questions I get. My opinion is that for the purposes of breastfeeding, I don't think there is any difference in outcomes between laser and scissors. There has never been a head to head study comparing the two techniques. While I currently use a laser for my procedures, I performed over 200 procedures using scissors when I began treating babies, and my revision rate and rate of improvement was no different then. There are some inherent differences between the two techniques:

The scissor procedure is faster than the laser procedure.
I allow parents in the room when I use scissors, but when using laser, they cannot accompany the baby to the treatment room (these are laser safety guidelines that should be followed).
The scissor procedure often needs injected local anesthetic to control pain and bleeding whereas the laser procedure has a delayed onset of pain but doesn't have issues during the procedure.

That being said, practitioners who embrace laser technology do so because they have a specific interest in breastfeeding medicine. It also implies that they are doing more procedures than most others. Because lasers are indeed expensive, the practitioner who does 1 or 2 procedures per month isn't going to make that investment. The flip side, however, is that some already have lasers in their offices for other procedures. We see this most commonly in the dental field, where lasers are used for a multitude of other problems. In those situations, going to a dentist who has never done a laser frenotomy on a newborn just because they have a laser may not be the best option. You need to be an advocate for your child and you need to be willing to walk away if you don't feel comfortable proceeding.

Lasers do offer a precision that can't be matched by a scissor revision. They are more effective in removing the entire upper lip tie in the setting of abnormal dental spacing and dental decay. In those instances, mere release of tension (that could be achieved by scissors) isn't going to completely deal with the dental problems, so I feel that laser is superior. The lack of bleeding during most laser procedures also improves visualization and can help complete removal of the restrictive tissue.

There are no peer-reviewed studies of frenotomy using lasers to date. The best studies available to us (specifically Dr. O'Callahan's study) were conducted using scissors, and in those studies, breastfeeding outcomes improved dramatically. While it might be difficult to do a head to head study comparing the two techniques, the coming years will bring us data using laser, and it will be curious to see if those outcomes are as good. I suspect they will be.

March 23, 2014

Rethinking Tongue Tie Anatomy: Anterior vs Posterior Is Irrelevant

by Bobby Ghaheri

There is no doubt that tongue-tied children have a higher propensity for breastfeeding difficulty. In trying to understand how best to treat children with tongue tie, practitioners have developed a classification system to describe tongue tie.

Most practitioners use a classification where the tongue tie is given a grade of 1, 2, 3, or 4. Classically, class 1 and 2 are thought of as anterior, whereas class 3 and 4 are posterior. Unlike cancer grading, where stage 1 is minimal disease and stage 4 is severe disease, that distinction does not apply for grading the severity of tongue ties. Instead, the tongue tie classification system is merely a description of where the tie attaches to the tongue. I have seen class 4 babies with severe breastfeeding problems and class 1 babies who feed normally, and vice versa. The problem with the word "posterior" is that those unfamiliar with this classification may erroneously think that the tongue tie is in the back of the throat, back by the tonsils. Better descriptive terms would be submucosal or hidden tongue ties, but we are unfortunately stuck with the term posterior.

**Class 1 Tongue Tie. This is the classic heart-shaped tongue that most doctors feel is the only real tongue tie. The tie inserts into the tip of the tongue.**

**Class 2 Tongue Tie. Considered to be an anterior tie, this tie inserts just behind the tip of the tongue. We don't see a heart-shaped tongue, but the tie is still clearly seen.**

**Class 3 Tongue Tie. Classified as a posterior TT, the distinction between this and a class 4 TT is that the class 3 still has a thin membrane present.**

**Class 4 Tongue Tie. No thin membrane is present, so this type of tie is the most commonly missed. The front and sides elevate, but the mid-tongue cannot.**

Unfortunately, what I have encountered when most practitioners treat tongue tie is that the procedure is done incompletely. This post will describe how to completely treat a tongue tie to completely release any tension on the tongue.

After treating over a thousand babies with breastfeeding problems, it has become clear to me that our previous understanding of the anatomy of tongue tie is inaccurate. In my training, we only were taught to release the thin membrane of a tongue tie if restriction was noted (this was in the setting of speech problems, not breastfeeding). Most practitioners who haven't done a significant number of tongue tie procedures also tend to just snip this front membrane. Parents are impressed because of the lack of bleeding, and the practitioners willingly do it because it carries no risk. They don't usually acknowledge the possibility that a class 3 or 4 tongue tie exists because the thin membrane that is present in class 1 or 2 tongue ties is minimal in size or absent altogether. I contend that the presence or absence of a thin membrane is irrelevant if the baby is having problems with breastfeeding. Why? It goes back to the mechanics of breastfeeding. A previous post demonstrated that the critical motion in breastfeeding is elevation of the tongue.

In my experience, every anterior tongue tie has a posterior tongue tie behind it. Reworded, every tongue tie that affects breastfeeding is a posterior tongue tie. Some of those also have an anterior thin membrane, but there is always a posterior component. I like to use a sailboat analogy to help describe tongue tie.

**Imagine the sail as a class 1 or 2 tongue tie. That sail is visible. But behind that sail, there is a mast that also needs to be addressed.**

**In this example. the sail is down. The only thing visible is the mast. The absence of that sail doesn't affect the presence of the mast.**

This concept must be understood if we are to understand how to effectively treat tongue tie in the setting of breastfeeding. Whereas treating just the sail (the anterior tie) may be sufficient in treating older children with speech problems, treating just the anterior tie is insufficient in helping the baby with breastfeeding problems. The ultrasound data show that the front of the tongue must advance slightly and then elevate to cup the breast against the palate. This motion may be helped by snipping an anterior tie. But the ultrasound data also show that the mid-tongue must be fully mobile to elevate towards the palate. If the tongue is only released up front (the sail is cut) and the posterior component is left behind (the mast), then the mid-tongue won't elevate and the latch will still be problematic. This analogy also applies to the baby with a posterior tie (where only the mast is the problem). In these babies, the front of the tongue may elevate just fine, but the posterior restriction won't allow the mid-tongue to elevate, again affecting the latch.

**A classic diamond-shaped wound seen in an appropriate release.**

It is absolutely essential that the practitioner gets through the posterior component of the tongue tie for the procedure to be effective. How can the practitioner know if they've gone far enough? The tongue tie that is fully released has a diamond-shaped wound. If there is no diamond, then the release is incomplete. The alternative way to know for sure that no further tie exists is to release the tie until muscle is seen. This is why I contend that the tool used to do the frenotomy is irrelevant: whether it's scissors or a laser, as long as the diamond is visible, then I know that the tongue has been fully released. This technique should be everyone's goal.

March 14, 2014

It Takes a Team to Improve Breastfeeding after a Tongue-Tie Procedure

by Bobby Ghaheri

All too often, patients come to me after a diagnosis of tongue-tie (or lip-tie) has been made, thinking that a procedure is going to suddenly change the way their child breastfeeds. Rarely, especially in the very young child (<2 weeks of age), that is possible. The majority of the time, however, that is not the case.

Because babies practice sucking skills in utero, a newborn with an intraoral restriction can have a latch that is quite abnormal the first time they try to nurse. If these restrictions are adequately addressed, the only thing that I provide the infant is the anatomical potential to have a normal latch. If that baby has habits that interfere with normal breastfeeding, little improvement will be initially shown.

An example I often cite was inspired by Dr. Brian Palmer: If I ask you to train for a marathon for 3 months, but during that 3 month period, your shoes are tied together, you will develop a specific way of running the marathon. You might be able to eventually finish that marathon on race day in that fashion. But if I untie your shoes on the morning of race day and ask you to run that marathon in a normal fashion, your training for 3 months won't help you much. You would have developed a different skill set and muscle strength to compensate.

Tongue-tied children practice sucking against resistance up to the moment their ties are released. Often, there is significant muscular discoordination and habit that doesn't allow them to nurse efficiently. I don't think it's reasonable to expect a mom and child to nurse normally right after a procedure. Unfortunately, despite my advice to see an international board certified lactation consultant (IBCLC), moms still often feel that it's an optional step. In my experience, there is a much higher percentage of babies who fail to improve after a frenotomy when an IBCLC isn't involved in the aftercare.

Why is it important to see an IBCLC afterwards?

As a breastfeeding mom, there's a chance you have no idea how to breastfeed. This isn't meant to be patronizing. If you are a new mom, and your baby's tongue-tie or lip-tie is causing you significant symptoms, you may have adapted compensatory mechanisms to deal with those symptoms. Furthermore, if you have multiple children but some or all of them have the same problem, there's a chance that you have no idea what normal breastfeeding is supposed to be like. IBCLC's can use their experience to help improve positioning and latch to optimize results.
You may have been given a nipple shield nearly immediately to help you breastfeed your child. This can result in some nipple confusion and weaning off the shield (which most moms don't want to use) can be difficult. Often, you will need an IBCLC to help guide you.
If significant sucking dysfunction exists, the baby may need to undergo suck retraining to help strengthen the muscles better suited for nursing.
Many moms use breast pumps that can exacerbate problems with their breasts. IBCLCs can help improve the right fit and technique for pumping.
Most practitioners are not IBCLCs. As an ENT, I know some of the basics of lactation support, but to equate my procedural expertise as expertise in lactation support would not be advisable.
This list is obviously not all-inclusive. It is only meant to demonstrate how a procedure alone can still fail to improve breastfeeding problems. I view the IBCLC as the focal point in the treatment plan.

Who else can be involved in treating specific breastfeeding problems?

Chiropracters/craniosacral therapists - significant muscle tension can be alleviated with bodywork. My experience is that there is higher proportion of children with tongue-tie who also have torticollis as a contributing factor to nursing difficulty.
ENT - if your practitioner isn't an ENT, involving an ENT for other potential issues of the mouth and throat can be helpful as well. Problems such as submucous cleft palate and laryngomalacia can also be present with a tongue-tie.
Speech and Language Pathologists - while they are less often than other practitioners, in situations where there is a suspicion of severe reflux, aspiration, or difficulty with solid foods, their expertise is to determine if different swallowing dysfunction exists.

How should you choose your Iactation consultant? My colleagues Renee Beebe and Lyla Wolfenstein wrote this helpful article to help you. While some may think that addressing tongue-tie or lip-tie is just a matter of proper technique and healing, I think it is vital that you go into the procedure with your team in place, rather than scrambling afterward to find someone who can help you.

March 8, 2014

Tongue Tie Procedures Don't Need General Anesthesia

by Bobby Ghaheri

One of the biggest hurdles to treating tongue tie or upper lip tie is the comfort level of the practitioner, especially if they do not perform a large volume of procedures. An additional obstacle is that the professionals who are capable of treating babies (ENTs, pediatricians, oral surgeons, family practitioners, midwives and nurse practitioners) all have varied training backgrounds. This makes a consistent approach to treating tongue tie and lip tie difficult to achieve. As a result, most practitioners simply practice what they were taught instead of looking for alternative options.

Mothers around the world have related to me frustrating scenarios like this:

Baby and/or mom have breastfeeding symptoms related to tongue or lip restriction
Their doctor or lactation consultant correctly identifies tongue tie or lip tie and refers them to an ENT or oral surgeon
The surgeon is not comfortable doing the procedure in the office and requires general anesthesia (GA)
The anesthesiologist is not comfortable doing "elective" procedures on babies until they are 3 (and often 6) months of age
While baby waits, mom and baby can't keep breastfeeding and the relationship is lost

Before explaining how to perform frenotomies in the office, I want to briefly review why general anesthesia should be avoided if possible. The first reason GA should be avoided has to do with the potential effects on children. There are numerous animal studies that have shown that inhalational anesthetics in addition to injected anesthetics like ketamine and propofol are neurotoxic. They cause nerve cell death in developing animals. There are several retrospective human studies that have shown potential problems. One of the most publicized studies from the Mayo Clinic in 2012 showed: "Children repeatedly exposed to procedures requiring general anesthesia before age 2 years are at increased risk for the later development of ADHD." While prospective studies are still in progress, I feel that there is enough evidence showing that GA can affect children, and if there's an alternative to using GA, it should be pursued. There are also obvious inherent immediate risks to GA - reactions to the anesthetics which can lead to other health problems. There is nothing safer than completing avoiding it if possible.

Secondly, the baby is away from mom and nursing after emerging from anesthesia isn't a fluid process. The baby must wake up in the recovery room, often connected to monitors, and getting mom back to the room to nurse isn't always easy. The effects of the anesthetic, even in short cases, can linger throughout the day and disrupt normal breastfeeding routines.

Finally, it's a cost. Because these babies are young, the procedure is almost always done in a hospital instead of an outpatient surgery center. There are two fees incurred when you choose GA: the anesthesiologist's fee and the hospital facility fee. By far, the facility fee is much higher, and in situations where families are already paying for the birth of their child, this can be cost prohibitive.

By far, the most common reason that is cited by those who wish to avoid performing in-office frenotomies is the fear of uncontrolled bleeding. This potential complication can be mitigated by proper training. Between April 2012 and April 2013 (prior to my use of laser), I performed 203 tongue and lip procedures with scissors in the office on children up to 12 months of age. None needed cautery or stitches. What is my basic protocol for performing tongue and lip-tie revision with scissors?

I have all equipment ready for the procedure ahead of time: tenotomy scissors, a grooved director, gauze, a topical numbing cream with Q-tips (I use EMLA as benzocaine is now contraindicated in children under 2 years of age), an injectable anesthetic (1% lidocaine with 1:100000 epinephrine using a 30g needle), and gauze floating in ice cold water.

**These instruments come in various sizes - I prefer the 6" long rather than the 4" long versions. Left - a grooved director for isolating the tongue tie. Right - tenotomy scissors.**

The baby is swaddled on a flat table with an assistant stabilizing the head (alternatively a parent or another assistant can restrain the arms. The upper lip tie (if it will be treated) is swabbed with EMLA. 30 seconds later, I inject a small amount of the injectable anesthetic into the lip tie (especially along the gumline). I then wait 10 minutes for the epinephrine to cause vasoconstriction. This same technique can be utilized for the posterior component of the tongue tie, although I do not feel it to be necessary. I typically use EMLA on the tongue tie right before the procedure.
After 10 minutes, I either simply snip the lip tie by hugging the gumline or completely excise the lip tie with several small cuts. I find that the excision of the lip tie (a frenectomy) results in fewer babies with reattachment of the wound. The key is pulling up on the lip with a gauze pad to prevent it from slipping. Adequate tension on the wound minimizes bleeding.
Once the lip tie is treated, a grooved director is inserted to isolate the lingual frenulum and a cut is made to go completely through the posterior component. A light finger sweep should confirm that no residual band exists. The result should be a diamond-shaped wound. If there's no diamond shape, there is more tie to be cut.
Pressure is held on the wound with cold gauze until mom is ready to nurse, and then baby goes directly on the breast (or bottle). Within seconds to minutes, the bleeding stops.

This technique results in effective release of tethered bands and can significantly improve breastfeeding outcomes without the use of general anesthesia. Despite all this, if a mom's only option is to go to a provider who uses GA, then I most certainly recommend it. In my opinion, the benefits of prolonging the breastfeeding relationship far outweighs the risks of GA. However, if you have a provider who is receptive to doing tongue and lip-tie revision without general anesthesia, please feel free to have them email me and I can help to facilitate these simple in-office procedures.