Breastfeeding Problems Can Affect the Emotional Health of Mom and Baby

As an ENT surgeon, my initial exposure to breastfeeding medicine focused on the technical aspects of frenotomy as it relates to breastfeeding problems. Early on, I would see babies for a specific purpose and beyond that, I relied on my community lactation consultants to begin the task of improving breastfeeding quality. However, as a father of tongue-tied children and as a husband to an amazing woman who suffered through breastfeeding our first child, I have always been aware of the toll that abnormal breastfeeding takes on a mom (and family). In this post, I want to look at some of the factors affected by breastfeeding that don’t necessarily focus on infant nutrition and latch quality. Some of what I will present will have references supporting my ideas, but there are also ideas I have about the impact of breastfeeding abnormalities that haven’t fully been studied.

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Emotional health for mom - I previously wrote about the importance of mom’s symptoms when considering whether a frenotomy is warranted. When a baby is having difficulty breastfeeding, mom’s stress is visible and almost palpable. Mom has an inherent instinct to nourish her child, and a disruption in that desire can have profound psychological impacts. An extremely important study tracking these impacts was published this year by Cristina Borra and colleagues. In this study, the rates of maternal postpartum depression (PPD) were measured in relation to breastfeeding success. The moms with the lowest rate of PPD were the moms who intended to breastfeed and successfully did so. The moms with the highest rate of PPD were the moms who intended to breastfeed but didn’t or couldn’t. Their risk of PPD was double that of the control group. That’s an alarming number that we cannot ignore. A similar study looks at what happens to breastfeeding when a mom has a diagnosis of PPD. Dr Stuebe and colleagues found that in instances of disrupted lactation, the median duration of breastfeeding was 1.2 months. The median duration of breastfeeding in those without disrupted lactation was 7 months. In the article, she also found that moms with a diagnosis of PPD had a higher incidence of disrupted lactation. The final article is, in my opinion, the most fascinating. While it is an animal study, Dr Hinde and colleagues examined rhesus monkey mother-baby dyads and measured cortisol levels in the mommy’s milk. They then demonstrated that the monkeys with high cortisol levels in their breastmilk had babies that were “nervous” and babies exposed to low cortisol breastmilk were more “confident”. Cortisol levels are often high in those undergoing some sort of physical or psychological trouble, so understanding the impact of cortisol is of particular interest to me. The cause of high cortisol levels and the downstream effects of these cortisol levels is very complex, and further information on the topic is found here and here. It's important to recognize that the cortisol implications regarding breastfeeding are still not completely clear, so more research is necessary.

Emotional health for baby - From a biological perspective, one of the most basic human instincts is the need to breastfeed. You may have seen a newborn crawl up a mother’s chest and latch on the breast without assistance. It’s an innate function for babies. When breastfeeding is disrupted, we know how it can affect how the baby feeds, but we don’t have data to show how much the baby suffers when this basic functional need is disrupted. One very interesting paper looking at how baby stress is measured was published in 2012 that studied infant and mom stress levels when they tried a self-settling sleep training program (like Cry It Out). What the paper found was when the mom and baby were actively struggling through the training program, their cortisol levels (an easily measurable hormone) were both very high. Once the baby was “trained” and mom moved into her own bedroom, her cortisol levels normalized, but the baby’s levels remained elevated even without signs of distress (apparently “successful” training). How does this relate to breastfeeding? I maintain that babies who have difficulty with breastfeeding are actively in distress, similar to the abandoned baby. A basic human function (like parental proximity during sleep OR breastfeeding easily) becomes disrupted, and cortisol levels can rise. At some point, we may be able to measure that. I routinely hear stories where moms email me shortly after a frenotomy and tell me that they “have a whole new baby”. These babies are often calmer, sleep better, and exhibit less body tension and just seem relaxed and happy.

It’s time that medical professionals start to look at breastfeeding as an important developmental process rather than a stair step to getting a baby to grow physically. The medical community is very good at measuring physical attributes - growth curves and physical milestones are part of well child visits. We need to focus on the neurologic and psychiatric well being of infants in addition to their moms. Our current system is failing the dyad from the emotional aspect, and we need to examine what happens as a result of that failure.

The Difference Between a Lip Tie and a Normal Labial Frenulum

The vast majority of those who read the posts on this site show an interest because of problems with breastfeeding. I have pointed out many of those symptoms before: pain, poor weight gain, poor latch mechanics, reflux and so forth. As our awareness about tongue tie and lip tie increases, more moms will be sharing their stories. We often underestimate the power of sharing a Facebook status, liking a Facebook page, or tweeting out information.

Sometimes, parents will come across information on social media that piques their interest, even if they aren't experiencing a specific problem with breastfeeding. One of the more common ways that manifests itself is when they see a picture of a lip tie. I wrote previously about how upper lip ties (ULT) can affect breastfeeding. Pictures of thick or tight lip ties seem to pop up everywhere. Not uncommonly, parents will see these pictures and then take a peek under their own children's lips. Some are surprised to find what they think is a lip tie. Some will come to see me for treatment; others will email me for advice. Hopefully, this post will clarify some misunderstanding to avoid unnecessary concerns for those parents.

Those of us who frequently diagnose and treat ULT use a classification system to describe where the frenulum attaches. Class 1 lip ties are quite rare (it indicates little to no visible attachment). To date, I've seen more than 1500 babies and have yet to see a class 1 tie. A class 2 ULT will insert somewhere on the gumline (gingiva) above the edge of the gumline. A class 3 ULT will insert at the edge of the gumline, adjacent to a structure called the anterior papilla. Finally, a class 4 ULT will wrap around to the hard palate.

Class 2 Frenulum (no restriction noted - good flanging)

Class 3 Lip Tie (Central restriction noted)

Class 4 Lip Tie (Central restriction noted, bone notching is present)

This classification system just describes anatomy. It does not determine severity, like a cancer staging classification does. A class 4 ULT isn't "worse" than a class 3 ULT - what matters is the degree of restriction.  This degree of restriction can be determined by feeling the lip and trying to elevate it, mimicking the flanging motion needed on the breast. Alternatively, an IBCLC (international board certified lactation consultant) can evaluate what the lip is doing on the breast.

The most important thing to recognize, therefore, is that the classification used to describe the attachment of the labial frenulum to the gum can describe normal labial frenula as well. Many times, I will get an email asking for opinions on a baby's "class 3 lip tie" in situations where neither the baby nor the mom experiences breastfeeding problems. So in this instance, the baby has a class 3 frenulum.

This video demonstrates how a normal frenulum can have a class 3 attachment but demonstrates no restriction - the baby sleeps through the examination

To illustrate the distinction, we will examine an important study out of Sweden from 1994 by Flinck et al. This study examined 1021 newborns were studied over 8 months to record normal oral findings. Keep in mind that these babies weren't having particular problems - they were just being observed. Of those 1021 babies, only 68 (or 6.7%) had "buccal" insertions of the frenulum (this would indicate a class 1 or 2 attachment). 782 (76.7%) had class 3 attachments and 170 (16.7%) had class 4 attachments.

Keeping this in mind, I maintain that the location of the frenulum's attachment to the gumline CANNOT be a deciding factor on whether or not a frenulum is tied. If that were the case, the Flinck study would justify treatment in 93% of babies, and we know that number can't be right.

If restriction is noted, and the restriction is from the frenulum itself, then treatment is warranted. But in what other situations would treatment be plausible if breastfeeding weren't problematic? The two most common instances are dental decay and a central gap in the teeth (diastema). 

The most important paper regarding the labial frenulum and premature dental decay comes from Dr. Larry Kotlow. In this study, he associates the presence of a prominent maxillary labial frenulum to premature dental decay of the two teeth on either side of the frenulum (the central and lateral maxillary incisors). The most likely mechanism of this premature decay is that a prominent frenulum can allow for pocketing of debris that cannot be cleared away, giving bacteria a reservoir of material to use. In my experience, the frenula that have a "hooding" appearance (like an awning over a patio) are the ones at highest risk. Because the majority of kids have class 3 or 4 frenula, but the majority of kids don't get this premature dental decay, I don't treat preemptively. I think that's bad medicine. But once decay is seen, treatment should be rendered.

The much more common question I get is about a central diastema or gap in the front teeth. Some parents are very worried about gap formation - they have brought otherwise asymptomatic babies to me before teeth have even come in, asking for revision. More commonly the gap is noticed once the front teeth come in. I still don't like to release those frenula at that stage - the gap can be temporary. As more teeth come in, the incisors can rotate forward, and the gap can be obliterated without the need for any intervention. My preference is to wait until all the teeth are in before deciding on a revision. Obviously, there are some exceptions - the severely thick frenulum or the ULT that is pulling on the gumline hard enough to cause notching of the border of the gumline will always have a gap, and treatment is reasonable. Other instances where treatment is helpful is when the child is experiencing pain from repeated minor trauma - this can occur during eating or brushing teeth.  Regardless, it's important to understand that both a lip tie and an untied normal frenulum can cause a gap between the teeth. It's often more about the presence of tissue that can cause the gap, even if that tissue isn't under tension. Finally, it's important for parents to understand that releasing a frenulum that's causing a gap may not result in closure of that gap. Dental spacing is much more complex than the simple presence or absence of a low frenulum. If parents want a frenulum released to "prevent the need for braces", I advise them that there's no guarantee in the result because of the variable causes of abnormal spacing.

A normal frenulum can act as a space holder between teeth and cause a gap, like elevator doors that close on you. The mere presence of tissue (like the guy in the red shirt) can hold the teeth apart. A lip tie, which can also have abnormal bulk, has added tension to keep the teeth apart, just like someone using active force to keep elevator doors open. Both a nornal frenulum and a tie can cause a gap in those teeth.

While some may argue that this is an issue of semantics, I feel that it's an important distinction to make. When parents realize that what their child has is considered normal, it makes non-treatment a much less stressful choice. My goal is to make sure that we are releasing the appropriate frenula for the appropriate reasons.                                                                                                                     

Tongue Tie and Lip Tie FAQ

This post was originally published on my Facebook page (www.facebook.com/DrGhaheriMD) but I've had requests to post it here as well for ease of reference. I hope to quickly answer some of the common questions surrounding tongue tie and lip tie here. 

1) Can a tongue tied baby stick her tongue out past her lips?

Absolutely. Just because the tongue has normal motion in one direction doesn't mean that the tongue has normal motion in ALL directions. The most important movement for the tongue during breastfeeding is UP and not OUT, so the normal outward movement of the tongue is as relevant as normal shoulder movement for the purposes of breastfeeding.

2) Can laser revision cause scar tissue?
Yes. Any wound can have scar tissue. The precision of laser and the lack of collateral damage because of focused energy is thought to minimize that scar tissue. Regardless of the technique used, however, if the entire tongue tie is released (including the posterior portion), then there is a higher chance of scar tissue because the wound is deeper and the opposing edges of the release site are closer together, increasing the chances of scarring.

3) Are stretches necessary to prevent reattachment?
Stretches are necessary to prevent reattachment for the lip and a released posterior tongue tie. If someone just releases the anterior component, then I don't really think that stretches matter. The opposing raw edges of the wounds in a lip tie or posterior tongue tie are too close, and will stick together to some degree without stretching. 

4) Do I need to have a thick lip tie cut in the OR in case it bleeds?
No. It's all about preparation. When I did scissor treatment, I just injected a small amount of numbing medicine that contained adrenalin. After 10 minutes, there's minimal bleeding, and the release can be done easily in the office.

5) Do stitches prevent reattachment?
If the release is done absolutely perfectly and the stitches are placed precisely, then theoretically reattachment would be difficult. That being said, my experience is that placing stitches requires general anesthesia, and the provider using stitches generally doesn't have an understanding of posterior tongue tie, so while it doesn't reattach, it's often inadequately released.

6) How often does a tongue tie accompany a lip tie?
In my experience, >90% of cases

7) Is there always a posterior tie behind an anterior?
Yes. The real restriction of a tongue tie is typically at the posterior component (for the motion necessary during breastfeeding).

8) My baby's tie has been cut. Why is her tongue still heart shaped?
The band that had tethered the tongue to the floor of the mouth travels from within the substance of the tongue down to the floor of the mouth. Cutting that band somewhere in the middle doesn't remove the portion of the band inside the tongue. That can still change the shape of the tongue but typically doesn't affect function.

9) Can a tongue tie cause speech problems?
Absolutely. The most common letters affected are R, S, L, Z, D, CH, TH, and SH but other sounds are also difficult. While some kids can make these sounds in isolation, stringing the sounds together during speech can be very difficult. Recent studies have shown some improvement in speech function following a frenotomy, although most studies don't show obvious benefit. I feel that speech can be improved in specific cases where restriction is prominent and the child has had speech therapy and improvement hasn't been noted. As more studies are done, I think we will see an improvement in objective speech measures with the procedure, but not every patient will benefit.

10) Can a lip tie cause speech problems?
Generally, I say no. In some severe cases, if the lip tie is causing the child some discomfort with mouth opening (because of tension), they may alter their oral anatomy to minimize pain, which could impact speech.

11) Do lip ties cause tooth decay?
Yes. The most affected are the 2 teeth on either side of the upper lip tie (the incisors). Cavities on the teeth in the back (molars) typically happen in the setting of tongue tie (can't sweep the tongue back there to clean). Dr Kotlow has a great article describing the impact of a lip tie on cavities, and if you want to print it off and give it to your dentist or doctor, go to:
http://www.kiddsteeth.com/articles/The_Influence_of_the_Maxillary_Frenum_on_the_Development_and_Pattern_of_Dental_Caries_on_Anterior_Teeth_in_Breastfeeding_Infants_Prevention,_Diagnosis_and_Treatment010%5B1%5D.pdf 

12) I have no difficulties with breastfeeding but it looks like my baby has a lip tie. What should I do?
Enjoy your normal breastfeeding relationship :)

Tongue Tie Interview!

I recently had the opportunity to speak with Veronica Jacobson, CLC, regarding tongue tie and the impact on breastfeeding. We discussed the following:

• Why is there more awareness of the issue now versus 5 or 10 years ago?
• What is the biggest hurdle to getting HCPs to understand tongue and lip ties and the health effects?
• Why do posterior tongue ties need to be taken more seriously as something that needs fixed?
• What kind of research is currently being done on the subject?
• What's your advice to parents who are having a tough time getting a pediatrician or other HCP to take their concerns about a possible tongue or lip tie?

Here's a link to the video