​Announcing My New Research Project

I’m excited to announce the beginning of a project that I consider to be very important. As many of you know, I've tried to stay active in various research projects surrounding the impact of tongue tie on breastfeeding. Two papers have been published thus far, but critics of the science surrounding tongue tie remain skeptical.

This project hopes to address some of those concerns. Because I'm not at a university, I'm not privy to funding sources for these sorts of studies. Hopefully, you will all take the time to read the details of this upcoming study and if possible, contribute anything you feel comfortable with.

Thanks in advance - even if you can't contribute monetarily, please please please share this post so we can spread the word.

https://experiment.com/projects/a-randomized-controlled-trial-to-examine-the-impact-of-lingual-frenotomy-on-bottle-feeding-mechanics

Further Evidence to Support the Benefit of Tongue/Lip Tie Release

In 2014, I set out to design a study that would help to clear up many of the misconceptions surrounding tongue-tie and lip-tie release. After nine months of data allocation from hundreds of willing dyads, followed by a long process of analyzing the data and manuscript submissions, I'm very excited to present our results. Future posts will look at the paper in more detail, but for those of you who are interested, you may download the article by clicking here. I have also had this paper made available with a Creative Commons license, so it can be distributed for educational, non-commercial intent.

The Problem With Breastfeeding Compensations For Tongue/Lip Tie

As the understanding of tongue tie and lip ties improves with respect to breastfeeding, so does the understanding of the long-term implications of untreated intraoral restrictions. Many of the compensations that a baby uses to make up for inadequate breastfeeding efficiency are evident when examining a baby’s latch. Some of those effects on the infant’s mouth can also be seen later as the child grows. This post will explain situations where a baby can overcome restrictions by making particular compensations, how those compensations are used, and why they can be problematic later in life.

There are numerous situations where a baby who has an oral restriction can seemingly do "well" with breastfeeding. The most common example involves focusing just on infant weight gain. How can a baby with a tongue/lip tie successfully gain weight?

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This baby underwent a procedure at 5 months of age. Notice the plateau in weight gain between 4-6 months of age followed by recovery of weight after that.

1. Early in life, a baby can successfully gain weight by being very tenacious. These are babies who have relatively high muscle tone and can cause significant pain to mom while breastfeeding. They often have enough muscle tone to not fatigue at the breast, but because their oral restrictions make them inefficient feeders, they can feed for very long periods of time. It’s important to recognize that weight gain is not the only marker of successful breastfeeding and if mom is on the verge of quitting because pain is unbearable, the early successful weight gain becomes irrelevant.
2. Mom can have an overactive letdown (OALD) or oversupply. I have seen numerous situations where the baby has gained tremendous amounts of weight and mom has no pain, but the latch is completely pathologic. Why would we want to intervene in these instances? When a baby is passively receiving milk and not actually actively emptying the breast, it can predict future issues: plugged ducts, mastitis for mom from inadequate breast drainage or a sudden drop in milk supply once the signal for lactogenesis switches from hormonal control to latch quality, typically at weeks 10-16. A plateau in weight gain can follow (insert weight curve) and it can be very difficult to recover the supply once this occurs.
3. Supplementation with bottles may mask the issues that would have been apparent with exclusive breastfeeding. While the normal weight gain may make the primary care provider satisfied, the loss of exclusive breastfeeding is associated with shorter durations of breastfeeding. Additionally, bottle feeding can cause changes to palate architecture that have downstream effects.

Often, I see doctors, lactation consultants and parents focusing on a baby’s compensations and trying to change that behavior instead of trying to determine why the compensation is occurring in the first place. The most common compensation I see is that the baby uses pursed lips to hold on to the end of the breast. Technically, the baby is latched on. But we know from previous studies that the suction that keeps a baby on the breast should come from the tongue’s movements in the mouth (specifically from the mid-portion of the tongue). If the tongue cannot generate a seal, the baby responds by using the lips to hold on. The focus should NOT be how to flip the lips out - the focus should be on the reason the baby is using the lips in the first place.

Similarly, a tongue/lip tied baby will try to latch on the breast with a “small mouth”. They don’t open widely, and that narrow opening allows only a very small amount of breast tissue to enter the oral cavity. What results is a shallow latch that can predispose the mom to significant amounts of pain and nursing inefficiency. All too often, I hear lactation consultants say “What you need to do is to get the baby’s mouth open wider”, as if the baby is simply choosing to not open widely. Again, we must investigate why the baby has a small mouth opening when trying to latch - when oral restrictions are present, a wide latch causes the baby discomfort and tension. The baby responds by closing the mouth until the tension dissipates, which forces the shallow latch. It’s also important to realize that a baby cannot simultaneously use the lips to hold on and have a wide latch on the breast. That’s analogous to using a really wide straw instead of a narrow one when trying to drink.

Finally, I want to address why the compensations that the baby employs can cause problems in the long-term. Before that can be addressed, however, I want to explain how normal breastfeeding promotes optimal craniofacial growth. Completely normal breastfeeding is nature’s palate expander. The malleable breast is carried up by the tongue and molds the palate into a broad shelf by putting pressure on the inside of the gums. This, in turn, allows the teeth to eventually come in with adequate spacing. Many of the orthodontic problems that we see are a result of a high palate and crowded teeth (maxillary constriction). There is good evidence that breastfeeding promotes better dental occlusion (Peres, et al). The nasal septum sits on the palate (anatomically, the roof of the mouth is the floor of the nose). When the palate arches up instead of staying broad, the nasal cavity is narrowed. Furthermore, the septum has to buckle if the floor it sits on comes up - this results in a deviated septum. Both of these consequences predispose the baby to mouth breathing. While the deviated septum happens over years, the high palate can be noticed immediately after birth (some babies are very snorty while nursing). Because babies are obligate nasal breathers, the nasal obstruction can even further complicate the latch.

The palate is the hub of facial growth as a child gets older. If the palate is low and broad, the child can breathe out of the nose and there is less chance of sleep disordered breathing and sleep apnea. Breastfeeding for as long as possible (even when it’s not primarily for calories as a child enters toddlerhood) is critical for optimizing palate formation. We are starting to see more evidence for the benefits of breastfeeding for reasons previously undescribed. Guilleminault from Stanford shows the correlation between tongue tie and sleep apnea (2015), which has many downstream consequences (fatigue, difficulty concentrating, teeth grinding, bedwetting, behavioral issues and even symptoms mimicking ADHD).

Medical professionals who care for infants can learn to identify common tongue/lip tie compensations and instead see them as actual symptoms of tongue/lip tie. If we focus on keeping a child on the growth curve without examining *how* the baby gets to where they are on the growth curve when compensations are present, then we can set them up for early cessation of breastfeeding, issues with dental malocclusion, and sleep disordered breathing later in life. Our goal as medical professionals should be a thriving human. If we don’t change our practices, we are setting our patients up for consequences that are preventable.

References

Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions: a systemic review and meta-analysis. Acta Paediatrica. 2015; 104: 54-61.

Huang YS, Quo S, Berkowski JA, Guilleminault C. Short Lingual Frenulum and Obstructive Sleep Apnea in Children. International Journal of Pediatric Research. 2015 1:1.

How The System Can Fail Breastfeeding Families

As a medical community, we are taught that breastfeeding optimizes infant health. When a family experiences breastfeeding problems they should turn to their established system of medical support for help. Unfortunately, the current system that many doctors and lactation consultants work within hampers their ability to troubleshoot certain breastfeeding problems, like tongue tie or lip tie. This situation is typically a combination of two main issues: lack of knowledge about some relatively new anatomical understanding about breastfeeding and the politics and/or workflow of the system hierarchy. The culmination of these issues is often that a medical provider believes there is controversy regarding tongue/lip tie’s impact on breastfeeding, and may convey that idea to the family.

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Reliable information about how tongue tie truly disrupts latch quality wasn’t available until 2008, when an ultrasound study showed what the tongue does during breastfeeding. This information presented a paradigm shift in the understanding of infant anatomy and physiology with respect to breastfeeding and had a huge implication for how restriction of normal tongue movement could impact successful breastfeeding. Most parents will assume that their infant’s medical provider is aware of the fundamental aspects of breastfeeding physiology. Unlike most medical conditions where specific training can be obtained, there is no accreditation system in place for doctors who have an interest in breastfeeding medicine. Doctors with an interest in breastfeeding medicine must be self-motivated to stay current with emerging medical information. Most parents, especially the parents of newborns, look to their healthcare providers as a source of medical authority. A healthcare provider cannot effectively practice unless they believe in their fundamental body of medical knowledge with respect to their field of medicine. Providers may feel confident in their training and become comfortable in their understanding and feel threatened by or resist seeking out new information/understanding. There is always the chance that a healthcare provider innocently dismisses the concerns of the parents because they don't even know what they don't know. The typical infant medical provider, with the typical lack of breastfeeding medicine education, should defer to a provider with more expertise (generally, a board-certified lactation consultant). If the uninformed medical provider insists on being the access point for appropriate medical care regarding breastfeeding but do not have the necessary information to determine if further treatment is necessary, they risk great harm to the breastfeeding relationship.

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Proper education leads to proper examination techniques

The typical hierarchy of medical information between infant medical providers can hinder the examination and treatment of some breastfeeding problems. With established medical problems, the typical flow of information involves the primary care practitioner, the patient, and if needed, a specialist. Sometimes, the patient bypasses the PCP and goes directly to the specialist for specific problems. These relationships are further complicated by the reality that the mom may have one doctor while the baby has another, with neither taking responsibility for the health and functioning of the dyad. There are many fields where a non-physician specialist is involved in the diagnosis and treatment paradigm (audiology, speech pathology, lactation consultants, etc) but the field of breastfeeding medicine is interesting in that it doesn’t really exist from a physician specialty standpoint. The typical pediatrician, obstetrician, family practitioner, surgeon, or dentist are not experts in breastfeeding medicine, as perhaps they would be with other topics (e.g. ENT’s have an expertise in anatomical and medical understanding of hearing disorders but utilize audiologists for diagnostic and treatment specifics). The gap in breastfeeding knowledge is typically filled by the (typically non-physician) lactation consultant, who then advises a course of action to a dyad or to the primary care practitioner with which they work. Many hospitals don’t employ international board certified lactation consultants (IBCLCs) and instead use people who have far less training, so tongue/lip tie may not be properly identified. When tongue/lip tie is identified, there are often political motives involved in the treatment referral process. There are many examples across the country (and world) where a hospital has placed a gag order on lactation consultants from mentioning tongue/lip tie to the parents. Why? Typically, the hospital comes under pressure from community doctors who are upset that hospital lactation consultants have identified a problem and have sent the patient to a specialist for treatment, despite the fact that the lactation consultant typically has more specialized knowledge about breastfeeding.

As a result of the various hurdles present in linking tongue/lip tie to breastfeeding problems, parents are often left in a very difficult position. Providers and lactation consultants may look at the potential diagnosis of a tongue/lip tie as a “fad” or “controversy”. A health care provider that calls a tongue/lip tie diagnosis in a breastfeeding baby a "fad" is taking a blatant stance against the diagnosis. No parent wants to subject their baby to a fad diagnosis and fad surgery, so for the emboldened provider, the word "fad" is a very effective tool to convince parents to not even pursue the topic. The use of the word "controversy" is more subtle but inherently negative and equally damning. A controversy is something a new parent would likely seek to avoid or explore only with extreme caution. A parent may assume that the provider who speaks authoritatively has an educated understanding of the evidence and literature available regarding tongue/lip tie and feels that there is room for controversy. New parents are being told that tongue/lip tie as related to breastfeeding is “controversial” without evidence *why* it may be controversial (it’s just a basic anatomy/physiology correlation), thus putting the onus of determining the validity of the procedure on the parents. The idea of something being “controversial” can also be contagious. If a medical provider or a lactation consultant’s first professional impression of tongue/lip tie is that it is a potentially controversial diagnosis, or if their hospital system has a gag order in place to prevent the diagnosis, it may prevent them from objectively analyzing new information and incorporating it into patient diagnoses and treatment.

Ultimately, doctors and lactation consultants are hearing about tongue/lip tie and its effect on breastfeeding more and more. It is crucial that emerging medical information be scrutinized and understood by medical providers so they can maintain (and update) the standard of care for their patients. The medical provider must resist the somewhat natural human inclination to doubt new information. The curious medical provider or hospital system should seek out those with the expertise to educate them on the topic of tongue/lip tie's impact on breastfeeding. It is important for parents to understand that the answer they may get from their medical team may be more of a reaction than an informed opinion. As is increasingly common, parents may have to step outside of the system to get the care needed to improve their breastfeeding relationship if tongue/lip tie is the problem. Hopefully, with time, more providers will understand how to help their own patients.