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

by Bobby Ghaheri


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

by Bobby Ghaheri


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?

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

by Bobby Ghaheri


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.

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.

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.


The Misunderstanding of Posterior Tongue Tie Anatomy and Release Technique

by Bobby Ghaheri


When medical providers and parents hear the phrase “tongue tie”, they most commonly picture a tight anterior tongue tie, where the tip of the tongue is tacked down to the floor of the mouth. I have previously described the difference between anterior and posterior tongue tie (PTT) but the concept still eludes many people. One of the most common statements I hear from medical professionals is that “posterior tongue tie doesn’t exist”. The most basic reason why people claim to not “believe” in PTT (as if it were a spiritual issue rather than an anatomical one) is that they know very little about breastfeeding and the relationship with tongue tie. Some of this sentiment comes from a blatant misunderstanding of the anatomy (they think the tie is in the posterior oral cavity near the tonsils). Others don’t understand the concept because they don’t know what normal infant tongues do during breastfeeding (as shown in ultrasound studies). Finally, most medical providers don’t understand proper examination technique, which prevents them from correlating the symptoms with abnormal anatomy.

There are some published data on the presence of PTT. Cliff O’Callahan and colleagues, in a 2013 paper, treated 299 babies with tongue tie. 84% of those babies had PTT; this number includes babies who previously had an anterior tie that was snipped by a different medical provider. Nevertheless, the majority of babies that presented to his office did not have an anterior tie. Dr. O’Callahan demonstrated clinically significant improvements in breastfeeding quality with a frenotomy. To those who don’t believe that PTT exists, I use this study to demonstrate that release of a tongue tie with no anterior frenulum results in clear clinical improvement. A more recent study from 2015 by Pransky and colleagues retrospectively evaluated 618 babies presenting with breastfeeding symptoms. In this study, almost 20% had PTT alone and a further 5% had both PTT and a lip tie. As is the case with the O’Callahan study, the vast majority of babies in this study showed improvement in breastfeeding quality following frenotomy.

A posterior tongue tie is the presence of abnormal collagen fibers in a submucosal location surrounded by abnormally tight mucous membranes under the front of the tongue. As I wrote in a previous post, a classic anterior tongue tie always has a posterior component behind it. Therefore, any tongue tie causing breastfeeding problems is truly a posterior tongue tie; a percentage of those ties also have an anterior component. Failure to release all of the abnormal collagen fibers results in persistent tongue restriction. When providers claim to release 80-90% of the restriction, the dyad can often see 0% improvement. The other major misconception that people have about PTT anatomy is the idea that the tie is somehow “deep” and that it intertwines with the muscles of the tongue. This is not the case. As seen in the diagrams below, the abnormal collagen fibers of the PTT are intertwined within the mucous membrane covering the tongue muscles. The muscle of the tongue beneath this mucous membrane (the genioglossus muscle) is in a completely different tissue layer and is therefore not involved in tongue tie anatomy nor does it need to be involved in the release procedure.

PTT fibers are centrally located in a layer above the genioglossus muscle

A small window is made through the PTT fibers to begin the release

Release of the mucous membrane on either side of the central window

Final diamond-shaped wound is achieved (top half of wound seen here)

Incomplete release of a tongue tie prevents the tongue from achieving its normal movements during breastfeeding. A common fallacy is that a tongue cannot be tied if it can extend out of the mouth beyond the gumline or lips. This is completely untrue. First, the tongue is capable of numerous different movements, and normal mobility in one direction does not guarantee normal mobility in all directions. Furthermore, the motion of the tongue during breastfeeding is very specific - the primary movement that is important is up, not out. I wrote about breastfeeding mechanics, where we have objective evidence from Donna Geddes’ paper in 2008 (and later corroborated by David Elad’s paper in 2014) demonstrating the importance of the upward motion of the tongue. The lack of strong upward movement, inhibited by a tongue tie’s abnormal collagen fibers restricting the tongue to the floor of mouth or mandible, is shown in common symptoms: poor suction/seal on the breast, frequent breaking of the seal with resultant clicking, air intake (aerophagia), slipping off the breast and having to bite down to hold on to the nipple and so forth. These symptoms can occur with bottle feeding as well.

With an understanding of the normal movement of the tongue during breastfeeding, the medical provider and lactation consultant MUST change how they examine the baby. Without challenging the upward movement of the tongue, they will never understand if a visible and palpable restriction exists. I have previously written about proper examination technique to try and standardize our approach to infant oral examinations.

Along with the misconceptions about PTT anatomy come misconceptions about PTT release. Many able and skilled providers combine a poor examination technique with apprehension about PTT release. Why is there apprehension about the procedure? The most common reason is the misunderstanding of how deep one must travel to fully release the tethered fibers. As I stated above, the PTT fibers intertwine with the mucous membrane and do not involve the muscle. Proper release technique involves a central release of the fibrous band and then a release of the mucous membrane on either side of the central band. One must release the mucous membrane lateral to the band (resulting in a diamond-shaped wound) because the mucous membrane around the tie has shrink wrapped around the muscle to only allow the movements that were present prior to the tie release. Once the central band is released, you must also release the mucous membrane to allow the tongue to actually move up. The actual depth of the initial incision is surprisingly shallow (approximately 1mm). Neither the central release nor the lateral mucosal releases involve the muscle, so bleeding is kept to a minimum. Also contrary to popular belief, a PTT can be released with scissors or laser - the release technique described above is far more important than the tool used.

Looking from the top down, the grooved director lifts the tongue out of the way, isolating the posterior tongue tie

After central release is made, the mucous membrane release on one side is started

Release is carried to other side

Final diamond-shaped wound is achieved with higher lift with the grooved director

I sincerely hope this post helps to clarify PTT anatomy and to demystify the procedure needed to release tongue ties properly. If you are a clinician reading this and would like additional pictures, videos, or descriptions of the procedure, please email me using the link at the top of my page. For parents, using this post may help your doctors understand PTT anatomy and that a tie can occur without an obvious visible frenulum. For clinicians looking to improve their clinical skills, I highly recommend shadowing a provider who performs this procedure frequently (and for those inclined, you may shadow me by contacting me). This improved understanding of PTT will decrease the number of inadequately released frenula and improve long term breastfeeding success.