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.

The Importance of Active Wound Management Following Frenotomy

by Bobby Ghaheri

One of the more common discussion threads surrounding tongue/lip tie division is the topic of wound reattachment, where dyads exhibit brief windows of symptom resolution only to reverse their progress and return to the original problems with breastfeeding. This post will explain the principles of a complete tongue/lip release, the biology of wound healing, and the necessity for actively managing a wound to prevent scarring.

Frenotomy Wounds

An appropriate procedure for the lip or tongue will result in a complete release of tension caused by the inappropriately tight fibrous band. The best way to know if a proper release has been done is to look at the shape of the wound. For lingual frenotomies, there must be a diamond-shaped wound for the release to be complete. If there is no diamond-shaped wound, then the procedure hasn't fully released the tension. For the upper lip, complete laxity of the central lip should be seen and the tie should be completely lifted off of the gumline. If only a small nick in the lip tie or tongue tie is made, there will be little to no chance of improvement because the wound itself is small. Along the same lines, if the initial procedure was incomplete and scar tissue forms, the wound did not “reattach” - it was just incompletely opened. In contrast, a fully opened wound will pathologically reattach if active wound management isn’t practiced. This pathologic reattachment is different than the typical attachment we see when the tongue or lip heal normally. What we are aiming for is a band that is more flexible and forgiving than what was there prior to the procedure.                            

This sketch of the release of a lip tie shows the result of proper wound management, where a finger is gently run under the lip to separate the lip from the gumline, versus poor wound management, where too much of the lip is allowed to readhere to the gumline. Remember, if the initial release was inadequate, then you would never have achieved the good mobility in the first place, so it can mimic the reattached lip.

This sketch of the release of a lip tie shows the result of proper wound management, where a finger is gently run under the lip to separate the lip from the gumline, versus poor wound management, where too much of the lip is allowed to readhere to the gumline. Remember, if the initial release was inadequate, then you would never have achieved the good mobility in the first place, so it can mimic the reattached lip.

The tongue tie wound is more complex. First, just snipping an anterior frenulum does little to improve tongue function for breastfeeding purposes. There is always a posterior, submucosal component of the tongue tie that needs to be released. If the procedure stops short and only the anterior part of the tie is released, no open wound under the tongue results. There must be a diamond-shaped wound in order to have a full release of a tongue tie. After an incomplete procedure, stretches are irrelevant because the size of the wound created is minimal, so it will heal with minimal scarring.  The problem in this scenario is that the tension of the posterior tongue tie is still present and function doesn’t improve. What we want is a procedure that fully releases the tension and doesn’t reattach. This can only be achieved by actively stretching the wound. My protocol for that is here.

Principles of Wound Healing

While some of the principles of wound healing inside the mouth also apply to wounds on the skin, there are certain characteristics that are unique to oral wounds. The best description of these characteristics is in the book “Oral Wound Healing” by Hannu Larjava (2012). When a wound is created, it will undergo specific, predictable changes in an attempt to close that wound. Within 24 hours of wound creation, the edges of the wound begin to migrate towards the center of the wound so that the edges can try and eventually zipper together with a mucous membrane covering. This migration is facilitated by a scaffolding that forms over the wound (this is the white/yellow color we see as an oral wound is healing).  At the same time, granulation tissue begins to fill the wound. Granulation tissue serves to reform the connective tissue that gives the new wound strength. It does this by migrating new blood vessels into the area and forming a matrix of fibers that are the precursors to scar formation. It can take months for the mature wound to finally form. During this time, wound contraction occurs as the scar fibers organize.

How does this apply to tongue tie and lip tie? When a provider creates a wound in the mouth to try and release a tethered band, the mouth will try close that wound. In the context of tongue tie and lip tie, we want those wounds to heal in an open conformation rather than closed back together. It is also important to translate this expected progression of wound healing into what should visibly happen to the wounds. Lip releases heal extremely well and aren’t typically subjected to what happens under the tongue. It is important, however, to understand that there will be a new band connecting the lip to the gumline - that's part of normal lip healing. For the tongue, the first 5-7 days following a frenotomy demonstrate a soft wound with good mobility. As time goes on, the diamond under the tongue will start to contract and get firm. This is most prevalent between days 10-21 after a procedure. The scar tissue developing within the diamond will ultimately loosen again after day 21, and can take months to fully soften and mature.

Horizontal vs Vertical Healing

Remember, once an open wound is created in the mouth, the body will try to close the wound and contract toward its center. The end result is that the lip will try to stick back down to the gumline and the tongue will try to stick back down to the floor of mouth. The trick to achieving optimal results is to try and guide the tissue, through proper stretches, to heal in a way that maximizes vertical movement. This vertical movement is important for upward flanging of the lip and more importantly, upward movement of the tongue towards the palate to form the seal necessary for vacuum generation.

Tools and Techniques

To my knowledge, there haven’t been any published studies that demonstrate superior wound healing outcomes with a particular surgical technique or instrument. Some laser studies show potential benefits when studied in the lab or in animal models, but so far no human studies exist that demonstrate a difference. What is important to recognize is that the tool being used for the procedure really doesn’t matter. What matters is the depth of the release - an adequate release resulting in a diamond-shaped wound needs stretching regardless of the instrument that was used to create the wound.

Why do some wounds behave poorly and result in inflexible scar formation? There are many potential reasons:

  1. The release was inadequate from the beginning so scar tissue forms on top of already immobile tissue    
  2. Poor adherence to wound stretching protocols
  3. Poor surgical technique - cutting too deep (muscle damage) and stimulating a more rigorous inflammatory response
  4. Delivery of too much energy to the wound, either by the inadequately trained laser provider who turns a 45 second procedure in a much longer exposure to laser energy or laser settings that are inappropriate
  5. Inherent scar forming tendencies of the patient

While the success of the procedure doesn’t come from the tool used, my experience has been that the use of electrocautery causes more collateral damage (when compared to laser or scissors), resulting in more scarring. There are always exceptions to this rule, so it is important to know how to choose your provider appropriately.

The most successful approach to tongue/lip tie revision includes:

  1. The IBCLC, who helps to establish better latch mechanics and positioning in addition to improving sucking skills
  2. A therapist to help resolve muscle tension which can inhibit both the latch and proper wound healing
  3. The provider, who should create a proper wound and manage the healing in a way to maximize the mobility of the lip and/or tongue 

This multidisciplinary approach is the key to successful rehabilitation from a problematic nursing relationship.

How to Take Appropriate Pictures for Tongue Tie or Lip Tie Evaluation

by Bobby Ghaheri

This post has one basic goal: to teach you how to take appropriate pictures of the tongue or lip to help others evaluate your baby from a distance.

1) taking good pictures requires 2 people. A tongue selfie does no one any good. One person lifts the lip or the tongue and the other snaps the picture.

2) get good illumination - a decent LED headlight now costs less than $20.

3) Proper positioning - the lip and the tongue should move up for normal breastfeeding. Getting your fingers under the lip or under the tongue is important for testing if you can easily pick the tongue up. Position yourself from above so that the baby's feet are moving away from you.

4) Here’s a video on how to elevate the lip or the tongue:

5) For the person taking the picture, make sure you position yourself so you can bring the entire frenulum in view. One trick is to have the focus already set by focusing on the mouth before you do the elevation. On iPhones (and possibly Android phones), holding your finger on the desired area of focus for several seconds will result in a locked “autofocus/autoexposure”, so that it won’t try to refocus as the baby moves. Another trick is to just hold the shutter down and take a rapid burst of photos to see if you can find a suitable picture. Along similar lines, you could take a video and then choose a screen shot later.