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

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.

Tongue Tie Procedures Don't Need General Anesthesia

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.

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• 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.

How Does An Upper Lip Tie Affect Breastfeeding?

Tongue tie division is a very effective procedure in the majority of babies with ankyloglossia. However, there are many reasons why an initial procedure to divide a tongue tie (a lingual frenotomy) can fail to improve breastfeeding symptoms.

• The procedure was not carried far enough under the tongue (the thin membrane of an obvious tongue tie was cut but the thicker portion behind it was left intact)
• The cut area under the tongue reattached (it healed too quickly) and the tongue's mobility mimics what it was prior to the procedure
• The tongue tie was not the only problem contributing to breastfeeding difficulties

It is this last point that I will address here. Most medical practitioners haven't even heard of an upper lip tie (ULT). While almost everyone has an upper lip frenulum, only those with restriction of function of the upper lip are defined as having a tie.

I previously touched on the importance of the upper lip flanging outward during a deep latch when I showed the various ultrasound studies that demonstrated proper breastfeeding motion. The normal breastfeeding motion is best achieved when the baby can widely open the mouth. This wide opening is best achieved when the baby is able to flange the upper lip outward, allowing the mucous membrane portion of the lip (rather than the dry outer portion) to contact the breast. This allows for a better seal, which is the first step in generating the negative pressure for breastfeeding. When a central ULT tethers the lip downward, that flanging motion is impeded. This results in a smaller mouth opening and forces the baby to adopt a more shallow position on the breast, leading to a multitude of problems.

The upper lip tie can affect the baby's ability to flange in several ways. The first is the most obvious - the shorter and tighter the frenulum is, the more uncomfortable it is for baby to flange that lip outward, even if mom flanges the lip out manually. I have repeatedly seen a baby with an ULT trying to nurse as mom attempts to flip the lip upward. Moments later, the baby will either pop off the breast completely or will very briefly relax the latch off the skin just enough to allow the upper lip to roll back in, which is a more comfortable position. The mom will often complain about repeatedly having to flip the lip upward in frustration. The second way that a tight ULT affects breastfeeding is just based on muscle flexibility. To widely open the mouth, a baby without an ULT pushes the upper lip up toward the nose. When an ULT is present and the lip is naturally rolled inward, the muscle around the lips (the orbicularis oris muscle) cannot be pushed up toward the nose. This puts an unnatural amount of tension on the muscle of the lip itself. Try this yourselves. First, open your mouths naturally as wide as you can. Compare that sensation to when you forcibly tuck in your upper lip followed by an attempt at widely opening your mouth. You will notice tension across the upper lip (and not on the ULT itself). A baby can't and won't open widely if the lip is tense.

It is important to know that there are no peer-reviewed studies showing the efficacy of dividing an ULT when breastfeeding is impacted. While there are qualitative objective measures that seek to grade the severity of breastfeeding dysfunction with respect to a tongue-tie, no such measures exist for an ULT. Many physicians and lactation consultants point to this and therefore argue that division of an ULT shouldn't be done. Of course, I disagree:

• As a physician, it is my duty to do what I can to help my patient (and their mothers). Like many other physicians, I practice the art and science of medicine by analyzing the available data and combining that with what is appropriate and safe. As a result, I often treat patients with medications or surgeries that have not been rigorously tested by a multicenter, double blinded randomized controlled trial. Like most other doctors, I use procedures and medications and tailor those to the specific patient's problems. Basically, I use my judgement. How can we generate data if we are asked not to investigate the procedure? Division of ULT is extremely safe. The anecdotal evidence in support of the procedure is quite overwhelming.
•  In a bulletin put out in 2004 by the American Academy of Pediatrics, Corrylos and colleagues write: "A baby who cannot flange his /her upper lip because of a tight upper labial frenulum may need to alter his/her nursing position or have it surgically released in order to permit effective nursing. A mother with a short nipple and inelastic breast tissue may have trouble even achieving latch-on with such a baby. It may be that a short or tight lower labial frenulum can cause similar problems by preventing the lower lip from flanging." This thought process isn't new, and its presence has been acknowledged by the AAP.
• In the best study of babies with tongue-tie, Dr. O'Callahan and colleagues (2013) found that 37% of babies with tongue tie also had a current ULT. Those ULTs were treated routinely as part of the study. While they were not specifically separated out and studied, it shows the importance of treating the baby to maximize breastfeeding outcomes. Many practitioners who routinely treat tongue-tied babies feel that this number likely underestimates the number of babies who would benefit from a lip tie revision. My experience has shown me the importance of addressing the ULT when it is present. Dr. O'Callahan's study confirms that importance. I feel that ignoring an ULT because of the lack of a dedicated study looking at ULT in breastfeeding is unethical. It increases the chances that babies need a second procedure, in addition to prolonging the breastfeeding problems that they are already having. A similar example exists when children with sleep apnea have large tonsils and adenoids. I don't think it's appropriate to just remove the tonsils because of the lack of good data saying that the adenoids should also be removed. We must treat the entire problem.

My goal is to get everyone who is involved in improving breastfeeding outcomes to step back and use a practical approach while combining that with a knowledge of anatomy. Many of us know what the ideal latch looks like; the flanging upper lip is part of that ideal latch. If an anatomical problem limits the ability to form an ideal latch, and a simple procedure exists to completely change that ability, I maintain that it should be done. With time, we will generate more data. But I will not allow the lack of data to paralyze me in treating babies and moms who need help now.

How Tongue-Tie Affects Breastfeeding Mechanics

So far, we've discussed the myths propagated about abnormal breastfeeding, how to examine for tongue-tie and the various symptoms that arise from breastfeeding a tongue-tied baby for both mom and baby. This post will explain the mechanism by which the tongue-tie affects breastfeeding.

Before defining how breastfeeding actually occurs, it's important to clear up some misconceptions. How does a baby actually breastfeed? Here are some older theories for the mechanics of breastfeeding:

• The baby sucks on the nipple as if it were the end of a bottle 
• The baby uses the lips and tongue to strip the breast (e.g. milking the breast)
• The baby just drinks breast milk (believe me, I've heard this)

The most common misconception is the second of those mentioned. People think that the breast fills up with milk, and it is the baby's job to remove that milk by undulations of the tongue and upper lip in a milking movement. Ultrasound data show us that this isn't true. Occasionally, the first and third misconceptions do happen. When a baby is tongue- or lip-tied, they will cheat down to the end of the nipple and will nipple feed instead of breastfeed. And in some instances, when mom has an overactive letdown or oversupply, the baby has to exert very little effort and just drinks what is presented. This isn't a sustainable method of nursing.

The best data to date come from ultrasound studies. These studies show two important concepts:

1. They show the minimal involvement of the nipple in children without tongue-tie and conversely, a mechanism for the damage that occurs to the nipple in the tongue-tied child
2. They show that the mechanism of nursing depends on the baby generating negative pressure inside the mouth, which draws the milk out

Panel A shows a tongue-tied baby compressing the nipple tip. Panel B shows less compression following a frenotomy. From Geddes 2008.  (HSPJ = hard/soft palate junction)

What happens to the nipple while inside the baby's mouth?

The data from Geddes' study show two separate patterns of nipple positioning when a baby is tongue-tied. Interestingly, I have seen this in the babies in my office who cause two different patterns of nipple damage. The first pattern occurs when the nipple is in the appropriate position in the mouth, which is at the junction of the hard and soft palate (further back than most people think). These tongue-tied babies are able to get around the length of the nipple but tend to clamp down and bite at the base of the nipple. Clinically, this can result in creasing and blanching at the base of the nipple. The second pattern occurs when a baby uses the tongue to block or thrust the nipple forward in the mouth. These babies are unable to keep the nipple in the appropriate position, so the damage is more on the nipple itself rather than around it. This may also explain why some babies are unable to tolerate a bottle or a pacifier. Instead of moving freely, the tether of the tongue forces the tongue to move in a forward, rather than an upward, motion. Why a tongue-tied baby uses one tongue motion over the other is unknown.

What are the mechanics of breastfeeding?

Now that we understand that the baby does not physically "milk" the breast, let's look at what a baby does to draw milk out of the breast. Again, we will turn to the ultrasound studies. The most plausible explanation for how a baby nurses involves the generation of negative pressure (a vacuum of sorts) within the oral cavity using an up and down motion of the tongue. First, the baby must have the ability to form a seal around the breast. This involves the upper lip flanging outward and the tongue cupping and elevating the breast towards the palate. If the tongue cannot elevate, cupping can be quite weak and the baby can "fall" off the breast. As important is the ability for the midportion of the tongue to freely elevate and depress within the oral cavity. This is how the baby draws milk out of the breast - the baby will push their tongue up towards the palate and then quickly depress it, creating a vacuum.

Please spend a moment to watch this brief video of an ultrasound showing the motion of the tongue in generating this negative pressure. Pay special attention to the fact that the nipple itself is not manipulated much in a baby that isn't tongue-tied. 

These data demonstrate that breastfeeding is less about the nipple and more about the depth of the latch and the mobility of the tongue. It explains how many babies with no visible tongue-tie can still have terrible latches. These posterior tongue ties are more hidden, but still cause significant restriction of movement (in that critical upward direction). It also explains why a baby's ability to stick the tongue forward is irrelevant in assessing whether tongue-tie exists.

The Geddes studies show us the importance of thinking about a baby's anatomy and how it will impact breastfeeding. I will make a similar argument when we discuss the importance of a tethered upper lip. If anatomy is preventing the latch from being initiated, a domino effect of compensatory movements begins. Prevention of that compensatory domino effect is critical in maintaining a long-term nursing relationship.

Reference: Geddes, et al. Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. Pediatrics. 122:1; e188-e194.