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.