Not All Breastfeeding Problems Are Caused by Tongue-Tie

As is the case with the identification of any new medical problem, there is bound to be excitement about helping those in need. Sometimes, that excitement can lead to false attribution of a problem to that "new" diagnosis. While tongue-tie or upper lip-tie are not technically new diagnoses, the correlation between tight frenula and breastfeeding problems is a relatively new one. Because I treat many babies each year where babies are having problems from tight frenula, I inevitably end up turning away many babies who aren't needing treatment.

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Not every nail needs the same hammer. Tongue-tie and lip-tie may cause some, but not all, breastfeeding problems.

The first place any mom and baby should go when breastfeeding problems arise is an IBCLC (international board certified lactation consultant). Here is a great post on how to choose a lactation consultant. 

There are many potential causes of breastfeeding problems. I asked a group of great lactation consultants for a list of other causes for breastfeeding problems (specifically, pain). Here's what they came up with:

• Technique problems - This includes poor latch technique, especially with positioning. Often, inexperienced moms picture breastfeeding like how a baby feeds from a bottle (this can also happen if the baby has nipple confusion when going from a bottle to the breast). They present the nipple instead of the breast, which can cause pain. Poor positioning can certainly be a problem (often caused by the wrong kind of pillow or how the baby is held). Nursing an acrobatic toddler who may forget that he/she is breastfeeding when something more interesting comes by can cause pain.

• Anatomical problems in the baby - There are anatomical issues other than tongue-tie or lip-tie that negatively impact breastfeeding. One of the most common is tight oral/neck musculature. This can stem from a traumatic birth, suboptimal intrauterine positioning, or torticollis. Congenital disorders of the baby can affect their oral or facial anatomy that can make breastfeeding extremely difficult (cleft lip or palate, for instance). 
• Specific factors affecting the breasts - While some of these factors can be caused by tongue-tie or lip-tie, diseases of the breasts themselves can be the sole cause of problems. Raynaud's disease or vasospasm can make breastfeeding extremely painful. Overly engorged breasts may make it difficult for the baby to latch on to a taut breast. Mastitis, plugged ducts, thrush and blebs can come from trauma during biting or chewing by the baby. Some moms have allergic reactions to products applied directly to the breasts (or to fragrances in toiletries or laundry). A small subset of moms have pain with letdown, or a painful milk ejection reflex. Others have severe negative emotions associated with letdown, called a dysphoric milk ejection reflex. A history of nipple piercings may have caused nerve sensitivity for mom during breastfeeding.
• Psychological or other health factors that can affect breastfeeding - Postpartum depression can magnify any discomfort at the breast or can be interpreted as discomfort. This becomes especially apparent when the baby has other reasons to have breastfeeding problems (specifically with tongue-tie or lip-tie). Any history of sexual abuse can become a major hurdle for successful breastfeeding. Primary pain disorders like fibromyalgia can also become very problematic for a mom who is trying to nurse. Some moms experience increased discomfort when menstruation returns.
• Equipment misuse - Improper use of a nipple shield can certainly cause problems breastfeeding, either leading to inefficiency of transfer, frustration for the baby or frank pain for mom. Additionally, improper use of a breast pump can cause undue pressure and pain on the nipples.

This list is by no means exhaustive. It is only meant to demonstrate that a mom who is experiencing difficulty with breastfeeding needs to visit someone who is versed in diagnosing these potential problems. Obviously, tongue-tie and lip-tie can play a role in breastfeeding problems, but I worry about the panacea-like mentality that can result when trying to solve a problem for a mom and baby. This is made even more likely given the desperation these dyads feel when something so basic and important becomes difficult.

Diagnosing Tongue-Tie in a Baby is Not a Fad

When a new mom and baby come to see me in the office, I always ask them if they were referred by someone or if they did their own research and came on their own. Specifically, I ask them about the attitudes of their pediatrician, midwife or family practitioner with respect to breastfeeding. I also ask what they think about them coming to my office to try and get a better sense of the idealogical hurdles that exist in my medical community.

One of the most frequent things I hear is that primary care providers say something to the effect of "Oh, diagnosing tongue-tie is just a fad" or "This tongue-tie business is just something new that some people are doing".

While that sentiment is frustrating, I think it is important to address the various reasons why we may be seeing and hearing more about tongue-tie and lip-tie as a cause of breastfeeding problems. As is the case with any new paradigm shift in medicine, the initial response is almost always one of conservatism and doubt. 

Why the surge in babies who are felt to have tongue-tie and/or lip-tie as potential causes of breastfeeding problems? 

• Genetics: There are several studies that examine the potential inheritance patterns of ankyloglossia (tongue-tie). 

1. Acevedo et al in 2010 identified a Brazilian family that had both ankyloglossia and dental abnormalities. While it only looked at 12 patients, the study demonstrated an autosomal dominant pattern of inheritance. (For clarification, an autosomal gene is located on one of the 22 chromosomes that is NOT an X or Y chromosome. A dominant gene needs only one of the two copies to be passed to cause a specific effect - a 50/50 chance of getting the gene.) 
2. Trying to answer the question why males are more affected by ankyloglossia than females, a Korean study by Han et al in 2012 identified potential X-linked patterns of inheritance.
3. Klockars in 2009 identified that the prevalence of ankyloglossia in the population is approximately 4-5% and that inheritance is also passed in an autosomal dominant fashion (like Acevedo).

What these studies demonstrate to us is that there is likely some genetic predisposition towards ankyloglossia. My own observation in my patients is that greater than 50% of babies have a relative who also has ankyloglossia. As is the case with many genetic disorders, if a gene is passed from generation to generation, and that gene is potentially passed in a dominant fashion, more and more babies will be affected by that gene with each new generation and with increasing population size (assuming those affected will be able to have kids of their own).

• More moms are breastfeeding now than they were previously. As rates of breastfeeding increase, the number of moms who have difficulty with breastfeeding is bound to increase. Before the formula revolution, doctors would routinely check a baby for ankyloglossia in the newborn nursery and perform a frenotomy if the frenulum looked tight. There are historical reports of midwives using a long and sharp pinky nail to lance the frenulum in newborns who had difficulty at the breast. Was it a fad then too?
• A major argument I make is that I am attributing a baby's breastfeeding problems to a specific set of anatomical problems. A doctor who doesn't know about these correlations may simply pass along what was taught to them in residency. If their mentors taught them common myths about difficulty breastfeeding, babies would be described as "lazy" or having a "small mouth or small tongue" as potential excuses for problems. If those excuses didn't seem to hold, the mom would also be blamed for not making enough milk or having nipples that weren't conducive to breastfeeding. I don't think these excuses are evolutionarily plausible explanations for why babies have problems breastfeeding. You would never hear a doctor explain away a patient's low oxygen level by saying "You just have lazy lungs." I feel that we must find the anatomical reason why some babies can't breastfeed and I will make the argument that many of these babies have problems because of restrictions at the tongue or upper lip.

Future posts will look at the evidence in favor of releasing tongue-ties when those ties are the cause of breastfeeding problems. Ironically, there are no data that argue against treating tongue-tie for babies having breastfeeding problems. When people describe this focus on ankyloglossia and how it relates to breastfeeding as a fad, it is insulting as it doesn't acknowledge the struggles of the mom or the baby. It minimizes the frustrations felt by the dyad and does nothing to help solve the actual problem at hand.

I am asking the doctors and lactation consultants to approach this problem analytically rather than passing old dogma on to their patients. 

How to Examine a Baby for Tongue-Tie or Lip-Tie

The only purpose of this post is to demonstrate how to examine a baby who may have a tongue-tie or lip-tie. Future posts will help to explain the symptoms of intraoral restrictions that can impact breastfeeding.

Our first year of medical school includes proper examination technique. For instance, if you don't know where to put your stethoscope, you might miss a heart murmur. Unfortunately, we aren't instructed on how to examine a baby who is having breastfeeding problems. If you don't know how to properly examine a baby for tongue-tie or lip-tie, you will be more inclined to say that they don't exist.

The first step is adequate illumination. A headlight is a great option and critical in freeing up both hands. There are very affordable (under $25 typically) LED camping headlights that can be used to get a great view of the mouth.

The next step is proper positioning. This is the most common error made by medical professionals looking for tongue-tie or lip-tie. The provider and the parent should face each other, knees touching. The baby is laid on the lap of this makeshift table, head towards the examiner. You cannot adequately evaluate a baby's mouth when they are sitting in a parent's lap in an upright position.

The goal of the examination is to try and determine the degree of tension of the frenulum of the lip and tongue on the surrounding tissue. Does the baby react or not? If it seems uncomfortable to them, they often squirm. If the frenulum is tight, it will often turn white or blanch. Look at where the frenulum is attaching to the gumline or tongue.

Many providers recommend stretching exercises after a releasing procedure to avoid the possibility of reattachment of the wounds. In those instances, a parent would turn the baby so that the head is in their laps and the feet pointing away. Alternatively, the baby can lay on a changing table or mattress as the parent positions themselves about the baby to expose the lip and tongue for stretching.

This technique is also the preferred technique for obtaining pictures of the lip or tongue. You will need a second assistant to take the pictures once you have the lip and tongue in proper position.

Breastfeeding Difficulty and Family Support

Imagine a disease that came on suddenly and left doctors baffled. Imagine that it was causing you pain and leaving you feeling completely helpless. Then imagine that your spouse didn't believe that anything was wrong. 

Unfortunately, if that "disease" is a mother's difficulty breastfeeding her child, this scenario is all too common. I hear stories like this on a frequent basis and we must do what we can to anticipate and stop such stories from occurring. 

Disclaimer: for the purposes of this post, I will address the father as the family member who is casting doubt. But we must be realistic that others can play that role: same sex partners who aren't doing the breastfeeding, extended family members, close friends, and on occasion, mom herself. I have even met families where mom is in denial that a problem exists but dad understands that there's a problem and pursues evaluation and treatment. 

So what kind of things are said? 

• "I don't see anything wrong." This is tacit denial that can be very hard to address. Often, it's because dad doesn't understand the significance of breastfeeding. Often, it's followed by "formula is just as good" or "you can just pump". To combat this statement thoroughly is beyond the scope of this post and I do not want to fuel the breast vs bottle debate. My role as a breastfeeding specialist is to listen to the family, and most who see me want to breastfeed. So dad has to understand that breastfed children have immunological and facial developmental advantages over bottlefed babies. Mom and baby also get tremendous psychological benefit from maintaining a nursing relationship for as long as possible. 
•  "I don't want to spend the money." While it sounds harsh, the reality is that a baby who was just born brings significant medical bills. Adding on new office visits and a procedure in the event of tongue-tie or lip-tie just compounds the problem. While it is a cost up front, the cost of formula and diminished immune capabilities can easily be more costly in the future. Dad's denial becomes especially apparent when the baby needs a follow-up procedure because of reattachment or lack of symptom improvement. The dad sees the first procedure as a failure and isn't hopeful that a second procedure (and cost) is beneficial. That's why I don't charge for follow-up visits or redo procedures for 6 months, which gives us ample time to see the results. 
• "I don't want my child to have a procedure done." This one is based on fear and a lack of information. 

I frequently point out to moms who are in this situation that it is reasonable for a dad to have this opinion if they are going to do the amount of reading and research that mom has done. If, however, they are going to have this opinion without doing any research at all, then it amounts to them being scared. I'm not saying that fear is unnatural -- quite the contrary. It's just important to address the reason why they are scared before you can move forward.

• "Our pediatrician said nothing is wrong." This also applies to family practitioners and lactation consultants. Surprisingly, this argument is easy to deflate. If you first realize that most pediatricians have very little training in breastfeeding medicine, my argument is that their opinion doesn't carry weight in these instances. If your child had a compound leg fracture, you would visit an orthopedic surgeon. If you returned to your pediatrician and they said "Don't worry, it's not going to be a problem so just hold off on treatment", you'd likely find a new pediatrician. This is the real crux of my argument. Pediatricians and family practitioners are very adept at dealing with moms who have no breastfeeding problems. They should encourage it as much as possible. But if there is a problem in breastfeeding, they usually don't know how to intervene because they haven't been trained to deal with that specific scenario. In my opinion, their opinion doesn't hold weight in this specific case.
• "We already saw an ENT (or other specialist) and they said that tongue-tie doesn't affect breastfeeding." The argument here is similar to the previous one. Just because a doctor is a specialist, it doesn't mean that the specialist knows how to treat this specific problem. As I alluded to in another post, like many ENT's, I received no education in breastfeeding medicine during my training. I pursued vast amounts of reading, studying, and consulting with other breastfeeding specialists for almost two years to educate myself about the association between tongue-tie and breastfeeding problems. My desire to further my education in this specific arena is relatively uncommon. For the majority of ENT's, however, the mom/dad/PCP all assume that the specialist knows what they're talking about, so any subsequent denial of association between tongue-tie and breastfeeding problems erroneously carries weight (and encourages the pediatrician to say the same thing).

Breastfeeding difficulty can contribute to postpartum depression and can taint the relationship between mom and baby. Adding spousal or family disapproval of pursuing a procedure that might help alleviate these problems often dooms them to fail. If you have a family member who is doubting what you think might be the case, have them read this post or have them email me. Have them join one of the many support groups to just read what is going on in families all over the world to help them understand that they aren't alone in having problems, and that a solution may be out there.