We are going to chat Tongue Tie or, as we are going to refer to it, Oral Tethers as it represents all the tethers that can occur in the baby's mouth - lip, tongue and cheek. We’ll discuss what our responsibility is as qualified Lactation Consultants (IBCLC) and what we are allowed to do within our scope of practice.
Each profession has a scope that you are qualified to perform within, for example, a heart surgeon is unable to ink a tattoo on you, unless they have this qualification. Similarly an IBCLC is unable to diagnose or medicate. We are able to assess a baby's behaviour or mouth presentation but are unable to revise an oral tether or state that it is an oral tether, unless it falls within our scope of practice. Exceptions to this rule are if your IBCLC is also a GP Doctor or a Registered Nurse, then, if they have had training in the process, they are permitted to assess, diagnose and revise.
An IBCLC's realm is to support the feeding of the baby and protecting the milk supply,
Why are tongues and lips so important to breastfeeding?
Breastfeeding is a whole of mouth approach, 6 nerves and 20 muscles are used in the process. The whole of the mouth needs to be engaged in order to effectively drain the breast and transfer the milk. The top lip’s function is to create a seal and stabilise the mouth at the breast. The bottom jaw and tongue does all the heavy lifting, taking in the majority of the nipple and areola and drawing the nipple to the soft palate area of the babies mouth. The tongue rhythmically waves at the breast in a fluid motion, and the fat pads on the babies cheeks help to hold the breast in the mouth. All this needs to happen smoothly in order to drain the breast, make more milk, and transfer milk to the baby.
Why would I think that my baby has an oral tether?
A baby that has a mouth that is having trouble triggering the milk transfer effectively may have low weight gain, be a sleepy baby, short feeds, unable to maintain the latch and might slip off the breast, unhappy and sad more so than normal baby behaviour. A mother might have cracked and bleeding nipples, painful feeding from day one, developed low milk supply and the nipple might have a lipstick shape to the nipple or even a compression stripe, which is a white line at the end of the nipple. However all of these things are also related to a host of other issues such as a bad latch or other medical issues. There are lots of reasons why feeding can go pear shaped and often an oral tether is only part of the picture or not at all.
So why would you see an IBCLC for oral tether issues if they can't diagnose?
IBCLC can perform a mouth assessment and report what we are seeing. When we see our families for the first time we perform a mouth assessment where it is appropriate. This involves looking for restrictions in the top lip by flipping the top lip to see how tight the labial frenulum is from the top lip to the gum to ensure that your baby is able to flange their top lip enough to both create a seal, and stabilise. The top lip can be integral to creating a stabilising seal on the top of the breast. When we look at the lip we are also looking for a significant lip blister, or a top lip 'tyre tread' look, which is indicative of friction where the top lip is working harder then it needs to; to maintain the seal.
We run our fingers on the gum and see if the tongue can "grab" the finger. This is referred to as lateralisation. Think about a goal keeper who is able to move all around the goal square. This goal keeper can grab the soccer ball easily, however, if that goal keeper is tied at the base of the goal square then they wouldn't be able to grab the soccer ball as easily. In order for the tongue to effectively move the nipple into the soft palate and then do a wave movement to milk the breast well, the tongue needs to be able to move all of itself freely.
We put our fingers underneath the tongue and gently lift the tongue up to see how restricted the connective tissue is from the base of the mouth to the tongue. If there is a lot of blanching or whiteness to the connective tissue then this is another example of restriction.
We also take a full history - How was the mother fed? How was the father fed? The reason this is asked is because often breastfeeding concerns can run in families. One side of the genetic line with consistent problems can often be a red flag. We also assess how the feeding is going and take into consideration weight gains, nipple damage and overall feeding.
What we aren't focused on?
We aren't as focused on what a feed looks like as much as much as how the nipple feels in your baby's mouth. There are many things that you can change with a position adjustment and this can directly affect how the nipple sits in the baby's mouth. How it feels is essential, your nipple should have gentle pressure, but no pain.
What we do care about?
We care about how the nipple and areola feels in the baby's mouth. We look at what the nipple looks like coming out of the baby's mouth, is it compressed to a large degree and is there pain involved? These are indicators that the nipple has not gone far enough back in the babies mouth to the soft palate area, that the nipple is being held at the hard palate. This is a concern as it is harder for the baby to milk the breast effectively and stimulate the milk making hormones to ensure a steady milk supply.
Assessing for an oral tether is not one factor but a multitude of factors that support an assessment. When we have finished an assessment you are given a detailed breast feeding plan that includes the mouth assessment which you can take to a clinician for a diagnosis and possible revision.
What if the clinicians don't agree with our assessment?
That is absolutely fine, we are happy to be disagreed with as it means this is one piece of the puzzle that is sorted, and we can refocus on attachment and positioning. We are not going to cry in our beer if there is disagreement. However if the situation isn't resolving and you have tried all sorts of attachment options etc then it is important to have this assessment reviewed. In the same way that we can be wrong, so can other professionals. We are all human and fallible.
If a revision is done, what then in relation to an IBCLC?
In some cases oral tether revision can make an instant difference, women report that feeding post procedure has been noticeably different, however, in our experience this is rare. Typically it is a slowly developing change rather than instant. It is really important to remember that babies have been using their tongue since 8-9 weeks in utero, so if your new born has a revision done at 2 weeks of age, they have been using their "old tongue" for 34-35 weeks and need to learn new muscle memories.
It is useful to think about breastfeeding after a revision as a whole new process. Both you and your baby need to start anew with positioning and attachment; your baby needs to relearn how to use their 'new' tongue. If you and your support team can take the time to start afresh, this will help in moving forward in a positive light.
We recommend a combined approach of Bodywork, such as Osteopathy or Bowen Therapy to assist loosening the muscles and creating new nerve pathways to help the tongue be as effective as possible. This takes time and can be a slow process. Often families have been through the wringer and when told that it may not be an instant result it can be very disheartening. This process is generally a marathon not a sprint. There are some excellent practitioners in Canberra that have emergency appointments for babies and can often be seen sooner rather then later.
Where is the research?
Unfortunately Oral Tethers is a newly developing field and there is very little research to refer to. We do have oceans of anecdotal evidence from mothers who have had revisions done on their babies and it has made the world of difference.
My neighbour's sister's cousin’s baby had a tongue tie and didn't get it revised and she is fine. Why should I get it done?
This is where we come to my favourite saying "Some baby's and some boobs". Some babies are able to pull the nipple into the soft palate area with a restriction and manage okay. This is normally combined with boobs that have a good sized nipple that can fill the mouth and make it easier. However some nipples are a bit flatter and some babies have a smaller mouth, and combined with the oral restriction, is too much for the baby to deal with.
The tongue is also responsible for shaping the soft palate, widening the jaw and preventing teeth crowding, and helping to clear food from the gums reducing teeth decay. Tongues are also integral for kissing and licking. But again, some babies manage well depending on the degree of restriction.
This is why an assessment should take in the whole picture and not just focus on one aspect of the mother and baby relationship. It is important to note that at the beginning of your breastfeeding relationship your breasts go into overdrive and over produce milk. When a baby has a restriction they are able feed without having to try too hard to trigger a letdown due to the overproduction of milk. After a number of weeks post birth, breastmilk production starts to become the responsibility of the breasts and the baby to manage. If the baby is having difficulty draining the breast due to a restriction this can make it difficult to maintain milk production and weight gains.
Unfortunately there are no hard or fast rules in regards to an oral tether. Having the whole of the breastfeeding relationship reviewed by a qualified IBCLC is essential to help build a picture to ascertain a way forward.
What can I do?
There are no concrete rules about how to move forward when breastfeeding is not going well. What we can give you is an iron clad agreement that it is always better if you can get some expert help early on. The earlier that you can get support and help, the easier it is to get back on track. It is probably not going to be smooth and simple, and it might take a while to get to where you want to be, but you’ll be professionally supported along the way
There are always solutions and ways to manage breastfeeding with an oral tether, and it is always better with people in your corner providing support, resources and encouragement.
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