Notes on Tongue Tie and Breast Feeding

In my pursuit to continue to educate myself on tongue tie and feeding, I attended a one day conference last week on Tongue Tie and Breast Feeding presented by  Catherine Watson Genna, BS, IBC LC, http://www.cwgenna.com. 

It was a wonderful conference and I highly recommend Catherine as a speaker. She is very engaging, loves questions, and her talk was very research based.  Here are some highlights on what I learned. Hope this is helpful!

Cultures have been performing frenotomies for centuries.

• problem, the more we clip normal tongues the more backlash we get for clipping abnormals
• everyone has a frenulum, doesn’t mean it needs to be clipped
• babies need to be selected carefully
• clipping incorrectly- can cause scar tissues, reduce movement
• 5-13% of population has restricted tongue

Look at whole picture , Understanding normal

–  at rest, babies lips should be closed

• where is the tongue while sleeping? (should be elevated with closed lips)
• frenulums should be stretchy
• touch to lips, baby opens mouth , this should bring the tongue out.
• does baby pull finger in. how well does baby groove
• check transverse reflex (look for twisting of tongue or poor movement).
• assess for torticollis which can cause tongue restriction or assymetry.
• – finger sweep under tongue to check for elasticity of frenulum
• when the tongue is elevated,  frenulum should be stretchy
• important- can baby lift tongue, do we get stretch?

what matters the most is the contact of the tissue

– elasticity, it’s all about the stretch

• no stretch is what gives us the problem

The Tongue- has 3 forms of papillae

From Wikipedia: https://en.wikipedia.org/wiki/Lingual_papilla

Lingual papillae (singular papilla) are the small, nipple-like structures on

the upper surface of the tongue that give the tongue its characteristic

rough texture.

-Rubbing tongue on palate rubs off papillae, if tongue is not rubbing on palate as in case of tongue tie,  it can result in coating on tongue which can be mistaken for thrush  (can indicate reduced tongue mobility from torticollis or retraction)

Can you stretch a frenulum?

-No,  studies show 3 different histological make ups of the frenulum. we do not think it can stretch.

Breast Feeding:

• baby uses a higher sucking pressure before milk flows with breast feeding, then it drops.
• if baby uses too much pressure, than baby can close milk ducts.

Recommended article to understand milk extraction:

Elad D1, Kozlovsky P, Blum O, Laine AF, Po MJ, Botzer E, Dollberg S, Zelicovich M, Ben Sira L.Biomechanics of milk extraction during breast-feeding. Proc Natl Acad Sci U S A. 2014 Apr 8;111(14):5230-5.

doi: 10.1073/pnas.1319798111. Epub 2014 Mar 24.

Assessment:

Catherine recommends the Martinelli screen as one of the best tools for assessment to screen newborns. It is in the public domain so I will attach it here.

 

martinelli-protocol  Click here to get the protocol!

 

-Martinelli Screen 2015- all new borns in brazil are going to be screened for tongue tie using this tool.

-Martinelli, Marchesan & Berretin-Felix Lingual Frenulum Protocol with scores for Infants; Int J Orofacial Myology 2012 v38 p 104-112.

Discussion on milk production

When frenotomy is indicated, delay endangers breastfeeding because milk production is calibrated in first hours after birth.

• increasing milk production by increasing pumping after nursing, takes 3 days to increase supply

True Tongue Tie Can Cause:

• often results in poor growth
• jaundice can be a sign of poor feeding
• poor latch can cause nipple damage. Better latch, reduces sucking blisters
• may be able to suck a finger for 1-2 sucks before pulling back.
• myths:“It will tear on it’s own”, “It will stretch as she grows”

Tongue tie prevents normal palatal expansion

• tongue muscle lifts and spreads the palate
• bones respond to weight bearing or muscle activity
• abnormal tongue patterns with restricted tongue can result in normal palatal expansion.
• We have not studied what happens to palates after frenotomy

Tongue tie: you may see 

• furrow through center of tongue
• sides lifted but immobile center, “stingray” tongue
• twisting with lateral movement
• low tone tongue posture
• lip blanching
• mucous or junky nose due to poor palatal closure

Tool: take pics while baby is breast feeding as an evaluation (may identify problems seen on photo).

Tongue tie may not be the only issue

• In infants with multiple problems, treating the tongue-tie may or may not improve breastfeeding (but usually won’t hurt).

– gene TBX-22 – (T-box transcription factor TBX22): often has cleft, tongue tie, and narrow nasal passages, hypotonia. x linked

– Torticollis: Tongue tie and Torticollis- can result in difficulty BF

– Torticollis can result in asymmetry of head and neck musculature

• we are not paying enough attention to torticollis

Catherine recommends for torticollis:

• if tongue tie is subtle, treat neck muscles first. Neck muscles release may fix tongue
• if tongue tie is severe, treat tongue first

– neuro impairment and tongue tie

• treating tongue tie  may help, but may not help baby feed normally

When not to treat tongue tie:

• We do not want to treat a tongue tie in a  baby who is micronathic EVER!
• can put infant at risk for airway obstruction

Frenotomy that works- gets the tongue the most elevation possible

• with restricted tongue- tongue connected to hyoid, you can get reduced mouth opening (tug between mouth muscles and hyoid attachment)
• problem may surface with transition to solids (Lori Overland’s work: need research to substantiate this)
• if mother has painful breast feeding- frenotomy may help more

labial frenulum– push up, if you see tight lip to blanching, it may be restricted. Otherwise, we shouldn’t be treating these automatically

Posterior tongue tie– term for tongue tie posterior to front of tongue (this definition is not always recognized). Now means submucosal tie, which are rare (suggested we call this type 5)

Frenotomy

• frenulum is clipped and then spread out.
• starts exercises before frenotomy
• post op exercise: we do not have good research, be gentle
• lifting tongue may help avoid scarring  after the frenotomy
• There is a device being worked on, a “groove director” to lift tongue after

frenotomy  without hurting baby

– we want it to heal open not scar down

Breastfeeding Strategies for Tongue-tied Infants : Tongue tie can make feeding inefficient

•Wavelike tongue movements impeded

•Latch is shallower

•Compensatory movements are less efficient

•   Decreased milk transfer: Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound, Donna T. Geddes, Diana B. Langton, Ian Gollow, Lorili A. Jacobs, Peter E. Hartmann, Karen Simmer.
• Studies showing improved milk transfer after frenotomy
• Reduced bolus handling, questionable aspiration risk

•Effort of feeding is increased –  fatigue tremor of jaw and tongue

•Reverse swallow

• breast wounds

Recommendation: – prone or semi prone feeding

Tongue tie and flow issues

• semi-prone position can help with infants with flow issues
• press on breast and reduce flow or take off breast
• increase grooving with finger play and exercises (tug with paci, tongue hugs for grooving)
• Simultaneous sublingual pressure and posterior lingual pressure to reduce posterior tongue elevation

Reducing Tongue Retraction

• walking back on the tongue- to stimulate tongue movement and forward movement
• after frenotomy- exercises for ROM

Feeding Issues in Congenital Torticollis 

– Torticollis happens in utero

• baby born with thickening and tightening of sternocleidomastoid muscle
• can cause facial asymmetry, jaw deviation, asymmetrical neck creases
• Torticollis impacts tongue function.

Assess:

• Elasticity of frenulum from Left to Right and Right to Left
• Elevation and Lateralization to both sides
• Better function in prone?
• Intervene:
  – Positioning and supportive strategies : we get huge improvement  when feeding in prone with torticollis
• –Active mobilization & tummy time
• Refer for physical therapy or body work to assist with muscle imbalance
• reduce swaddling, we want the baby to move.

Resources:

Luna Lactation, http://www.lunalactation.com

http://tonguetie.net

http://www.brianpalmerdds.com