February 01, 2015

Top 10 Myths in Diagnosing and Treating Tethered Oral Tissues (Tongue Ties and Lip Ties) in Breastfeeding Infants (Guest Blog Post by Dr. Kotlow)

Dr. Chang's Note: Dr. Kotlow is a pediatric dentist who has done much to advance the understanding of infant factors leading to breastfeeding difficulties. This is a guest blog post by Dr. Kotlow.

by Lawrence Kotlow, DDS
"Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.” PEDIATRICS Vol. 129 No. 3 March 1, 2012 [link]
The concept that our tongue could be considered an organ rather than just another muscle, affecting many of the other body systems, seems to be foreign to many in the healthcare community. If we consider all the different body systems, it becomes obvious that our tongue interacts with many of these systems.

One of the first problems involving a tethered or restrictive tongue attachment is that it often goes undetected, misdiagnosed or ignored. Difficulties and symptoms associated with a poor latch during breastfeeding include: difficulties in breathing (apnea), nasal congestion (silent reflux), colic, reflux (aerophagia), nipple damage, bleeding and pain. In addition, babies are often diagnosed as failure to thrive infants. These mothers may display signs and symptoms of postpartum depression.

Unfortunately, rather than having these ties corrected, often mothers are just told to use formula and a bottle or worse, are told the attachments will stretch or tear without treatment. When an infant is tongue-tied and left untreated, as the infant matures it may also affect the skeletal and oral facial development. Ankyloglossia may contribute to speech difficulties, which can play a role in psychological development and behavioral growth of these children. Dr. Chang has made excellent contributions to resolving these problems by not only caring and treating many of these infants, but by continuously reaching out to the medical community by speaking and developing excellent educational tools and videos to reassure and explain to parents the rational behind treatment.

So here are 10 myths in diagnosing and treating tethered oral tissues (tongue ties and lip ties) in breast-feeding infants:

1. Myth: Tongue-ties (ankyloglossia) do not have anything to do with problems related to breastfeeding. Fact: Breastfeeding depends on the ability of an infant to create a vacuum to express milk from the breast. The upward and downward motion of the posterior portion of the tongue creates this vacuum. If the tongue is prevented from making this motion, the infant may not be able to express milk painlessly and efficiently leading to many breastfeeding problems such as; failure to thrive, reflux, colic, non-nutritional breastfeeding, short episodes of breastfeeding, crying, gagging, obstructive sleep apnea, plugged ducts and mastitis.

2. Myth: Upper lip-ties do not have anything to do with breastfeeding. Fact: Breastfeeding depends on the ability of an infant to form a good seal on the mother’s breast. When the upper lip is prevented from flanging upward this seal may be shallow or incomplete. This often leads to clicking and swallowing excessive amounts of air in the infant’s belly. This creates the appearance of colic and reflux. It is not a true acid reflux but AEROPHAGIA or the swallowing of air. This also leads to similar problems such as failure to thrive, reflux, colic, non-nutritional breastfeeding, short episodes of breastfeeding, crying, gagging, obstructive sleep apnea, plugged ducts and mastitis. Infants may display lip blisters. Lip-ties may also hold mother’s milk on the facial surfaces of the upper front teeth during nighttime at-will feeding and contribute to dental decay.

3. Myth: Placing an infant on acid reflux drugs will aid in the resolution of reflux. Fact: In reality these drugs do little to relieve the pain and discomfort. In addition, when reflux continues during the nighttime hours, an infant may display morning sinus congestion, which is sometimes diagnosed as allergies or other medical conditions. Reflux and vomiting are usually due to swallowing air when a poor latch results in clicking on the breast or bottle. (Aerophagia)

4. Myth: A healthcare provider can adequately rule out the presence of a tongue-tie and lip-tie by examining an infant in a parent’s lap. Fact: When examining an infant for tethered oral tissues (TOTS), the examiner should be able to examine the entire oral area including the outer lip condition, cheeks, the upper and lower lip attachments, tongue attachment, hard and soft palates. In order to accomplish this the examiner needs excellent visualization and infant control. Optimal visualization and patient control is achieved when the infant is placed in the examiner’s lap with the infant’s head facing the same direction as the examiner and the mother controlling infant movements.

5. Myth: Infant suffering from reflux should see a pediatric GI doctor and undergo extensive tests. Fact: The prudent treatment should include ruling out the presence of a tongue-tie and lip tie. If there are tethered oral tissues present, revising the attachments will often improve or eliminate the problem.

6. Myth: Revising the upper lip-tie will create floppy lips require sutures to close the surgical area, will result in the upper primary anterior teeth’s roots to rot out, surgery should wait until the infant is 12 or 13 years of age, after orthodontics closes any gaps (diastema), the surgery will cause scarring, completing surgery will require general anesthetics in the operating room, or even the idea that a parent should wait until an infant falls and rips the lip-tie. Fact: Not one of these so-called facts is based upon any evidence-based studies. They are all based on hearsay and have no scientific data to support such statements.

7. Myth: Lasers are not safe for use in infants and children. Fact: The FDA approved the manufacture of both soft and hard tissue lasers in the late 1990s. Lasers are safer than scissors, scalpels, and electrosurgical instruments. Lasers are fast, efficient, and bactericidal. They pose no risks to patients. They do require the surgeon to have taken courses in laser safety, laser physics and instruction on the particular laser is being used. Laser glasses are required for everyone in the surgical area when lasers are being used.

8. Myth: Once the lip and tongue have been revised, no additional care is required. Fact: After the lip and tongue attachments are diagnosed as the probable cause of any breastfeeding symptoms, just surgically revising these areas does not complete treatment. Post-surgery active wound management is required to prevent the surgical sites from healing back to their original location. This requires keeping the surgical areas apart for least two weeks by actively separating the tissue three times a day. If the lingual frenum begins to reappear, it needs to be reopened. In addition to this active wound management, infants and mothers should be followed by their lactation consultant (IBCLC).

9. Myth: Mothers need to understand breastfeeding may be painful. They need to wait until their nipples get tough and not be so wimpy. If they cannot breastfeed, just pump or switch to formula and give the baby a bottle. Fact: Breastfeeding should be a time where a mother and her infant can bond together. This bond created lasts a lifetime. Mothers who cannot breastfeed often become depressed and are told it is their fault. Breastfeeding should not be an all day effort and painful. Mothers know best. When a mother thinks there is something wrong, there usually is.

10. Myth: My infant was examined in the hospital and I WAS TOLD EVERYTHING WAS JUST FINE. Fact: Many hospitals, all over the world, have what is quietly called the “GAG ‘ rule. Nurses and Lactation consultants based in hospitals are told they cannot discuss tongue and lip ties with patients.

by Lawrence Kotlow, DDS

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

1 comment:

Celina Dykstra, IBCLC said...

Thanks for this blog post and helping to educate parents and providers!

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