Frenotomy–a procedure to clip the tissue that connects the tongue to the floor of the mouth– was once well accepted as a simple intervention to treat certain breastfeeding difficulties.
When formula become the most common form of feeding, health care providers stopped investigating why even mothers who wanted to breastfeed were often unable to do so.
Now breastfeeding advocates are picking up the pieces, working to restore frenotomy as a helpful and safe intervention for tongue tied babies. Over half of newborn males are subjected to circumcision, but a much smaller procedure intended to help a baby eat well and grow is often disregarded.
Evidence supports treating tongue tie for breastfeeding difficulty, but it isn’t a cut and dried solution to all problems, and is woven into the intricacies of modern parenting.
Our Milky Way spoke with internationally recognized tongue tie pioneer Dr. Evelyn Jain MD FCFP FABM to shed light on the many issues that surround frenotomy. Dr. Jain also presented at this year’s International Breastfeeding Conference.
Why is it important to investigate tongue tie?
Besides feeding difficulty, tongue tie has the potential to create other problems later in life.
Dr. Jain reports speech being the most prevalent function affected by untreated ties. Children struggle with articulation of consonants that involve the tongue tip like ‘r’, ‘l’, ‘sh’, ‘th’, ‘z’, and ‘t’.
When the tongue doesn’t have proper range of motion, dental hygiene can also suffer.
“A lot of our dental hygiene is done way before we brush our teeth. When the tongue cannot reach the outer surface of the molars to clear away chewed food, there is more risk of dental caries,” Vancouver dentist and Dr. Evelyn Jain’s daughter Dr. Anita Jain pointed out.
“As the mouth develops, untreated tongue ties can affect the bony structure of the face and cause a narrow palatal arch. This in turn affects the wideness of our smiles. A tied tongue can’t flatten out to create enough pressure to widen the structure.”
Eventually, narrowness of the entire oral cavity may cause sleep apnea, Dr. Jain explains.
What are the most damaging myths surrounding tongue tie?
Dr. Jain reports the most common myth about tongue tie is that that it doesn’t affect breastfeeding and should be delayed to a later age.
“If there is a tongue tie that appears to be likely to affect breastfeeding, then it should be done as early as possible,” she clarifies.
The second myth Dr. Jain deflates is that every posterior tongue tie should be cut. Many times the situation can be corrected by other methods, like proper positioning and latch.
“I do get referrals at least twice a week where it appears to me that nobody has mentioned anything about positioning and latch,” she says. “Attention to position and latch can often correct an entire situation without clipping posterior tongue tie.”
The third myth Dr. Jain brings to light deals with post op care of a posterior tongue tie. Appropriate post op care is essential to prevent reattachment.
It is very common to see complete reattachment.
A firm push–called a blunt dissection– is necessary so that infants need not be recut.
“I am starting to see babies who have been cut three times,” Dr. Jain reports.
Sometimes parents haven’t even been informed about proper post op care, and other times improper care stems from discomfort.
“It is important to do some posterior tongue ties, but when we make our diagnosis and make a plan, we have to factor in the risks and benefits as we would any procedure,” Dr. Jain explains.
Practitioners need to assess if parents are willing and able to prevent the wound from healing improperly and the distress involved.
Dr. Jain acknowledges the controversy of nipple shields, but she does not discourage their use if doing so will benefit the mother and baby as the dyad learns to breastfeed.
What factors should be considered when tongue tie is present?
Tongue tie should be a functional diagnosis, not based solely on the appearance of the tissue. But beyond function, there are other factors to consider.
For instance, if there is a significant anterior tongue tie restricting tongue movement even when other factors are ideal (mom’s nipple size and shape, mom’s breastfeeding experience, etc.,) it is very desirable to clip, because it will almost always affect speech and dental hygiene, Dr. Jain explains.
But if there is a subtle, small tie present– like a fleshy posterior tie– the practitioner should assess baby’s palate and chin. A high palate and receding chin usually exaggerate the effects of tongue tie.
Although relatively few, there are some cases where a significant tongue tie will have minimal effect on breastfeeding. In these cases, mothers have established excellent milk production, usually have large, elastic nipples and prior experience with breastfeeding.
Dr. Jain recalls one lactation consultant’s observation that tongue tied babies almost always have mothers with flat nipples. This phenomenon may lead one to believe that these attributes may be linked. However, Dr. Jain explains that this combination makes breastfeeding difficult, and so these mothers are seeking help more often than the mothers with more protruding nipples who seem to have an easier time breastfeeding a tongue tied baby.
Is tongue tie over-diagnosed?
Speech-language pathologist Debra Beckman, MS, CCC-SLP spoke at this year’s International Breastfeeding Conference and stated that tongue tie is over-diagnosed.
Dr. Jain says that there isn’t a simple answer to the question of whether or not tongue tie is over-diagnosed.
In the overall population it is still under-diagnosed, she says. Differing views are presented to patients in the hospitals –even in the NICU where it would be particularly beneficial for the baby to have frenotomy to enhance nutritional intake, Dr. Jain continues.
In a 2014 interview with Nikki Lee, Dr. Jain said, “I would say from what I see in referrals I receive, about 90 percent are legitimate referrals and probably 10 percent would be cases that can be solved by other methods without a release.”
“It behooves all of us in lactation work to do the whole job and not just pick this one condition and blame that,” Dr. Jain continues in the interview with Lee.
How can mothers find balance between intellect and intuition in the age of the internet?
When Dr. Jain became a mother for the first time, her mother told her “in true blunt Northern English style” to get rid of the “stupid books and get on with feeding the baby.”
Dr. Jain remembers her mother looking over her shoulder and observing, “See? She likes it. Just do it whenever she wants it.”
“I was so obedient,” Dr. Jain says. And it worked.
Even so, she admits that “few of the educated people in this generation would listen to that without quite a bit of discussion.”
Mothers today struggle with an overwhelming amount of information which often usurps our intuition.
How can we find balance?
This is the central question about the state we are in with breastfeeding, Dr. Jain says.
“It’s one I struggle with many of the mothers I see,” she reports.
When Dr. Jain started working as a doctor 25 years ago, she says mothers didn’t know that much about breastfeeding. So she taught them things that applied specifically to their situation. Sometimes, she says, she wished they’d known more.
“But now people know a lot, but it’s not always helpful,” she explains.
“I love seeing moms and babies in clinic because every single one is different and of all the info on the web and in books only a small amount of all that information applies to a specific person.”
Dr. Jain works to build up new mothers’ confidence by asking them to consider questions about how their baby acts and responds, so that they discover their own answers.
Parents have all experienced those desperate times when we do not know why our baby is crying. Dr. Jain reminds them that babies have very few basic needs like sleeping, eating, having their diapers changed, and snuggling.
“So—no harm offering any or all of these!” she exclaims.
Dr. Jain wonders, how much impact do “I have in these sessions, because most of the people I see have already gathered such a huge amount of information and are in such a heightened state of intellect.”
Many of the rules created in the lactation world have backfired and “unwittingly, those of us in the profession can disempower the mother by giving so many strict rules.”
This applies particularly to the lactation professional working within a hospital or public health system where protocols like waking the baby every three hours must be followed.
The anxiety that modern mothers experience is the greatest change Dr. Jain has seen in the population she works with.
This is not to say there should not be any standards or guides to the baby’s well-being. It is essential that baby’s nutrition and healthy growth occur and all measures including formula supplementation should be done judiciously when needed, Dr. Jain explains.
Why is frenotomy still inaccessible to many families?
Treating a tongue tie for breastfeeding difficulty is a time sensitive matter and needs to be readily available to families.
“It shouldn’t have to be a big issue,” Dr. Jain says. “I have people in Canada who will drive 12 hours to see me. I find this quite heartbreaking; I’m not going to be here forever. And why so much stress for them to travel with a new baby?”
She wonders why frenotomy hasn’t been accepted on a wider scale.
In 1990 when she first started doing frenotomies, it was understandable that some were reluctant. Nowadays, it is impossible to justify the hesitation or even in extreme cases, the refusal to entertain the idea, Dr. Jain says.
It was in 1994 when frenotomy was first officially acknowledged by the Canadian government as a procedure. At that time, the fee for the treatment was 30 dollars. (Dr. Jain recalls that number clearly because she remembers wondering why it was so high.) Now, the fee is closer to 50 or 60 dollars.
In the U.S., one source cites the fee for frenotomy between 250 and 1200 dollars. Dr. Jain plans to educate others in smaller communities about frenotomy so that people can access more local assistance.
She also has a comprehensive DVD available intended to aid physicians in identifying posterior and anterior tongue tie and performing frenotomy. It demonstrates a comprehensive assessment of the impact of tongue tie on breastfeeding, shows many frenotomy procedures and a follow up management plan. You can find the DVD here.
Learn more about Dr. Jain’s practice here.