Geez. Another article from The NY Times. Who there has ants in their pants about ankyloglossia or maybe a deep and lingering childhood fear of dentists?
So we are going to do it again. We are going to talk about “tongue tie” in the context of infant feeding challenges.
Let’s start with the AAP statement the Times was referencing. Did you read it? It sounds kind of whiny, like this group of pediatricians are upset they have been left out of the diagnosis and treatment loop. They cite significant increases in surgery to release tongue tie over the last several years but you know what else we also see during that time? Yup, significantly increased rates of breastfeeding initiation and duration.
The article mentions that other, more conservative methods should be addressed before surgical release and I absolutely agree. They don’t however have any steps in their algorithm which mention a referral to board-certified Lactation Consultants (IBCLC). How do you assess a functional diagnosis without observing a feed, making interventions, observing the outcome and repeating until you have ruled out that positional changes and the use of feeding tools does not correct the issue? How do you rule out torticollis, TMJ dysfunction, swallowing problems, and more without watching the baby complete a feeding to see how they function in the context of feeding?
It's a process. Observe, intervention, observe, care plan, follow up. Repeat as needed.
Tongue restriction and feeding challenges can have multiple causes. It’s true that I do see a lot of tied babies and that’s because in my area, we have a strong breastfeeding culture and our nurses are great at teaching most parents basic positions and correcting latch problems not caused by anatomic or physiological restrictions. By the time parents come to me, it's well beyond the basics of position and latch. However, sometimes tongue restriction may be caused by a “tongue tie” which is a short or fibrous frenulum under the tongue which impedes function or baby may have a normal stretchy frenulum, but also have structural muscle tension making the frenulum seem more restrictive than it is. Some tongue restrictions may be resolved by releasing the tight muscles and tissue surrounding the tongue. You have to be highly and skilled and knowledgeable to know the difference.
When baby has this muscle tension, it can look and even feel like a “tongue tie”. Where I work, we offer the in-office procedure (frenotomy) with topical pain medication and our doctors do great releases. And while frenotomy is safe and effective, it's best to address any muscle and tissue tension before a formal diagnosis of tongue tie (or ankyloglossia as it's called medically) is made and definitely before any surgical procedures.
There are exercises to help move the tongue better, to correct the supporting structures of the mouth like cheeks and lips, and movements or gentle stretching to help baby unwind from the constraint of birth.
There are also referrals for manual therapy (which can include pediatric chiropractic, CST, PT, etc) these may be a good option for baby both before a frenotomy and in some cases these techniques may improve help improve feeding enough to make it comfortable for the parent and effective for baby. In this case, the frenulum tension is caused by the surrounding muscles and we don’t do a procedure. We set a plan for follow up and continue to check in on these families over time.
However, these strategies may not be enough to fully resolve the functional problem caused by truly tight and fibrous lingual frena. In that case, baby may need a frenotomy. I’m super lucky to work pediatricians who respect me professionally and trust my evaluations. They respect my expertise and ability to manage feeding plans for their patients.
I’m really, really lucky.
I’ve not always been so lucky to be trusted and respected. In the past, I’ve worked with pediatricians who were skeptics even though day after day, month after month, and year after year their patients had improvements to feeding and great outcomes when I recommended the above interventions. I guess you just can’t change some people’s minds. The one-sided article from NYT expresses all the hesitancy and skepticism of the AAP’s statement in regards to the necessity and safety of frenotomy also fails to offer any sort of balanced approach by citing any of the dozens upon dozens of research articles which show improvement to infant feeding and parent comfort with frenotomy and certainly doesn’t cite any of the articles which show that conditions like infant regurgitation improve through the reduction of aerophagia when baby can use the major muscles of feeding to swallow properly. I didn’t see any interviews with infant feeding experts, IBCLCs or pediatric SLPs, to ask about our clinical experience or approach either. That type of nuance seems to be missing from The Times fearmongering, unbalanced coverage of this topic. Again, who there has personal vendetta against frenotomy and why?
Do I jump straight into frenotomy for all my patients? No. I’m very demure…very mindful (this post isn’t going to age well but I’m happy to be on trend, for once). We address all the basics and rule out other causes for baby’s feeding issues first.
Do I recommend frenotomy pretty quickly for some patients, yep.
Sometimes, it’s very clear that baby has a super restricted tongue from a tight, fibrous frenulum but that tension hasn’t had time to do its dirty work and create other problems and baby doesn’t have other issues contributing to their feeding problem. I see this most often with my second and more times parents who are going through this process again and have tried all the conservative management they used with their first baby.
At that point, we go through risks: all procedures can involve pain, bleeding, the risk of infection (never even heard of this occurring) or damage to surrounding areas (not with the providers I refer to). Serious risks with this procedure are very low and the release provider should minimize these risks by using pain relief, reviewing baby's full medical history, doing the minimum required for full release of anatomical structures, and using the safest tools and techniques possible (this can include a CO2 laser. I promise it’s not shooting around the room wildly like a 1980s space movie. The CO2 laser is a precise tool and it’s more important to choose whose hands the tool is in than if it’s laser or scissors).
In addition to risks, we have a full consent conversation to discuss potential benefits and have a conversation about a realistic timeline for improvement. The goal of the procedure is to release the tongue to have normal mobility which improves feeding function over time and to reduce any symptoms which are a result of compensatory behaviors of the tongue not moving correctly that parents report and we observe in baby. The improvements often take time to notice though many people notice a difference in the quality and comfort of baby's latch immediately.
We discuss the necessity of aftercare to allow for proper healing.
“Stretches” (as the active wound care is often called) are needed to maintain the surgical opening and prevent reattachment. This care should be gentle and quick – the goal is just to maintain the opening created with the frenotomy with as little infant distress as possible. Post-frenotomy wound care instruction varies from provider to provider. There is not a standard of care and much of our instruction is developed from experience, observation, and what we know about oral wound healing. The point of a frenotomy is to release the tongue from the floor of the mouth so this type of wound should be actively managed to heal open which allows for correct healing and better function.
When frenotomy is needed, I refer to the pediatricians at my office and very skilled and experienced ENTs in my community. With our internal referrals, the providers I work with trust me to educate parents regarding wound care and we have developed evolving guidelines and recommendations. If parents see the ENT, they are instructed to follow the aftercare provided by that doctor.
The process of treating ankyloglossia has 3 major steps: pre-release preparation, a full release with good aftercare, and post-release therapy for functionality.
Perhaps the authors of the AAP statement don't follow this process and refer to an IBCLC to assess and intervene to get the best outcomes. I could see how that would result in poorer outcomes and skepticism.
How often do I see reattachment? In the last year, I’ve seen a handful. The majority of those did not follow up with me, as recommended, and at least one did not follow my recommendations for pre-release preparation. This is why we discuss in full the entire process and I share a timeline of expected outcomes and needed steps for full resolution. I want parents to be informed, prepared, and empowered to make their decision. I do a lot more than just refer for frenotomy though. An IBCLC should be managing the feeding plan to meet parents’ goals and create a plan to maintain milk production, protect mental health, should be able to instruct families and how to use supplement tools like bottles, manage maternal conditions and concerns, and do all this within the means and resources of the family. I also work in a community which is full of some pretty amazing and knowledgeable IBCLCs. I know this is not the case in every community and resources for parents are rare and inaccessible. This is another issue which the AAP statement does not address. How can parents find and afford to see an IBCLC to rule out differential causes for feeding problems or to carry a family through the entire process of release if we are not employed in the outpatient setting? Again, I’m very lucky because I work at an organization who recognized that need and filled it for their patients. We have several offices across the metro area and every single one has at least a part time IBCLC. Patients can almost always get a same day appointment if they can travel to one of our sites. Perhaps instead of the AAP making a statement that frenotomy is overdone and ankyloglossia is over diagnosed, they could seek to solve the problem by hiring - or at least referring - to highly skilled and knowledgeable IBCLCs. They could form professional relationships with specialized care providers and bridge the gap of care that their patients so desperately need.
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