Understanding Tongue Tie from Birth Onwards – Post 3
The go-to treatment for infant tongue-tie is a surgical procedure called a frenectomy, which works by releasing restrictive embryonic fibers, or connective tissue, from the mouth in order to free up the tongue to move without restrictions. When parents receive a diagnosis of a tongue tie for their child, they are understandably focused on having the tie surgically corrected as soon as possible, believing that this will solve all of their child’s issues.
The pediatrician’s recommendations are often limited to information about the surgery itself. However, the reality is more complex. While it is indeed important to correct the tongue tie by surgically “releasing” the frenum, but there are a number of factors which come into play both before and after the procedure. These will have a significant effect on the recovery and effectiveness of the operation.
In our previous post, we discussed the challenges involved in the modern birthing process, and how tongue-tied infants contend with them. Today, it is my goal to illuminate the value of the services rendered by a qualified IBCLC in order to maximize the effectiveness of a frenectomy, while minimizing pain and recovery time.
What is an IBCLC?
An International Board Certified Lactation Consultant’s primary goal is to help a Mom achieve her breastfeeding goals. One important part of her role in tongue tied babies is to protect the milk supply of breastfeeding mothers, and to ensure that the baby is getting sufficient milk for healthy growth and development. However, not all IBCLC’s have the training needed required to work with tongue-tied children. For purposes of this blog series, there is an important distinction to be made here, as the right IBCLC plays a critical role in preparing the baby’s mouth for surgery, as well as assessing post-surgical process.
Finding the right IBCLC
Working with a baby with a tongue tie can be more challenging and not all IBCLCs have had the extra training required to help these families. Parents should ask the IBCLC directly how much experience they have working with tongue-tied infants. If they answer with only cursory experience or in some cases, skepticism, it is crucial to keep looking around. After all, there is some debate in professional circles about the diagnosis of tongue ties, with some people even saying that tongue tie is a “fad diagnosis”. So, make sure that you find an IBCLC who will treat the issue with the seriousness and expertise it requires.
Your first visit with the IBCLC
New parents might not know what to expect from a IBCLC, so let’s walk through what a typical first visit might look like. It starts off with a complete assessment of the problems that the infant and the mother are having, and then a complete medical and birthing history from the mother. For example, if the mother has had breast reduction surgery, then she will have fewer mammary glands and will produce less milk, which is important for the IBCLC to know.
The IBCLC will then assess the baby’s latching and positioning to make sure that they are feeding properly. They may try to determine what the issue with breastfeeding is at this stage – it could be that the mother is not supplying enough milk due to a thyroid problem or vitamin deficiency, or it could be that the baby is not latching onto the breast properly and is therefore not receiving enough milk. Both oversupply and undersupply of milk can cause issues, so the IBCLC will monitor for these issues. Sometimes, an IBCLC is even able to create a pain-free latch in a baby with a tongue tie before the surgery takes place. This can be critical in setting the stage for success following surgery, as both mom and baby will have experienced precedent for proper latches.
A next step in assessing breastfeeding is a “weighted feed” in which the baby is weighed before feeding, without clothes (a fresh diaper is okay). The baby is then fed for a certain amount of time before being weighed again. This information can highlight problems. For example, if the baby was feeding for 45 minutes but only took in half an ounce of milk, then this indicates an issue. The IBCLC will then investigate whether the issue comes from the baby’s inability to transfer milk from the breast, or whether there was only half an ounce of milk in the breast in the first place.
Preliminary steps before a frenectomy
Depending on what issues the IBCLC identifies, they may recommend some preliminary steps for parents and child before they undergo the treatment for tongue tie. Some typical interventions include:
Feeding the baby for a set amount of time on each side, for example 7 minutes feeding on each breast. This can help the mother’s breasts continue to receive input to produce milk, while also preventing the baby from expending too many calories during feeding.
As well as the set feeding, the mother may pump around three times per day to empty the breasts after feeding. This stimulates the breast to “refill”, which helps ensure there is a supply of milk available for the baby when they need it. “Powerpumping” is a term used for a pumping strategy in which the mother repeatedly empties her breasts of milk to encourage increased milk production.
Another strategy that can help is “triple feeding”, in which the parent nurses, pumps, and bottle feeds every time that the baby is fed. The idea is that the baby will receive as much milk as the mother is able to produce, but if they are still hungry, then their feeding can be topped up with a bottle of pumped milk or formula.
These strategies are crucial to have in place before the frenectomy, as a baby cannot have an operation unless they are strong and well-fed. There can be cases where babies will have a “feeding strike” where they will not eat after the surgery due to pain from the recovery process, so it is doubly important to make sure that they have a healthy weight before the operation is performed.
These feeding strikes are becoming less common as the tools used for the frenectomy become more sophisticated, like CO2 and water lasers which are much less painful for the baby. However, a tongue tie is a “midline defect” which means that the baby’s brain recognizes a change that happens following the surgery, presenting a major challenge for the brainstem to adapt to. It can take some time – typically up to three days – for babies to finally relax and feed comfortably after the frenectomy.
Another aspect of pre-procedure care that a IBCLC can help with is assigning preliminary intra-oral exercises for the parents, which can help them understand what is going on in their baby’s mouth. Parents need to get used to being inside their baby’s mouth prior to surgery, and these exercises help prepare the baby’s brain for the change after the tongue tie release. Babies who have these exercises performed up to two weeks before the surgery will be far better positioned to receive the benefits of the frenectomy procedure.
Helping with breastfeeding
A IBCLC is invaluable in tackling general breastfeeding issues. They can show mothers how to mix breastfeeding and bottle-feeding in a way that will not cause “nipple confusion”, in which the baby struggles with the different flow rates between breasts and bottles. Another option is using a supplemental nursing system (SNS), a syringe and tube system which connects the baby to the breast and controls the speed of milk delivery.
Advice on tummy time
A further area in which a IBCLC can advise parents is the importance of time an infant spends on their stomach. Parents hear very often about how important it is for their babies to sleep or nap on their backs to prevent Sudden Infant Death Syndrome (SIDS). however, what many don’t know is that the baby should be spending the rest of their waking time on their bellies to ensure proper neurological and motor development.
Parents who know about tummy time often assume a few minutes a day is enough. What’s more, babies often become grumpy and uncooperative when placed on their front, leading to acquiescent parents to quickly give in and turn them over onto their backs. An IBCLC can show parents how to prepare their babies for tummy time without fuss (yes, it is possible!) Babies who spend more time on their bellies experience a proportionate improvement in neurological integration of their primary reflexes, as well as cross-body sensory integration. Tummy time also strengthens and coordinates the muscles associated with breathing and feeding.
Other ways to help your baby
An IBCLC can also offer information on “baby containers” like swings, car seats, or other contraptions which hold a baby in place. It can be dangerous for a baby to be held in place for more than 10 minutes at a time due to a risk of suffocation and a risk of developing problems with the head and neck like torticollis and plagiocephaly. Swaddling can also become an issue after a certain age when the baby is laying on their back.
There are also important ways that an IBCLC can help after the frenectomy procedure. However, most offices do not have an IBCLC who is available to parents immediately after the operation. Therefore, I advise parents to talk with the IBCLC about post-operative care in the weeks leading up to the surgery, or to make an aftercare appointment on the same day or the day after the procedure. For more information about this topic, come back soon as my next post will be on the role of an IBCLC after a frenectomy.