Monday, March 10, 2014

Tongue-tie CLIPS.

As the vast majority of my clients globally contact me for assistance with complex feeding issues commonly associated with gut healing or tongue-tie (or both), I thought it might be helpful to begin a new series here entitled Tongue-tie CLIPs, addressing tongue-tie facts, myths and other information. I will post as topics come up within my practice, on social media or among my colleagues.
Photos©2014, Jennifer Tow, IBCLC

1. The myth that adequate weight gain rules out tongue-tie or lip-tie.

Often mothers of tongue-tied babies will be falsely reassured that their babies' adequate or even rapid growth and perhaps even sufficient diaper output will either rule out a tongue-tie or lip tie or rule out the need for revision even when ties are known to be present and other symptoms exist. Often such reassurances are associated with an abundant milk supply, leading the mother to presume her problem lies elsewhere. Unfortunately, these babies may be just as much at risk over the long-term as slow-gaining babies. An assumption that a tie is irrelevant is especially likely when the mother also reports no pain at breast, even though it may be just as common for tongue-tied babies to feed passively, causing no pain, as it is for them to feed aggressively, causing blanching, compression stripes or pain. Mothers will be misled into thinking all is well while their babies slowly begin to drop off their growth curves and milk supply is lost.

Unfortunately, in these cases unskilled providers will tend to neglect an assessment of oral structure and function altogether or will dismiss ties as irrelevant. It is not normal for babies to present with a pattern of sputtering, choking, gagging, vomiting, clicking, spilling milk, refluxing or arching at breast, no matter how well they are growing. Such a pattern is an indication of a baby under stress, often due to untreated ties, although structural misalignment due to birth trauma or intra-uterine lay may also be implicated and should be ruled out or treated with bodywork.

In fact, IBCLCs skilled in tongue-tie assessment have noted for some time that apparent oversupply and/or OAMER (over-active milk ejection reflex) often coincides with tongue-tie. While this oversupply can allow babies to gain weight on passive feeding, sometimes even quite robustly for a significant period of time, the risk that mothers and caregivers will be diverted away from treatment of ties towards efforts to reduce supply is a serious concern. Babies who grow rapidly on an oversupply or rapid MER (milk ejection reflex) are typically not emptying the breast efficiently and may trigger a non-physiologic down-regulation of milk supply that often means unexpected poor growth by 3-4 months. These are often the mothers who report "my milk just dried up" and have no idea why they went from such abundance to struggling to feed their babies.

Sometimes mothers find temporary relief in the down-regulation of their supplies as they may have been experiencing frequent plugged ducts, bouts of mastitis or even abscesses associated with oversupply. Many mothers have been instructed to intentionally reduce supply by drinking teas such as sage or peppermint or taking medications such as Sudafed. The instruction to “block-feed” is very commonly offered by IBCLCs, doctors and other mothers (feeding on only one breast at a time for a block of time such as 4, 6 even 12 hours to reduce supply) as the solution to oversupply and its associated maternal and infant discomfort.

Once supply is reduced in these cases, babies will often become fussy or even angry at breast and either drop weight or drop off their growth curves. Stooling often becomes infrequent. Restoring supply can be very challenging once this happens as the problem usually goes undetected for weeks or months, commonly playing out in the 2-4 month period where babies are not likely to have weight checks and when other developmental milestones such as teething can be blamed for the infant’s change in behavior.

It is also important to note that many mothers whose babies struggle at breast with symptoms commonly associated with oversupply do not actually have an oversupply at all. Often these babies exhibit no symptoms associated with oversupply as soon as their ties are revised, indicating that an ability to coordinate the suck-swallow-breath synchrony was the issue, not milk supply at all.

It is very important that IBCLCs become adept at assessing tongue-tie in all of its presentations, not only the most obvious. While the basics of latch and normal infant behaviour should always be addressed first and foremost, it takes very little time to accurately assess for tongue-tie and lip-tie while delaying treatment only increases the risk of premature weaning and a possible life-time of negative long-term consequences. A combination of feeding assessment, oral structural and functional assessment and taking time to hear the mother’s “story” and her feelings is necessary for a thorough assessment of any feeding problem, including tongue-tie and lip-tie.

Jennifer Tow, IBCLC, RLC is a founding member of IATP (the International Affiliation of Tongue-tie Professionals) and consults globally with families via Skype. 

WEBINARS for professionals to learn more about tongue-tie:

Optimizing Human Potential Through Normalizing Infant Feeding: An Integrative Approach to Tongue-tie, Lip-tie & Breastfeeding: the Interdependent Roles of the Lactation Consultant, Surgeon & Bodyworker—presented in 2 parts in collaboration with Larry Kotlow, DDS, 6.5 bours, $145,