Thursday, December 27, 2018


There are still so many ENTs and dentists who perform tongue-tie releases with no preparation, no IBCLC referral and no follow-up in place. When no referral is required, parents are misled into believing the release is a silver bullet. It is not. In fact, while the skill of the release practitioner is very important, the ability of that practitioner to understand their role as the member of a collaborative team is just as important. This is because the release only allows the bodywork and the lactation support to be effective. In and of itself, the release cannot solve feeding problems. 

No other surgical procedure is performed with such frequency, yet primed to fail due to inadequate preparation and follow-up. 
I see far too many dyads suffering the consequences of a surgical procedure that can't possibly deliver on expectations, because the release itself cannot resolve issues. 

If you imagine the analogy of someone who has learned to hobble along with their shoelaces tied together, never having walked any other way, you can imagine what that looks like: short, unstable, inefficient steps. Untying those laces (similar to releasing the ties) is only one step in preparing to walk with comfort and ease. The laces will need to be tied properly so that the person doesn't trip over themselves in all new ways, the weakened muscles that have never been used properly (or perhaps at all) will need to be strengthened, muscles that may have been overused will need to be softened, quieted, new pathways between the brain and muscles need to be established, a new sense of balance must become normal. 

All of this is accomplished in a tied baby when the IBCLC functionally assess the infant as the first step. While the release provider will perform a structural assessment, they must rely on the functional  assessment done by the IBCLC, because functional means while feeding. So, the IBCLC makes an oral assessment, using proper positioning of the baby to gain necessary visual information, as well as tension in the baby, reaction to reflex triggers, tongue mobility, range of motion, stamina and so on. In addition, the IBCLC makes a functional assessment, taking into account many variables, such as how old the baby is, impact of factors such as birth and intra-uterine positioning, how the baby is being fed, whether supplemented and by what means, whether there is pain with feeding, whether baby is hungry or full at time of assessment, whether baby us feeding passively, milk supply, milk transfer, growth trajectory, positioning, latch, postural stability and more. A brief visual inspection and baby's suck on a finger is not a functional assessment. 

The skilled IBCLC is not in a hurry to send a baby off for release, even when restriction is evident. The skilled IBCLC knows a baby needs to be prepared for release, that reflexes need to be supported, the nervous system organized and neuromuscular rewiring begun prior to release. The IBCLC will support the parents in this process, by providing tools such as movements and oral exercises customized to their baby, that parents can do at home to prepare the baby for release. 

We need to be careful not to hyperfocus on the baby, over the dyad however. We cannot think the goal is to "fix" the baby, rather than to bring function to the dyad. For this reason, the IBCLC (who is the only practitioner who cares for both members of the dyad) will simultaneously develop a plan to support ongoing breastfeeding where possible, as well as implementing appropriate interventions to support milk supply, ensure the baby is growing well and the dyad develops skills for efficient and functional feeding. 

In addition, the skilled IBCLC can guide the parents in collaborating with a bodyworker (chiropractor, osteopath, CFT, CST, Bowen therapist, rolfer, etc) who can correct structural misalignments that typically accompany ties. The IBCLC should communicate with the bodyworker and together with the parents, determine when the baby is ready for referral to a release provider.
In my practice I frequently see families who have paid $600-1600 for releases, yet their babies still cannot nurse effectively, if at all. You cannot take a baby, release the ties and expect that baby to know how to feed, especially to feed functionally. But, how the baby is fed is just as important. If the baby is fed in the same compensatory way as prior to release, the release will fail, and those changes need to be planned for and begun prior to release. 

Unfortunately, I frequently see families in my practice after failed releases, sometimes because the release was not done well, but much more often because the timeline and management of the release was not guided by a skilled IBCLC, the bodywork was not sufficient, the release was done too soon, there was insufficient follow-up with the IBCLC or other issues such as food intolerances or gut issues were not addressed. Not only is the stress much higher the second time around, but the risk of breastfeeding failure is higher and in the end, the cost in time and money is much higher. 

It can be understandably tempting to rush off to release ties. It can be frustrating when you find practitioners who refuse to listen to clearly lack knowledge and skills. But, as in every profession, there will be a range of skills, experience and focus. While it was once very difficult to find skilled IBCLCs, it's become much easier as so many of us work remotely. I see as many as 80% of my clients on-line and have done so for a decade. Many other IBCLCs now do as well. The trick is to find someone skilled in functional assessment and habilitation, who also collaborates with other providers. That way, you have access by referral to competent bodyworkers as well. Ask questions about the IBCLC's education specific to oral anatomy and function, whether they collaborate and how they prepare for and follow-up after the release. 

Click here
 for a list of North America/US IBCLCs who have taken a three day MasterClass that includes learning the process as I've described. Rest of North America Asia Australia South America

The bottom line: An IBCLC should guide the process and ensure that all issues are addressed, not only baby issues. In addition to bodywork, oral exercises, reflex assessment and integration, postural stability, nutritional/gut issues, milk supply, metabolic issues, positioning and latch, nutritional/gut issues, supplementing, appropriate use of feeding tube, bottles, and so on need to be addressed.

Ultimately successful release of oral restrictions is all about a properly managed timeline resulting in fully functional breastfeeding. 

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