Friday, October 12, 2012

Tongue Tie – Gentleness and Compassion for the Baby - Part 2

To recap - we are talking about babies who become orally aversive due to tongue-tie after care.  Why does this happen?

First:  There is no judgment here – none at all.  As a mom with a baby who was tongue-tied and struggled for months to get breastfeeding right, I understand the desperation to have it just WORK once and for all.  Some moms struggle for so long, weeks and even months in pain, pumping and trying to breastfeed.  They are so desperate, and understandably so, to fix their breastfeeding problems and get that baby breastfeeding once and for all.  Sometimes they inadvertently create this problem of oral aversion with aggressive stretching.  This absolutely does not happen on purpose of course, though sadly it is happening and the truth is it does not need to. 

I have heard some moms state that the baby cries when the diaper is changed and it’s no big deal, and this crying during aggressive stretching is just like that.  Well, no it isn’t.  A diaper change doesn’t cause the baby pain.  And I have heard others say that it HAS to be done this way in order to make sure that frenulum doesn’t reattach.  Well, no, it doesn’t – it can be done gently and still be effective.   

I have spoken with moms who had significant mom guilt when they realized that their actions (aggressive stretching) had caused their baby’s emotional trauma and oral aversion.  These moms were devastated that, in their attempt to help their child – they hurt their child.  The fact is, as I see it, and those moms too, this is avoidable.  
Stretching consists of lifting/stretching or massaging the underside of baby’s tongue in order to keep the tissues mobile and from healing closed and causing lack of tongue mobility (which is why we did the frenotomy in the first place, right?).  However, there are various thoughts on this process, how it should be done, how often and to what extent.  Some recommend using a tongue blade (wooden tongue depressor), or just your fingers.  Some recommend massaging the tongue, some recommend stretching.  Some recommend breaking the wound open at least a few times per day to prevent scarring down or reattachment.  Some recommend these procedures not be done at all while others recommend 5-8 times or more per 24 hours or prior to every feeding.

As a Lactation Consultant who specializes in tongue-tie I would not recommend anything other than using your finger to do the stretches, unless you have been specifically taught by the Dr. who did the procedure how to properly use the tongue blade.  Stretching the wound is uncomfortable for the baby at best, and can be painful at worst.  It is the rare baby who can handle the stretching/massage with a smile – at least initially.  

So let’s talk about how to do this in the most baby friendly manner.  These are my own recommendations to my clients.

Tongue massage/stretching should be an in and out fast procedure. Gently slide your finger under the tongue and massage the incision site as such: from bottom:  massage up the tongue, then back down 2 - 3 times using gentle but firm pressure - then get out of the mouth.  This is 3-4 second procedure at most. If you are doing the stretch, you can use the Kotlow method of coming under the baby's tongue from behind: Baby is laying on his back with his head close to you, you gently slide two fingers under the tongue and lift the tongue up with a gentle push back - hold for count of 3 and then get out of the baby's mouth.  I recommend 2-5 times per day for at least 2 weeks, and strongly encourage some sort of complimentary body work.  And check in with your LC or Dr. to evaluate how the healing process is going.

These stretches/massages should be kept as enjoyable as possible for baby. The last thing we want is for baby to fight, scream and cry inconsolably when we are trying to help them.  It is one thing for them to fuss and complain - it is quite another if they are screaming.  Also, I do not recommend purposefully breaking open the wound several times per day because 1) it is painful for the baby and 2) it is painful for the baby.  Breaking open a wound repeatedly slows down healing, causes emotional and physical trauma and should not be needed in order for the wound to heal properly.  If the wound breaks open on its own without extreme pressure that is different - doing it in purpose should not be needed.

If there is fighting and screaming happening with stretches and massage - then we should take a look at WHY.  If stretches are being done to the point of doing them for minutes rather than seconds – Stop.  It should be seconds.  Doing the stretches for minutes will cause baby much pain and discomfort.  If baby is screaming and crying for an extended period afterwards – as in more than a minute or two – too much is being done. This type of overdoing can actually cause oral/feeding aversion, whether it is breast or bottle.  

Anything we do in the mouth MUST be done with respect and as much gentleness as possible.  And while these stretches are important, we can do them in a manner that does NOT potentially cause other issues.

You can do these gentle stretches when baby is asleep, awake and relaxed, just before feeding, or after feeding. If you do 2 reps of the stretch and baby is getting mad - STOP. Don't push the issue at that time. There will be a later time (half hour?) where you can finish. Keep this time and activity as happy and as relaxed as you can.  Make funny faces, sing, or make funny noises!  Talk to your baby in an encouraging and supportive tone.  Whether you do these exercises twice a day or 8 times a day they can be done in a gentle and respectful manner and still be effective.  Using pain relief is a good idea as well.  Talk to your Dr. or IBCLC about pain relief measures (acetaminophen, ibuprofen, homeopathics…).  Get that bodywork to help baby’s body move and groove the way it needs to help that tongue move the way it should.  

Finally, many moms have told me that they would rather deal with some breastfeeding discomfort, pump and bottle feed, or just bottle feed formula than to cause their babies the kind of pain they see happening with others or that they themselves have inadvertently caused.  And you know what?  I agree with them – 100%.  And frankly, it is my professional opinion that, if it requires hurting the baby repeatedly, to the point of causing oral aversion, in order to make breastfeeding work, then perhaps we should reconsider that.  

Is the causing of injury, emotional and physical trauma worth breastfeeding?  I don’t happen to think so.   

And I implore you to put yourself in the baby's would you feel and what would you ask for in this situation?    

Gentleness and compassion for the baby while working with tongue-tie…it can be done. 

Tongue Tie – Gentleness and Compassion for the Baby - Part 1

Lately I am getting more and more emails, private messages and phone calls from mothers and professionals regarding tongue-tie.  The concerns are the same and actually kind of frightening and sad at the same time.  I will discuss these shortly in Part 2 but first let’s lay some groundwork so we all understand what we are talking about.

What is tongue-tie?

The ‘lingual frenum' (or lingual frenulum) is the cord that stretches from under the tongue to the floor of the mouth. 

‘Tongue tie', ‘Ankyloglossia' or ‘short frenum' are the terms used when the lingual frenum is short and restricts the mobility of the tongue.  

Tongue-ties can cause all sorts of problems or none at all.  If there are problems with breastfeeding (or feeding in general) and tongue-tie is determined to be the cause, a frenotomy is usually recommended.  A frenotomy is also known as:  Clipping, revision, or frenulectomy depending on who you are speaking with.  I have heard all of the above.  

Clipping simply means the frenulum is snipped (ether by a scissors or laser) – kind of like snipping a string in two.  It is generally painless for the baby and bleeding is typically minimal.  Only rarely and in extreme cases will a baby need general anesthesia to have a frenotomy done.  Most all frenotomies can be done with the child awake with little to no anesthetic.  Babies typically are angrier because someone has their fingers in their mouth than they are about the actual procedure – which is generally very fast.  And as soon as the procedure is done, baby can breastfeed which will help calm the baby and encourage proper tongue motion and mobility.  Follow-up with bodywork, such as Chiropractic, Bowen, an Osteopath or Cranio Sacral Therapy is strongly recommended.

There can be long term consequences of not having a tongue-tie that is causing problems clipped.  Speech issues (lisping), sleep apnea, snoring are just a few long term possible challenges.  However, if there are no feeding issues with a tongue-tie and parents are unsure about clipping, the decision to clip or not needs to be discussed with someone who is knowledgeable about tongue-ties and their potential long term effects.  Sometimes it is simply a 'wait and see' situation.  Many babies have been tongue-tied and gone on to breastfeed just fine (or with minimal discomfort to mom) and there were no long term consequences observed.  

However, just because there are times when there doesn’t seem to be an issue, we still need to monitor baby’s weight gain and moms milk supply.  It can be difficult at times to know for sure that baby is transferring milk well on his own or if he is getting milk primarily because of mom’s healthy let-down reflex.  If baby in unable to transfer milk well on his own, mom will notice a decrease in her supply at some point in time.   If that happens other steps will need to be taken to preserve the supply and baby’s intake.  At this point a frenotomy may definitely be in order.  As long as the parents are aware of the risks and know what to watch for, how they choose to handle their situation is entirely up to them.
If parents decide to proceed with a frenotomy they should be well informed, by their Lactation Consultant (IBCLC) and the Dr. doing the frenotomy of the procedure itself as not all Dr.’s do frenotomies the same way.  Aftercare exercises and possibly needed pain relief for the baby will need to be discussed.

The aftercare exercises are where we start running into trouble and are the point of this article.  Many LC’s and Dr.’s recommend stretching of the tongue to prevent the wound from healing ‘down’ or the frenulum from ‘reattaching’.  Other exercises may also be discussed to work with tongue mobility.  I am focusing on the stretching because it seems to be the biggest issue. 

What I and many other IBCLC’s are hearing and seeing is increasing cases of oral aversion in babies directly caused by excessive/aggressive stretching of the frenotomy site.  Frenotomy wounds are being stretched open, to the point of bleeding, repeatedly each day causing baby pain and distress, day after day, for up to weeks on end.  Babies are being reported crying for hours after stretching exercises and even closing their little mouths up tight when they see a finger coming towards them.  Some babies even learn to recognize the ‘stretching position’ and begin to protest and cry immediately when placed in that position.   Sometimes breastfeeding does not get better, and in fact sometimes gets worse, and in some cases ends completely as the baby flat out refuses to nurse due to oral aversion.  What that means is baby is so averse to having anything in the mouth because of trauma that they refuse to nurse or eat, and/or scream anytime the breast, a bottle or finger approaches the mouth.  

So why is this happening?   See Part 2 for the rest of this story...