The confusions and controversies around the Tongue and Lip ties!

• When we talk about babies with oral restrictions, what does it mean? 
• My LC tells me my baby has a tie, my paediatrician says it’s nothing, I’m about what to do! confused
• Why is there so much controversy in it?
• Why is it that we are seeing so many cases these days? 
• Is frenotomy a complete solution. I hear many times symptoms do not get better or can even worsen post frenotomy?

If you have any of these questions, Read on….

At the outset it is very important to understand a few facts:

1. Feeding is an all-body function so just looking at the mouth will not give us the complete assessment of the situation. So even if your baby has obvious ties, there is much more that needs to be assessed and worked on.
2. We need to look at the whole body.
3. Breastfeeding is a complex interplay of many factors (Birth, earliest skin to skin contact, initial breastfeeding experiences, infant anatomy, maternal feelings, maternal knowledge, support to the mother, and many more)
4. There are large knowledge gaps in the health care workers, in relation to skilled lactation support.
5. Even among lactation Professionals, clinical skills are widely divergent, depending on their qualifications and experiences.

With the above facts in mind lets discuss further.

Oral restrictions in the baby are the Frenula (mucosal connections) that can be present under the upper lip(labial frenulum) and /or under the tongue (lingual frenulum) and or between the cheek and gum(buccal frenulum).They can cause problem if they restrict the normal functioning of tongue and other muscles during the process of breastfeeding / bottle feeding.

There is so much controversy around it because of many reasons.

1. Mostly it’s something that we have started exploring recently and most of the health care providers have not had much knowledge and experience about these issues.
2. As oral restrictions are not the ONLY reason to cause breastfeeding difficulties, If we just cut these restrictions, without addressing the other issues as well, the challenges do not settle (or at times worsen), thus making people feel that corrective procedures are useless.
3. Similarly, if other factors are worked upon, in quite a lot of dyads, even in the presence of oral restrictions, the challenges settle, thus the hypothesis that we do not need to do any procedures!
4. There are not much conclusive studies on these topics.

So, most of the clinicians/ providers see things based on their perspective and experiences only and give their opinion accordingly. What is needed is a comprehensive assessment of the whole mother baby dyad, so that an idea of all that’s going sub optimally can be assessed and thus corrected.

This needs a team of trained professionals working together and thus can mean more expenses.

In a country like ours, there is a scarcity of teamwork or rather appropriately trained professionals (except maybe in major metro cities) and also there is lots of skepticism and hesitancy in families against paying for breastfeeding support!

To understand it further let’s talk about a few factors that can have implications on breastfeeding.

1 Positioning of the baby inside the uterus

A baby in a vertex position, with ample amniotic fluid, no cord issues, Versus a baby who had positioning issues in utero (eg: Cord around neck, oblique lie, twin pregnancy, uterine myomas etc), both can behave differently while breastfeeding.

2 Type of birth:

A calm comfortable spontaneous vaginal birth, with baby being kept skin to skin with the parent, generally results in baby latching on his/ her own without any need of support..

(while we are at it, lets discuss birth here too! Contrary to popular belief, we ourselves are the people most responsible for our changing births and increasing rates of cesarean sections.For example,Our dietary habits, Our sedentary lifestyles, Lack of knowledge about pregnancy and child birth…..are a few factors)

Versus an augmented labor with lots of non-natural uterine contractions, Interventions like fundal pressure/ forceps / ventouse/cesarean…..resulting in possible physical and mental trauma, separation , delayed initiation of breastfeeding. Versus a Cesarean section….All have different impact on baby’s natural reflexes and thus on baby’s breastfeeding efficiency.

3 Early days after birth

The kind of breastfeeding knowledge and motivation the family has. If they have had Antenatal Breastfeeding education.

The kind of support / information they got post birth.

4 Later days how the baby is being kept, like if the baby is kept mostly swaddled on his or her back, or mostly on the parents’ body. If the baby held and soothed each time the baby is distressed. Is the baby kept lots in baby carriers / car seats etc

For a mother and baby to breastfeed well, we need a healthy and comfortable mom a healthy and comfortable baby and ample opportunities to breastfeed on demand.

Anything that interferes with it can cause breastfeeding challenges.

So if we just look at the frenulums and overlook the other issues, problems will remain.On the other hand if we sort out the other challenges and then if the challenges persist , we get the frenulums corrected, we get optimal benefits!