I just saw one the other night.  Mother asked for a private consult for unresolving nipple pain at four weeks out, baby gaining, growing, thriving.  mom beginning to dread feeding and weeping during feeds.  surprisingly, there was little nipple damage.  Mother had learned a lot about position and latch over the weeks and was able to help her baby compensate. She didn't know he had a tongue tie. But I checked his suck and noted the tongue behind the lower alveolar ridge. Then I put him thru his paces, trying to see what his tongue could do, which he and I both enjoyed. His tongue couldn't extend past the gum line and couldn't elevate either, it pulled down. it was a simple type one. parents could see it clearly. No one had noticed it b/c this little guy didn't like to gape and has some postural thing going on.  He likes to have his head tipped toward his chest and needs to be freed up in that way too by a specialist. anyway, I'm not one to jump on a bandwagon but there it was, no denying it. 

    I have seen posterior tongue ties too, at least that's what we are calling them. I wonder if we might come up with a more specific nomenclature. I'm getting so that i can see them coming before they open their mouths. It took me a long time to "believe" in them.  But these are the babies who can't achieve an effective latch and can't transfer because they don't have normal use of the tongue and they share a characteristic oral/facial presentation.  It does trouble me that the answer is a surgical procedure involving relatively extensive cutting and I am intrigued by the possibility Nikki raised about PT instead of surgery. Just to put things in context though, most of my clients don't bat an eye about having their baby boy's foreskin removed surgically, and releasing a simple type one or two tongue tie is almost a non-event for the baby.  The worst part is the few moments of being restrained. That doesn't mean I am cavalier about recommending the knife. But ultimately, I am for babies breastfeeding.

    I am more troubled by the possibility of missing a posterior or anterior tongue tie than I am about over dxing. I don't treat tongue ties, I refer on for treatment and the pediatrician and the ent are involved and parents make an informed choice to treat or not.  We have all learned about tongue ties together and we are happy to be able to share our knowledge and offer options to the breastfeeding women in our community. 

    But what is a shame is that I have told clients that there was nothing remarkable about their baby's oral anatomy, simply because I didn't know any better at the time. Yikes! I do take responsibility for that, but at the same time our field needs to do some serious growing up in terms of expanding and standardizing a core body of knowledge. when Iworked in the hospital setting I used to envision something along the lines of an Advanced Nurse Practioner degree specific to lactation. Mostly that would have been good for me. I would be on an equal or superior footing with the people I worked with, earn more money and have autonomy in a medical situation. But now I think that a straight up medical model would be deficient and do mothers and babies a disservice.

    I am curious about tongue ties, if there are more or less of them or if they are simpler or more complex these days. A tongue tie is a midline defect that happens at a specific point in gestation. Maybe we could look there for answers.  On the other hand I think its somewhat irrelevant to pine for a day when babies weren't born with tongue ties. Poverty, poor nutrition and brutal or unsanitary living conditions that might bring to bear on gestation weren't invented yesterday.  They've been around a long time. What can we do  about it now, that's the question.

Kristen Panzer, MS IBCLC

New York
 

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