Dear all:

Just a short 10 years ago, my obstetrician was very reluctant to do sonograms. She did 
not like exposing the fetus.  Now, when I ask how many prospective parents have been 
breastfed themselves I get about 70-90% of the class raising their hands, have seen 
breastfeeding --- about 30-50% of the class, and have seen their baby on sonogram it is 
always 100%.  Since this is a group of parents who are convinced they want to try 
breastfeeding,there may be more in this group who have been exposed to breastfeeding -
-- but I constantly find it ironic that 100% have seen the fetus whereas half or less have 
witnessed breastfeeding before having to do it.

In terms of tongue tie --- remember that we see a self-selected group.  We see mothers 
and infants who are struggling and so we may be seeing a higher proportion of infants 
with tongue tie than in the general population --- or not --- if many of those just give up 
and bottle feed.

As for Africa --- yes, there are tongue ties there and the upper labial frenum that causes 
spaces between the teeth is probably quite prevalent.  The gap between the upper front 
teeth is considered a sign of beauty --- just as goiter has been considered a sign of 
beauty in certain populations even though goiter too is a sign of a much deeper 
physiologic problem.

Remember, it is only in recent human history that we have been keeping track of death 
rates.  Infant mortality is highest in west and central Africa --- so there may be many 
feeding issues that are invisible in those high death rates.  The unfortunate tendency to 
assume that traditional societies have all the answers tends to gloss over the fact that 
there are as many problems there as in industrialized societies --- its just that many of 
the problems are different. And as for pollutants, many developing areas of the world 
have far more pollutants -- particularly agricultural pollutants because as the dangers of 
these chemicals became well enough known to ban these in developed areas, they were 
dumped on developing areas of the world.

I have finally found a pediatric ENT that I like for posterior tongue ties.  I must confess to 
a certain reluctance to refer when I have seen what appears to be badly performed 
procedures that then requires repeat procedures.  In quiet conversations with my 
colleagues, I discovered the same reluctance about the posterior tongue ties. Also, there 
may have been incidences of miscommunications whereby parents come away with the 
impression that the procedure alone will fix the problem and it does not immediately do 
so.  Since these conversations usually occur in a group setting, I cannot really speculate 
on the exact source of the confusion because I was not party to the original conversations 
with any confidence.  Merely, there appears to have been a breakdown in either follow up 
or communications in some of the cases of posterior and even other types of tongue tie.  
Now that I've found someone with both good surgical skills and consistently good bedside 
manner, I'll be more confident with my referrals.

When the consequences of one condition are more distant ---- such as when a mother has 
a copious supply and the infant appears to thrive on that high supply in the first few 
months, it is much harder to establish the connection to that condition in ways that are 
plausible and even harder to establish statistical probability.  I have not yet seen good 
clinical trials on the outcome of the posterior tongue tie, but am starting to see plausible 
explanations of potential physiologic consequences.  The challenge I find is when is the 
procedures necessary and when is it not?  Clipping, especially repeat clipping is more 
invasive than some of our other interventions and it is sometimes hard for parents to 
want to intervene when it involves "cutting". There is some viscerally negative reaction 
for many parents when you mention it, despite the fact that circumcision is routinely 
practiced in our area due to religious observances.

Best, Susan Burger

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