I also seem to see a lot of little tongues that aren't quite doing their 
jobs.  But then, no one calls us to say how great breastfeeding is going 
-- by definition, we're seeing little muffins in difficulties, and the 
tongue is a major factor in breastfeeding..   But I'm  always hesitant 
to confidently peg the problem as a tongue-tie, particularly the more 
subtle ones.  (I'm hoping that Catherine Genna Watson's new book will 
build my confidence on that topic.)  It seems to be so difficult to get 
even obvious tongue-ties clipped,  I'm so afraid of sending parents on a 
hopeless mission.  Would Dr. Coryllos be interested in starting a 
franchise -- one of her in every major city?

If breastfeeding isn't going well,, I might say (probably also stolen 
from someone) "Each mother and baby fits together in their own way -- 
breasts are shaped lots of different ways and there's lots of variation 
in babies' oral anatomy.  And some combinations require more fine-tuning 
to get a comfortable fit."  Then I will point out whatever seems 
unusual,  like "see, when he cries, his tongue stays curled down in his 
mouth.  It seems restricted in how far it can move."

Then we try really hard to make the anatomy we have on both sides work.  
"Maybe if we experiment with rolling a great big mouthful of breast in 
deep, he'll be able to compress and milk the breast without having to 
lift that tongue so far, and without pinching you so painfully."  Diane 
Weissinger's hamburger analogy ("See, a couple years from now you'll be 
telling him not to take such a big impolite mouthful,"), and Rebecca 
Glover's very asymmetrical approach -- tipping the nipple up and having 
a big pouch of areola precede the nipple, which flips in last, with the 
finger assisting -- can get a lot of breast in there, and often the 
mother will note a big improvement.  (Hands-off, baby-led attachment is 
probably optimal when a mother and baby are just starting out.  But I 
admit to being more hands-on, with permission, when mothers have been in 
pain for days or weeks -- sometimes we have limited time to convince her 
that they can fit together so it doesn't hurt.)

Anyway, I feel that this approach covers me.  I've raised the  
possibility of the tongue being the issue, without making it sound dire, 
final and hopeless.  It reinforces to the mother that she and the baby 
are a unique combination of two different human beings. If we can make 
it work with adjustments to the latch, then she feels she has 
successfully worked out a individual challenge with her little partner.  
If we can't make the fit work,  it seems logical to proceed to talking 
about a further evaluation of the tongue, because the topic is out on 
the table already.

I do sometimes wonder, even if we can make breastfeeding work ok with 
exaggerated asymmetrical latch, how vehemently to to encourage parents 
to take further action on the posterior tongue ties, because of the 
potential for longer-term issues. 

Margaret Sabo Wills, LLLL, IBCLC Maryland
(who's written more in one day than in a year of largely lurking)

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