I am seeing it frequently here in NH. Of the referrals I have had either to LLL or to my PP over the past 8 months, almost every mother with nipple damage or low weight gain has had a tongue tied baby,  specifically posterior tongue tie accompanied by a tight maxillary frenum or lip tie. Those mothers who have chosen tongue tie release have noticed a marked improvement. Some of these moms had previous babies with posterior tongue ties which were undiagnosed and babies either breastfed for a short time or were not breastfed after the first few weeks due to ftt or extreme pain in mother. We always go over improving latch technique before anything else and if that doesn't work quickly, then we reassess. In every case where improving the latch has not been effective, it has been a posterior tongue tie. In one case, which I have posted about with permission in the past, the baby had amazing tongue mobility. So much so that I did not suspect tongue tie and after a couple of CST appts and two weeks later - it was so obvious that I did some head banging... HOW did I miss it???? So my personal belief now, based on experience, is that if latch adjustment does not yield very quick results (and we've all seen this - pain and then no pain.. almost instantly), then I am referring for tongue tie assessment. Unfortunately, more than 1/2 of the mothers who have chosen ENT assessment were told there is no tongue tie by at least one and often 2 or more ENTs when indeed, there is definitely a tight submucosal frenulum.  I have recently heard of a mother who had her first baby assessed by two ENT's and 3 LCs who all ruled out tongue tie, even though baby's tongue was definitely heart shaped when extended. They were not able to breastfeed for longer than 5 months due to nipple pain and trauma.  So, personally, I think it is being under diagnosed. Then, there is the added factor of other issues that are like the big wound on the arm that is being attended to when the patient has a pneumothorax and can't breathe.. the obvious is taken care of while the less obvious tongue tie is overlooked. We have seen the mom with other obvious issues, be they IGT or ppm hemorrhage or inverted or flat nipples or whatever.. and the tongue tie is never addressed because no one looks that far. In many of these babies, the pain is not intolerable, but the baby has reflux or colic, mother may even have oversupply, or baby doesn't gain well no matter what mother does. And we are influenced by what other professionals are telling us... Ped said no tt, ENT x3 said no tt, previous LCs said no tt, midwife said no tt.. and so we assume it has been ruled out and don't look at all the evidence before us. So I have to agree, referring for further assessment by a professional who is skilled at identifying and releasing all levels of tt is never bad practice - not referring because we don't see it can be very harmful to mother and baby. The issue I am struggling with is finding reliable practitioners who can identify and treat ptt and lip tie. Not easy in this state and few mothers are able to travel due to finances or family issues. 

Am I seeing more than I used to? I am beginning to believe that there has been a much higher level of ptt and lip tie than we ever knew about because we did not have the information. I suspect that the reason the breastfeeding continuation rates have been so low compared to initiation rates could very well be that breastfeeding is so painful or ftt happens in many dyads due to tongue tie that is undiagnosed. When you think about it, if breastfeeding is going well ie: doesn't hurt, is pleasurable (as we know it can be else we would none of us do it), baby is gaining well, has no "colic" or gerd and mother's milk supply is abundant but not overly so - continuation rates would be much higher. I have yet to meet a mother who was enjoying breastfeeding quit because... well... she just felt like quitting... there is always an underlying reason.  Something so easy to do won't be given up at the drop of the hat.. right? So maybe.. just maybe.. the tt rates are much higher than we suspect. 

Maybe we need to do a study, like Kathy K-Ts recent sleep study, of a few thousand breastfeeding women, to find more about this..

Celina D, IBCLC, LLLL

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