I would like to share another perspective, currently based on observation, personal experience and theory.  What is more concerning to me is the number of  babies who have so much trouble with breastfeeding, a skill so basic and necessary for survival prior to the invention of artificial milks and antibiotics. In the past we have  blamed the birthing process, and there are certainly factors in western birthing practices that have contributed to breastfeeding difficulties after birth, but are we going to lay it all at that door? I just can't.

My own family history: My mother nursed me for 6 months and my brother for 3 months, but was plagued by repeat mastitis that led the doctor to "forbid' her to breastfeed my two youngest siblings. I had a lip tie that was released due to dental problems around age 7, and now in seeking treatment for lifelong TMJ issues, I am coming to learn that my type 3 frenulum that I thought was good enough may be part of the problem.  I nursed all of my four children; my oldest gave me cracked nipples and I had plugged ducts and lots of nipple pain, but we managed to work through them and survive.

But now the next generation... of my six grandchildren, five have had posterior tongue restriction that caused pain and/or frequent feedings and popping on and off. Despite my skills we could not "fix" these and the exasperated mothers made the decision to seek treatment, and have been very happy with the results.  The one grandchild who didn't have significant nursing problems recently had a severe lip tie released because it was forcing her upper teeth apart and crowding other teeth.  My niece's two sons both caused her pain and fed constantly until their posterior restrictions were released. My sister had twins late in life; she suffered pain for nine months (and I stayed with her a week and worked on positioning all of that time and could not get rid of all of the pain!). I suspected posterior restriction but did not pursue it, and now I regret that because while my niece is fine, my nephew cannot elevate his tongue well and has speech problems. His dentist identified a diastema due to a severe lip tie that was not on my radar at the time and that has been released, but still not the lingual frenulum because it doesn't "look" bad and despite the continued functional limitations.

My generation had struggles but got by-so why in the heck are all of my grandchildren having issues that could not be overcome with positioning and latch refinements?

I get tracked down by local mothers who are desperate for answers after going through the system while problems persist. Last week was a worn-out mother of a 3.5 month old whose suspicions about her baby's tongue function were denied  and who was given no other explanation for the baby constantly unlatching. I checked the baby, noting the poor elevation and bunching of the tongue with elevation attempts. I felt the tightness of the lingual frenulum. After observing a feeding, I was able to validate her suspicions and applaud her continued efforts to find answers and help. Baby was treated a few days later and that same day she posted to the local TT support group about how the baby actually stayed on the breast the whole time for 4 feedings in a row.

Several years ago I ran across a study about an observed association between maternal cocaine use during pregnancy and a higher incidence of tongue-tie. [Harris, E. F., Friend, G. W., & Tolley, E. A. (1992). Enhanced prevalence of ankyloglossia with maternal cocaine use. Cleft Palate Craniofac J, 29(1), 72-76.] It occurred to me that something in the cocaine was acting as an endocrine disruptor and altering fetal development such that the tongue was not separating completely as it should have. Of course, this is not happening to all of the babies, but a higher number.

My suspicions, theoretical and unproven, have centered around folic acid. FA supplementation is being used in effect to alter fetal development to ensure closure of the neural tube. Would it be so far-fetched to consider that such intentional manipulations of fetal development might lead to additional unintended side-effects, like preventing the normal separation of the tongue from the floor of the mouth?  I am not arguing against the benefits of reducing spina bifida, but just saying that perhaps this intervention is having unintended secondary consequences. Some people believe that a mutation of the MTHFR gene, prevalent in 40%+ of the population, may result in incomplete breaking down of FA (remember it is synthetic) with resultant alterations in normal apoptosis of tissues like the lingual frenulum . Given the increased push in folic acid, both via prenatals and in fortified foods, this is one *possible* reason for a high incidence of restrictive lingual and labial frenula, both of which are midline issues as is spina bifida.

In my family we clearly seem to have genetic vulnerabilities. My lip tie and other minor oral midline defects suggests it, my oldest son's subtle but significant issues now being identified clearly suggest it, and thus when all of my grandchildren have issues, I wonder what factor pushed our genetic vulnerability over the edge.

If there is indeed an environmental factor altering fetal development of the tongue, then the question becomes not why are so many being diagnosed, but why are we not pursuing identification of the cause more diligently?  If there is indeed an iatrogenic cause of this epidemic of suck-related breastfeeding problems, shouldn't we be pursuing this instead? And *if* folic acid turned out to be the problem, if we decided that the benefits of this therapy outweigh the unintended side-effects, the conversation must then turn to the significance of the secondary problems and how we are going to put out those fires.

I don't want to see our profession pulled apart by this, I want us to pull back and try to see the bigger picture of the phenomena that is affecting of our babies and start looking for the root causes.

With respect and appreciation for everyone on both sides of this critical issue,
~Lisa Marasco





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