Date:    Fri, 20 Jun 2008 09:34:16 -0400
From:    "Amy Slotten, RN, IBCLC" <[log in to unmask]>
Subject: posterior tongue tie

I have permission to post on a client I am working with.  I believe that this 
3 wk old babyhas a type 3 or 4 tongue tie.  Mom does not have pain but did in 
the early days.  I just began working with them this week.  Baby can briefly 
extend tongue slightly past gums but rarely does and when she is crying with 
mouth open her tongue stays on the floor of her mouth.  I couldn't really lift 
the tongue to even visualize the frenulum.
I would expect her palate to be higher and domed but it is not.  It is 
actually relatively shallow.  Even when I help to get a deeper latch baby doesn't 
stay open wide and seems to tuck bottom lip in and overly-flange the top lip.  
She is pretty content to keep hanging out and breastfeeding like this but has 
very small milk transfer and is fussy when not on the breast. She did go to the 
ENT clinic here and they said there was no problem or at least nothing for 
them to do.  I have read Catherine Genna Watson's book.  I guess my question is 
really about the fact that
her palate does not match what I am seeing of her tongue movement.  Does 
anyone have any comments about this case?
Amy Slotten, RN, IBCLC
Ann Arbor, MI

Dear Amy,
I noticed that no one else who seems to be having a lot of experience with 
babies with PTTs has jumped in to answer your question. 
For the last almost 2 years my practice is pretty much PTTs and oral 
mechanical issues causing probs with initiating/completing latch, sustaining latch, 
effective milk transfer, falling asleep without having reached satiety, and 
nipple soreness. 
All have some VIPs (Variations in Infant Palate), but they are not all 
elevated palates. I had one before and one just this week where the palate was flat 
and had a sharp slope to it. So, there is not always a bubble or domed palate.
There is not always nipple pain. Moms usually had pain to start with that may 
or may not have resolved. So, don't be fooled by mother reporting slight 
discomfort/irritation or not much discomfort/irritation at all. 
There usually is a change in nipple shape to ovoid/compressed or beveled from 
the side view.
The biggest red flag for these is function at the breast, as Dr. Betty 
Coryllos so succinctly describes in her chapter of Cathy W. Genna's book.
When I do a suck assessment, how the baby grasps my finger tells me a lot:
Does the tongue go over the lower gum ridge and to the lower lip? Is the 
tongue bunched or humped in the back? Can your finger feel that? 
When the baby gets a good sucking burst going, I will slightly draw down the 
lower lip to confirm tongue placement. I will then place my thumb further down 
on the lower jaw and applying slight traction, pull straight down. For 
A/PTTed babies the tongue will lose contact with my finger pretty quickly as the 
frenulum (pulled by the lowering jaw) pulls the tongue away from your finger.
If you look at the Hazelbaker Assessment Tool for Lingual Frenulum Function 
and use all 5 of the function items (elevation, extension, longitudinal 
grooving, peristalsis and lateralization), you will have a pretty good idea whether 
or not there is a lingual restriction and be able to make your case to the Pedi 
or ENT. 
And a sublingual sweep with my finger is the final test: can I feel a 'speed 
bump' as my finger moves laterally under the tongue?
However, it sounds as though assessing a PTT is not the only challenge you 
have to deal with. The next level problem is: who will help resolve it?
An ENT in my area who is now a convert to understanding PPT's effects on 
Bfing and long term health did a medline search of the otolaryngology literature. 
There is nothing in it about PTTs. The pedis aren't aware of this information 
nor are the ENTs and when they first hear about it they are extraordinarily 
skeptical if not downright dismissive and resentful. 
This is all new information to the world, first discovered by Cathy W. Genna 
and Dr. Betty Coryllos, in 2003 and shared with the world in the 2004 AAP 
article. You may be the first 'in your neighborhood' to be aware of these and 
raising a hue and cry about them. It is a lonely, frustrating position to be in 
and you may find that there is a tendency to 'shoot the messenger.' 
Do you have a closer relationship to any of the ENTs so that you might fax 
them a copy of the AAP article and maybe the chapter from Cathy's book that Dr. 
Betty' wrote abt resolving hidden TTs and then call him/her to discuss this? 
Remember, as my dear ENT out here told me: if a surgeon can't see it, s/he 
can't clip it. So, they have to be able to visualize it. Most ENTs want to do an 
initial assessment with a tongue depressor, moved directly into the frenulum. 
That occludes it, pushes it deeper into the base of the tongue and there 
truly is NOTHING to see. So, you have to gently offer the possibility of either:
a.    Using the tongue depressor coming from a side angle to help make it 
more visible to isolate it, or
b.    Using a groove director/ groove-seeking director, grooved tongue 
elevator - the most effective tool the   
       ENT can use. 
With many of the PTTs, the Dr. has to elevate the tongue with the director 
and move it slightly back and forth, applying some greater pressure toward the 
base of the tongue to isolate the frenulum to see the restriction and then it 
can palpated to reveal the fibrous bands.
If no one is open to receiving this information or clip these TTs, then 
another step is to cast a wider net from where you are to see if anyone in a more 
distant geographic area has an ENT who is clipping the PTTs successfully. If no 
one is in that category, they can call Dr. Coryllos or have the parents call 
her and consider having them fly to NY to see her. and resolve the issue. She 
has had families fly there from all over the country and all over the world.
Good luck!
Ann Russell, IBCLC, RLC
North County Lactation Services
12621 Hedgetree Court
Poway, CA 92064
858-513-1327



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