Hi, I've worked with a number of babies with Submucosal Posterior Ankyloglossia (Tongue Tie.)  Many of these babies have a very difficult time maintaining suction. I'm currently working with a little girl who clicks and pops off the breast with every swallow. Her Maxillary lip tie was revised, via laser revision two weeks ago, and I've sent her back to the Pediatric Oral Surgeon we work with to revisit submucoal posterior Ankyloglossia. He agreed with me that we needed to revise the lingual frenumlum and did so yesterday via laser revision. 

This baby (as per report from our oral surgeon) now is able to maintain suction for an entire feeding. 

Submucosal Posterior ties can be difficult to assess and identify. There is no cleft in the tip of the tongue and often it is not easily identifiable visually. It's easier to FEEL the problem through an oral/digital exam. Many people describe it as a "speed bump" palpated under the tongue, and often it is very difficult to get even a pinkie finger until the tongue of a baby with submucosal posterior Ankyloglossia. Also, some babies may have gagging issues in addition, which can make identification more difficult. Usually the gagging resolves after the laser revision is completed as the baby has more mobility of her tongue and can compress the breast tissue more easily which greatly aids in the ability to swallow without gagging. Suction at the breast also usually improves greatly after revisions are completed and healed. (Laser revision heals quickly. Scissor revision.... not so much.) 

I've seen a number of these babies go on to do quite well after both Maxillary Labial Frenulum and Submucosal Posterior Ankyloglossia were revised via laser with a good Pediatric Oral Surgeon. IMO, this type of tie cannot usually be done properly with an ENT via the scissor method. I've seen too many "chop jobs," left behind submucosal frenulum tissue, scar tissue, extreme  inflammation, pain, bleeding and even tissue growing back when the old scissor method is used. 

Do you know why the parents are adverse to a simple 2 minute laser procedure that may well save them a great deal of time, energy and money in the long run and may well save their breastfeeding relationship? Often, it is our job to gently persuade an otherwise perhaps reluctant parent who may not have any knowledge of midline oral anomalies (and often this lack of knowledge is encouraged by some less educated Pediatricians who try to sway a parent from pursuing treatment for these anomalies or assume "it will stretch" when we know from research that these frenulums rarely "stretch" and in reality often become thicker and less elastic as the baby ages.) 

Some body work (CST, Chiro etc) may still need to be done, but the first step is to correct any midline oral anomalies before proceeding further in most cases. 

If the physiology is a problem, all the therapy in the world is not going to help much until the underlying anomaly is corrected. 

Good luck with this mama and baby. I've seen almost miraculous results when a good laser revision is completed. Of course, the older the baby the more time it may take for the latch to be corrected after the laser procedures. This baby has been nursing with a poor latch for a while, but your working with her on adapting the latch after the laser revision procedure would be immensely helpful. 

About the lips: is it possible that the baby also has a Maxillary tight labial frenulum that may be causing her to overcompensate by over flanging? I'd take an other look at both frenulums, labial and lingual and talk to the parents about the simple and quick procedure that could make all the difference. 

Warmly,

Mary Jozwiak, IBCLC, RLC
International Board Certified Lactation Consultant, Registered Lactation Consultant, Post Partum Doula
Birthwaysinc. Chicago IL 
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