I Love Laura's posts on speech pathology.  We did have a speech pathologist for our conference on infant oral anatomy in the fall of 2009 and it is always great to get different perspectives.  I really appreciate the thoughtful insights. 

To clarify my post -- I specifically included the word "might" and I know for a fact that the ENT in question does not state that it WILL happen -- just that it is a possibility. And like the case with thrush and the breastfeeding medicine specialist who treats complicated cases, there are those lactation consultants who believe that they don't treat aggressively enough and those who think they are too aggressive. Both are murky conditions -- without solid clearcut yes/no diagnostic tests.  Both require a significant amount of judgement.

I also agree that for some babies it may very well be painful.  Furthermore, I believe that scar tissue should not be taken lightly either.  I had my anesthesiologist cracking up before I had my broken nose fixed (completely smashed to bits by an overenthusiastic yellow belt who didn't understand that you do NOT smash someone as hard as you can with your fist when you are doing a drill with no protective gear -- when the instructor tells you to use light touch to practice slipping your head to the side).  I had not realized how many surgeries I have had until we discussed how I wanted the minimum possible anesthetic and no narcotics.  For the first three surgeries -- two fibroadenomas and my son's delivery (his head was turned sideways and his ear was coming out first -- just no way to get him out) no one mentioned working on the scar tissue.  I was also not told by the first surgeon that she was going to cut around the areola.  Sensation was permanently damaged in that area and I was only able to release about one third the milk.  I have just recently felt all these scars while contemplating what this might do for some of the more extensive posterior tongue ties and really wondering if sometimes it does do some damage that needs to be balanced against potential gains in other areas of function.

The second surgeon not only avoided general anesthesia (much to my abundant satisfaction) he also just went straight in.  The feeling in that second incision site is also impaired as is the incision site for the surgical delivery.  Its as if it isn't really a part of my body and feels very alien.  The fourth surgery was to insert a plate around my wrist after I broke it snowboarding.  The difference this time was that I had extensive physical therapy during which the DPT worked on the scar to break up the adhesions.  Sensation in that region is 10 times better than the other scars - but still not the same.  In this case, it was clearly worth it because I have full range of motion in that wrist and really need it for my work.  So, in thinking about tongue ties, my own sensations from my own scar tissue really illustrates to me how important the exercises are after the tongue tie is clipped.  Someone on Lactnet gave the link to Dr. Kotlow's website showing the exercises and so I often give parents that link even though I know the ENT I refer clients to also tells parents about these exercises.  Sometimes parents forget or simply don't do the exercises.  

The last surgery, really wasn't truly surgery since there was no slicing involved, but I must say that breaking my nose was a blessing in disguise because I can breath so much better now.  It may due to the fact that I broke my nose in college playing rugby and they didn't do anything to fix it.  And the ENT was so good that I had no pain whatsoever afterwards nor black eyes.  I didn't even need any tylenol post surgery.

So, while I said that I don't think if tongue mobility really is a problem that it is better to fix it sooner rather than later -- so there may be less retraining involved, I was thinking from the baby's perspective.  At the same time, I also agree with Laura that the timing of when you tell a parents and have them do something about it is important.  Sometimes the parents are completely willing and the tongue tie is so evident and function is so impaired that sending them early on to have an evaluation is great.  Sometimes you have to give parents time to realize that function is impaired and that the mom's nipple pain is not improving or the baby is not improving in their intake.  Then they may be ready to consider an evaluation.  Some parents just simply will not consider it.  Sometimes, I really don't think it is a problem and I do everything I can to improve their breastfeeding and nothing seems to work -- then I might confess my own doubts, let them know that I'm not sure it will have an impact, but that they might just have the evaluation to be sure that we have done everything possible.  Only once ever did one of those cases result in an improvement in breastfeeding.  In this case, the baby was almost able to finish feedings on the breast and it tipped the balance.  I will never forget the look of that tongue so that I keep it in mind for future reference.   

In providing feedback from one ENTs perspective, the ENT doesn't like seeing babies very early (in the first week) because parents are not really ready to think their baby may have a problem and they tend to be very defensive and scared by the procedure and then if they don't see immediate results they get resentful.  This ENT finds a better psychological result when the baby is slightly older and the parents are more ready to consider the procedure.  

As for speech, I did go to a speech language pathologist in third grade to play cards and work on enunciating "s".  Couldn't do it.  My tongue is fairly long, my frenulum very stretchy.  Depending on how I hold my tongue, it either looks like it attaches at the base of my tongue - when fully stretched or the midline when I pull it back. I have no idea what it might have looked like when I was in third grade or as a baby (since I was bottle fed). So, I have also been thinking a lot about how you assess the attachment and how the tongue functions in different positions.  Sometimes a tongue will look great in one position and restricted in another.  

Finally, I sometimes the baby's state can make a big difference.  I often find it impossible to really assess a baby's suck if they have lost a lot of weight.  Once they have gained some weight and are not longer lethargic or really frantic, then I have a better time understanding if their suck is a problem.  

I'm sure Cathy Genna would find all of this primitive since she has so much more experience.  I highly recommend her lectures.  I need to go to one of hers again sometime soon since it has been a while!!

Best regards, 

Susan E Burger, MHS, PhD, IBCLC

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