Amy

Thank you for asking your questions about tongue function during
breastfeeding.  As you might know, there has been much debate on this topic
on Facebook in the last couple of days.  I do hope that others will come in
to respond to your question, because I have the feeling that the answer may
help to lay to rest some of the controversy.

Firstly, let me say that I didn't attend Dr Ghaheri's session, and I don't
have a copy of the 2008 Geddes video to watch, but I have seen it before,
and I think I have still pictures and diagrams from it. The description of
what you saw in the video seems to be key!

Writing about the Biomechanics of milk extraction during breast-feeding, in
the Proceedings of the National Academy of Sciences 2014,

http://www.pnas.org/content/111/14/5230.full.pdf  David Elad and colleagues
have this to say (highlighted portion between the asterisks)

" We have shown, for the first time to our knowledge,
that latch-on to draw the nipple–areola complex into the
infant mouth, as well as milk extraction during breast-feeding,
require development of time-varying subatmospheric pressures
within the infant’s oral cavity. Analysis of the US movies clearly
demonstrated that tongue motility during breast-feeding was
fairly periodic. The anterior tongue, which is wedged between
the nipple–areola complex and the lower lips, moves as a rigid
body with the cycling motion of the mandible, while the posterior
section of the tongue undulates in a pattern similar to a propagating
peristaltic wave, which is essential for swallowing."

Now this is interesting because it reflects what you saw in the Geddes
video. What I feel is significant in the Elad abstract is that he describes
the anterior tongue as being "wedged" between the nipple/areola and the
lower lips (jaw?) and that it _moves as a rigid body with the cycling
motion of the mandible_ - in other words, the anterior tongue does not lift
during sucking.  Consequently is it possible that current methods for
assessing tongue tie which mark tongue function as impaired if it cannot
elevate could be wrong??

Secondly, you describe that you observe elevation of the mid tongue
occurring as a result of _internal expansion rather than truly lifing off
the floor of the mouth_  This would also fit with the Elad description
which suggests that the posterior portion of the tongue elevates in a
peristaltic motion _essential for swallowing_.   Could we conclude that if
an infant can swallow, then this function of the posterior tongue is
happening normally?  You have added a piece of the puzzle here by
suggesting that the posterior tongue lifts by its own internal expansion.
This is intriguing.   I wonder if the expansion you see might be due to
narrowing - ie maybe the tongue becomes narrower and thus higher to
facilitate moving the bolus of milk to the back of the throat and then to
swallow it.

Like you, I do hope that others will add their insights and opinions.

Pamela Morrison IBCLC
Rustington, England

You wrote:
I watched the GOLD conference recently and ended up more confused than ever
regarding lingual function and the need for frenotomy. Dr Ghaheri
referenced ultrasound videos from the 2008 Geddes study which showed the
middle of the tongue rising then dropping to create vacuum for milk
removal.  He pointed out how the anterior portion of the tongue barely
moved during this process and that there needed to be complete release of
the posterior frenulum in order for the mid-tongue to elevate.

When I watched the videos it looked like the mid-tongue lifted by its own
internal expansion not by the tongue elevating off the floor of the mouth.
If the tongue truly lifted off the floor of the mouth I could understand
the need for a posterior release, but since the underside of the tongue
seemed to remain on the floor of the mouth during sucking, why is a
posterior release needed ? Make sense?  What don't I understand?

Also,is anyone aware of any videos of lingual function that could be used
to compare pre and post-frenotomy function?  I couldn't find any.

Thanks again for any insights.  I truly appreciate the ongoing sharing of
knowledge that Lactnet has provided me over the years!!
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