Mary Kay,
 
    I will stick my neck out with you.  I have had  many frenulum cases over 
the past 10 years, and although I do not always use  them, I find that a well 
fitting nipple shield saves the day.  The  shield is longer than the nipple, 
saves a lot of wear and tear, and puts a  descent amount of pressure on the 
tongue.  I have had some instances where  due to mother and baby anatomical 
issues there would not even be a latch  without it.
 
    Most recently, a relative gave birth to a tongue  tied baby with an 
overbite.  The upper gum is clearly 2 cm over the  lower gum.  Babies tongue never 
clears the lower gum.  Mom's  nipples do not protrude very far.  One nipple is 
borderline flat.  I  set her up with nipple shields immediately.  Milk supply 
is in, and the  shields are full of milk during feeds.  When I work with my  
mothers, I do not always have the same exact care plan for each case, but I  
am not afraid to use a nipple shield to perpetuate breastfeeding.  We all  know 
what it is like to work with a mother who has reached her LIMIT, and how  
frustrating it is for anyone to go on at that point. Nipple shields  help these 
mothers move on.  Paula Meier's research indicates that premie  babies may 
actually gain weight better with them.  I feel that a nipple  shield used in the 
appropriate time and manner make a BIG difference  until a frenotomy is 
performed.
 
    My relatives case was further complicated by an  early case of thrush 
because she was pumped with 2 grams of Ampicillin during  her delivery.  So we 
started an over the counter version of Dr. Jack's  cream (equal parts 
polysporin, monostat, and cortaid--thanks Pat  Lindsey!).  Anyhow, not every case will 
involve thrush or mastitis,  but they do tend to come up because of the wetness 
and  abrasion.    
 
    The psychological part of this process is  almost as important as the 
physical.  Besides needing to protect the  nipples from wear and tear 
(literally), mom and dad need to come to grips with  the decision to do this procedure.  
Although LCs know how important  they are, doctors and parents aren't always 
convinced.  Many parents  go through a form of denial.  As soon as a procedure 
is mentioned, they  fight it.  I had one mom have a melt down and scream that 
she was not  cutting her son's tongue!  I am sure that I am not the first LC 
to deal  with a ped or parents who don't see the value of the procedure.  Often 
our  opinions are not as valued as the doctors.  I have been lucky in my  
relative's case, because her ped has been so supportive that he is actually  
conversing personally with the pediatric ENT that will do the procedure, but we  
all know that all cases don't work that way.  For me, it is important to  have 
doctors that will provide the right information and care.  One of my  mom's 
went to an ENT on her med plan, and he told her he won't do the  procedure until 
the baby is 6 months old.  There goes the  breastfeeding!  I also heard that 
another will not do the procedure  until the baby is 10 lbs.  Why can they do 
a circumcision on 4 and 5  lb babies, but not a frenotomy?
 
    When providing info to parents, I use Brian  Palmer's Frenum Presentation 
_http://www.brianpalmerdds.com/frenum.htm_ 
(http://www.brianpalmerdds.com/frenum.htm) ,  articles about tongue tie from different sources, and I provide 
referral's to  pediatric ENTs.  Most importantly, I provide a list of mom's who 
have  gone through the procedure, and offer themselves as support.   The  
frenotomy is not the magic bullet, but it is definitely a great start to  an 
upward trend. However, it doesn't work without follow-up and  support.
 
    To me a tongue tie care plan requires a  combination of physical, 
psychological, and educational endeavors.  Every  success story makes it worth all 
the effort.  My relationships with  these mothers often turn into rewarding 
friendships because we have worked hard  together and they manage to successfully 
breastfeed despite the  difficulties.
 
Debbie Albert, RN, Ph.D., IBCLC, RLC
Tampa Lactation Counseling 
Tampa, FL         
 

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