/Please continue reading
/
Now, why do I bring up*FACT 10*? Because two interesting theories have
emerged in the last ten years. One theory proposes that the upper lip
frenum can cause breastfeeding problems. One case history was published
detailing the way in which the upper lip frenum created a problem. (4)
Recently, an article fleshing out the theory was published proposing a
classification schema to help people determine the presence of a lip
frenum that negatively impacts breastfeeding. (5) Unfortunately for the
proposer, the classification system proposed did not go through the
validation process so it really cannot yet be said that it accurately
identifies the type of upper lip frenum that could cause a breastfeeding
problem.
Let’s look at the assertion that a tight, prominent upper lip frenum
causes breastfeeding problems more closely. We can use anatomy,
physiology and development as our guide.*First:*the upper gumline
changes with growth. A frenum that appears to be restricted in early
infancy may substantially change as the baby
grows.*Second:*breastfeeding does not require a lip flange, merely lip
eversion.*Third:*the assertion that dental caries is caused by an upper
lip tie begs to be proven. Breastmilk does not pool in the mouth. The
position of the nipple in the mouth and the manner in which that milk is
moved into the pharynx for the swallow won’t allow it. Both the
peristaltic action of the tongue and the pressure differential created
by tongue movements quickly push/pull the milk to its ultimate destination.
*Fourth:*the lips follow the tongue, if the tongue retracts, the lips
move inward toward the gumline and when the tongue everts, the lips also
evert. This is a developmental reflex that remains active throughout
life. Anyone who has ever French-kissed can assert the truth of this.
Tongue position plays such a keen role in the positioning of the lips
that many types of*/acquired/*structural issues, like torticollis, can
cause the tongue to retract thereby pulling in the lips. In my
experience, this can be mistaken for what the theorists call an upper
lip tie.
In my clinic this past year I saw such a baby. She had been misdiagnosed
with both a tongue-tie and an Upper Lip Tie (ULT). She actually had low
cheek tone and overactive, tight lip tone. One of my colleagues
performed some very effective bodywork to bring down the lip tone and
bring up the check tone. It took her 3 minutes to rectify the problem at
no cost to the mother*/and/*the baby was saved from unnecessary surgery.
That leads me to my next point, without a valid definition of upper lip
tie (one based on solid facts about how the labial frenum impairs lip
mobility in the SPECIFIC manner that actually impairs breastfeeding)
then we are hard-pressed to be able to assess it properly. The exact
characteristics of a phenomenon must first be established before
assessment tools can be generated to assist the clinician in proper
diagnosis. No such work has yet been done.
We have put the proverbial cart before the horse when it comes to the
theory of upper lip tie. How many babies have suffered the consequences
as a result?
Does that mean Upper Lip Tie doesn’t actually exist?/Theoretically/it
could because any connective tissue in the body might, out of tightness,
negatively impact function. Does a tight, prominent labial frenum
actually negatively impact breastfeeding? Only future research will
prove or disprove this theory. Until the evidence shows us what is true,
ethics dictate that practitioners remain conservative in their clinical
approach.
*Let’s talk about the second theory:*that of the sub-mucosal posterior
tie. I have been liberally accused of not believing in the posterior
tie. Belief has nothing to do with it! Any clinician operating by belief
is shirking his or her professional and ethical duty.
My clinical approach to the sub-mucosal tie theory is conservative. To
my knowledge, no research has ever been done to verify that a
restriction at the tongue-base that presents as a thick, shiny string
under the mucosa is an actual tongue-tie. My experience as a structural
therapist, and in the experience of many a bodyworker throughout the
world, has shown that this type of tongue and/or mouth floor restriction
resolves with simple bodywork; that the actual cause of this type of
restriction is an acquired soft tissue strain pattern due to
intrauterine or birth events.
Once again, anatomy can inform us. That tight shiny string of tissue
underneath the mucosa at the tongue base may very well be the septum of
the genioglossus muscle, the tough aponeurosis (a type of fascia) that
connects the two halves of the genioglossus muscle together helping to
stabilize the tongue in the mouth. The septum attaches to both the
inside of the mandible at the mentis and to the hyoid bone in the upper
throat and is confluent with the hyo-epiglottic ligament. The septum is
easily visualized when two fingers press back against the tongue-base.
Some practitioners claim this maneuver renders an accurate diagnosis of
“sub-mucosal tongue-tie” but it may be revealing the septum of the
genioglossus muscle. One has to know what one is visualizing to avoid
making an erroneous diagnosis.
Ultimately, what seems to get lost in the argument over sub-mucosal
tie’s existence or non-existence is that theories must be proven. We all
share the burden of that proof (or disproof.) It is completely
legitimate to remain skeptical until more data emerges, especially when
the “cure” suggested involves cutting on a baby! I remain skeptical. The
dearth of evidence for this phenomenon, which may or may not be the
congenital anomaly we call tongue-tie, coupled with my own experience
working with these babies as a bodyworker keeps me sitting on the fence.
*Let’s now turn to the myths:*
*Myth 1:*The incidence of tongue tie is increasing. No one, anywhere can
make this assertion. No accurate incidence statistics existed prior to
Todd’s 2014 study. (2) The incidence may well indeed be population-based
but epidemiological studies must be done to assert this as fact.
*Myth 2:*All babies who have a tongue-tie have an upper lip-tie. How can
this be true? We have no idea what a lip tie actually is and no valid,
reliable assessment tool to even begin discerning who may have an issue
and who does not.
*Myth 3:*Laser frenectomy is better than scissors frenotomy. No evidence
demonstrates that this is the case. Any advantages of either are postulated.
*Myth 4:*All tongue-tied babies need a deep frenotomy. It might be true
that some babies will achieve optimal range of motion of the tongue with
a shallower snip. We need more evidence to make such a determination.
*Myth 5:*LASER frenectomy is completely safe. LASERs are, in fact, very
dangerous and can do significant damage when used by an untrained
practitioner. A definitive set of safety rules guide practioners to
utilize LASER equipment without posing harm to themselves or their
patients. There are several different types of LASERs; some more suited
for soft-tissue surgery. The wrong LASER can damage collateral tissue
and create excessive scar tissue that may cause re-attachment.
Currently, there is no requirement for a dentist or doctor to receive
training to use LASERs before performing surgery on babies.
*Myth 6:*The scar tissue in the wound bed must be broken down several
times per day to prevent excessive scar tissue formation
(re-attachment). According to new research, the frenum is a tendon, a
type of fascia. (6) Breaking down the scar tissue in the fascial wound
bed causes myofibroblasts to lay down a dense collagen network
(excessive scar tissue formation). (7) Gentle is better, both
physiologically and psychologically. It is a shame when we cause a baby
trauma from too aggressive post-surgical management. Come to think of
it, there is no*solid*evidence that post-surgical aftercare prevents
re-attachment. Two studies have been performed; one was extremely flawed.
*Myth 7:*There is a posterior tie behind every anterior tie.
Histologically this is not true. (6) This cute statement is misleading
if the purpose is to encourage surgeons to remove enough tissue to
adequately mobilize the tongue. It seems much clearer to say that enough
tissue must be removed (without cutting into muscle) to restore optimal
tongue mobility in some babies.
*Myth 8:*Posterior ties are more common than anterior ties. Oops! Todd’s
research definitively shows this is not true. Proper assessment, proper
assessment, proper assessment and differential diagnosis!
*Myth 9:*Classification schema serve as proper assessment. Nope, they
don’t. An assessment tool must possess the following: validity,
reliability, sensitivity and specificity. (8) In other words, they must
be designed and be proven to accurately identify the phenomenon being
assessed, be able to do so accurately from assessment to assessment and
from assessor to assessor and must be able to do so nearly 100 percent
of the time. A tool that falsely identifies someone as having a problem
when they don’t or not having a problem when they do is not accurate enough.
*Myth 10:*Any lactation consultant knows how to properly assess for
tongue-tie. As in any profession, members of that profession must be
trained to properly assess for any given phenomenon. For that matter,
not all physicians, dentists, speech-language pathologists, etc. have
been trained to assess for tongue-tie. It behooves parents to ask if the
practitioner has been trained to assess for tongue-tie using an
evidence-based assessment tool.
*For some reason*, tongue-tie has become the poster child for dogma and
controversy. We are at the very beginning of our understanding of this
congenital anomaly. (Don’t let anyone tell you otherwise!) That means
that no one knows the entire story, yet. Time and more research will
tell us what is true and not true about this phenomenon. Until then, we
must exercise healthy skepticism, continue to ask the hard questions,
engage in respectful dialectic and err on the side of caution. Our
vulnerable babies depend on us to keep them safe from harm, and that
includes holding off on surgery if no evidence exists to put them
through such surgery.
Our egos must learn to stand the strain of not knowing.
*References:*
1.Hazelbaker, A.K. (2010)./Tongue-tie: morphogenesis, impact, assessment
and treatment/. Aidan and Éva Press.
2.Todd, D. (2014)./Personal communication./
3.Dollberg, S. et al. (2014)./Lingual frenotomy for breastfeeding
difficulties: a prospective follow-up study./Breastfeeding Medicine:
Vol.9: 6: 286-289.
4.Weissinger, D. & Miller, M. (1995)./Breastfeeding difficulties as the
result of tight lingual and labial frena./Journal of Human Lactation:
11: 313-316.
5.Kotlow, L. (2010)./The influence of the maxillary frenum on the
development and pattern of dental caries on anterior teeth in
breastfeeding infants: prevention, diagnosis, and treatment./Journal of
Human Lactation: 26: 304-308.
6.Martinelli, R., et al. (2014)./Histological characteristics of altered
human lingual frenulum./International Journal of Pediatrics and Child
Health: 2: 6-9.
7.Schleip, R., et al. (2012)./Fascia: the tensional network of the human
body/. New York: Churchill Livingston.
8.Greenhalgh, T. (2010). How to read a paper: the basics of
evidence-based medicine (4th ed.). Hoboken: Wiley-Blackwell BMJ Books.
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