Nancy Mohrbacher, thank you for writing about the "epidemic". You are right
that seeking frenectomy/frenotomy is a "terrible place for mothers to
start" in addressing breastfeeding problems.

The first step should be for mothers to grow up seeing many effectively
breastfeeding dyads of all ages, learning what effective positioning and
normal frequency look like. At the least, mothers should attend
breastfeeding peer groups several times during pregnancy.

Another step should be the establishment of good prenatal nutrition, which
includes consuming significant quantities of dark green leaves (source of
reliably bioavailable folate and so many other nutrients) and having a
fully functional biome -- the lack of which is a serious First World
problem we are only beginning to assess.

Another step should be physiologic birth -- also a rare phenomenon in much
of the First World.

From LACTNET participants and their colleagues, mothers should be able to
obtain:

   - prenatal education about what works in breastfeeding, wherever bottle
   feeding has been the cultural norm.
   - reliable breastfeeding assessment immediately postpartum.
   - if breastfeeding is difficult, reliable education and troubleshooting
   wherever mother and baby are located throughout the first week.
   - if compensations (such as pumping, supplementing, breast compression,
   or nipple shields) are necessary, prompt and thorough follow-up by an IBCLC.
   - if medical (frenectomy/frenotomy, prescription galactagogue, etc.)
   and/or therapeutic (CST, OMT, MFR, SLP, OT, chiropractic, etc.) help is
   needed, prompt, appropriate referral.

I don't know whether to call myself a "dissident", Pamela Morrison, since
there are so many gaps in knowledge and care that it is hard to figure out
what I disagree with. I do ponder, however, whether a clue is hidden in a
very important detail of Nancy's helpful infographic on Milk Storage
Capacity
<http://www.nancymohrbacher.com/blog/2014/1/17/infographic-on-breast-storage-capacity.html>.
At
the lower left, where it states, "May change from one baby to the next.
Baby 1 does not equal Baby 2," an important factor might be milk *transfer*
capacity, greatly affected by the volume afforded by baby's posterior
tongue mobility. When I see a baby's chin doing double time rather than
drawing down during the mother's let-down, I look to how close baby's
tongue can get to the palate. If baby can't even draw in or form a seal on
the breast though the mother has been trying all the laid-back techniques
<http://www.nancymohrbacher.com/blog/tag/laid-back-breastfeeding> Nancy has
reported on so effectively, oral restriction is a prime suspect. Somehow, a
lot of these cases are showing up in my small practice.

How do we determine without 20/20 hindsight whether a dyad will wean
prematurely because of the effort of dealing with limited storage or
transfer capacity? Or because of the discomfort for the mother, or the lack
of suckling stimulation for the baby that banish the pleasure of
breastfeeding? How do we determine what oral and other functions will be
affected later in life by oral restrictions, which may make the expense and
disruption of frenectomy/frenotomy worthwhile? How do we determine what
will be most helpful in improving breastfeeding, when oral restrictions may
be only one factor making it difficult?

The missing links in knowledge persist. The International Affiliation of
Tongue Tie Professionals has only had two conferences -- not a lot of time
to sort, debate and disseminate what has been observed and investigated by
professionals who are actively involved in serving breastfeeding families
who deal with oral restrictions.

The missing links in care are even more intractable. In the U. S. and many
other places, lack of funding and of communication among professionals
leaves many families with nowhere to turn but Dr. Google. How do we get
health care providers to provide, and health care payers to pay for what
works, when we do figure it out?

We continue the quest for the Truth about oral restrictions and what to do
about them. LACTNET will be important to at least tackle the communication
gaps.

Ruth Piatak
-- 
Ruth Piatak, BA, MS, LLLL, IBCLC
Tulsa, Oklahoma
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