Catherine Watson Genna BS, IBCLC  NYC  www.cwgenna.com

On 12/11/2016 5:10 PM, Amy Wagner wrote:
> .... I remember my coworkers participating in an in-service on the "RAM technique” (aka: Rapid Arm Movement) as I was giving birth in the room next door!!!!!  As many of us now know, this technique, which seemed GREAT at the time, is not a good way to encourage effective latching, but at the time, who knew?
Thank Goodness breastfeeding is robust, and that we don't have to be 
perfect to make it work!
>
>   Because I did not feel confident in my assessment of lingual function, I made it a point to assess every baby that I cared for (as I still do today!) in order to learn as much as possible.  My assessment is very focused and brief, using techniques  that many of you have shared, since I do not want to contribute to oral confusion/aversion.  Cathy Watson Genna’s, Supporting Sucking Skills, and Allision Hazelbaker’s, “ATLFF” tool, are my most often used resources.  What I have found in my own personal “research” was that almost all babies that I have cared for, with an occasional exception, have some degree of what I would describe as a posterior lingual frenulum.
Yes, almost everyone has a lingual frenulum! It's only a problem if it 
restricts tongue mobility enough to impair function.
>
>
>   Starting out in my career, I tended to be more quick to refer a baby for evaluation of the lingual frenulum than I currently do today mainly because many of the babies who subsequently underwent frenotomy had brief, minimal or no improvement with breastfeeding as compared to the mother’s that opted not to intervene.   Occasionally some got better, but not so much overall.  Why is that?  Is it technique? Lack of attention to the basics of breastfeeding (ie.positioning/latch….)???  I’m not sure, however I am continually amazed at the mothers whose infants have pronounced type 1 restrictions, but refuse frenotomy, that go on to successfully breastfeed without problems.
Again, the most important thing is mobility - anterior frenula are more 
likely to be thin and elastic. A small histological study of the altered 
lingual frenulum by Martinelli, Marcheson and Berretin-Felix confirmed 
this observation, that there are different presentations. The thing all 
altered frenula had in common were reduced elasticity.
>
>
>   My ongoing questions:
>
>   I struggle with understanding the need for release of the posterior frenulum (diamond-shaped wound) for every frenotomy.    It just doesn’t make sense to me biologically or from what I saw on the Geddes videos that such extensive release is needed.  It looked like the tongue tip only needed to reach over the lower alveolar ridge (and stay there) and the body of the tongue “humped up” internally.  Cathy, I am so looking forward to the results of the research you are participating in to help me understand lingual movement better than I do now!
We are still learning! The one thing that is clear is that the better 
the tongue elevation after frenotomy, the better the results. Our study 
is showing that mobility of the entire tongue is important.
>
>
>   In counseling parents of a TT baby, I do feel strongly that even if breastfeeding is going well, other issues like risk of dental caries, eating and speech issues should be addressed.
We don't have as good research on those areas, so we are not on as firm 
ground with them.
>
>
>   Why does a person with a restrictive lingual frenulum have an increase risk of sleep disturbances?  When a baby has Pierre-Robin syndrome, I read that MD’s prefer that a TT exists to keep the tongue forward to prevent airway obstruction.
Lack of tongue elevation reduces spreading of the hard palate laterally. 
The spreading of the palate causes spreading of the choanae (the bony 
nasal apertures in the posterior skull), improving the nasal airway 
during sleep, when the oral airway may collapse.

Pierre Robin Sequence is a very special case, the very short mandible 
causes the tongue to be placed back much farther than usual, endangering 
the airway. A tongue-tie helps hold the tongue forward and prevent the 
tongue from falling into the airway. Kids with PRS should sleep on their 
bellies, laying on the back increases the risk of respiratory obstruction.
>
> Anyone have any thoughts?
>
>   I truly apologize for the length of this entry.  As you can tell, issues from the past and present continue to challenge my understanding of the issue of lingual function, however I am optimistic that ongoing research will shed more light on this issue.
That's what we are all  here for! No one knows everything, Lactnet 
allows us to access a brain trust
>
>
> As always, thank you to everyone who participates in LACTNET.  Let’s keep it going strong!!
>
> Sincerely,
>
> Amy
>
>
>
> Amy Wagner, BS, RN,CCES, IBCLC	
>
> Hershey PA
>
>     
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