Hello Pam, Cathy, Attie, Margaret, Lisa, Barbara, and anyone else I may have missed who has responded to my Lactnet post recently!!

 As always, a big THANK YOU for sharing your knowledge and wisdom with me, and the entire Lactnet group, regarding the very challenging issue of tongue-tie management!   I truly value your time and insight.  I do not participate in Facebook since I prefer this format and truly hope that it continues!


 I am a relatively new IBCLC, being certified in 2012.  My past experience includes 29 years of working in at a teaching hospital in Women’s Health in various capacities including Inpatient Obstetrics for 16 years (Maternity, Antepartum, Labor and Delivery, Newborn Nursery), Childbirth Educator for 20 years, Outpatient OB clinic for 3+ years and as an Inpatient IBCLC for the past 4 years.  


 Since the beginning of my OB career, I have seen dramatic changes in maternal-infant care, especially with breastfeeding!  In the late 80’s, I remember the big focus was on SIDS prevention and the “Back to Sleep” campaign.  In the 90’s, when I had my children, a renewed focus on breastfeeding was beginning to emerge.  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?  


 It seems impossible to me now, but in my days as a floor nurse, I do not EVER recall seeing a baby with a tongue tie, most likely because no one ever looked!  I can honestly say that in the 16 years that I cared for mothers and newborns, not once did I, or anyone I worked with to my knowledge, look in a baby’s mouth specifically to assess tongue mobility!  We just never thought to look!  It was not until I began my training to become an IBCLC that I was enlightened regarding this issue.  Many of my colleagues who still work on the OB unit agree with me that we never looked!!  In retrospect I find this amazing.  So Pat, in response to why we see so many now, this might be one explanation, especially in my hospital!


 So, fast forward to 2012 when I was certified and began my formal practice………


 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.


 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.


 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!


 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.


 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. 

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.


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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