July 4, 2015 at 10:35 am #5255Vanessa PrinzIBCLC
Happy 4th of July!
There hasn’t been anything super grabbing on lactnet the last few days so I’m pulling a hot topic from back in April. I work for a private practice in Chicago and TT is kind of a sensitive/controversial subject for us. We take kind of a “wait and see” approach, we don’t diagnose it unless we find, over time, that it is causing a problem with breastfeeding (e.g. baby isn’t gaining, mom’s nipples are falling off.) When we do rise the issue, some pediatricians push back. We liked this perspective from a NY IBCLC on Lactnet. (See below.) Please share your thoughts/perspectives on TT.
Date: Thu, 30 Apr 2015 09:23:14 -0400
From: Kathy Lilleskov
Subject: Re: Guidelines for diagnosing or ruling out tongue tie
Ah tongue ties! I love reading everybody’s take on this and I have to say it is the only subject on Lactnet where I agree with everyone! Depending on the practitioner they are over diagnosed or they are under diagnosed, I try to be the mama bear of diagnosing and slide right down the middle – not papa bear or baby bear 🙂 But it is so tricky because breastfeeding issues are so often multifactoral. Tongue ties are frightening to talk about because none of us can predict with certainty that a release will fix things and suggesting even the most minor surgical intervention is a huge responsibility. A discussion that helps us understand when, how and why to intervene can be truly exciting but also overwhelming when you get contradictory opinions. If you recommend a release and things don’t improve you feel bad. If you advise caution and mom dives right in and things get remarkably better, you kick yourself for being overly cautious!!! I like the idea of recommending body work first because it is noninvasive, but all these interventions add up!!!! She is paying me, then she has to pay for CST, then if that doesn’t work, she has to pay for a release. Good possibility she is paying for a hospital grade pump on top of everything. My goodness, before the baby is a month old she may have shelled out almost $2000!!! I think we also need to remind ourselves that we don’t have to do into anything immediately and lets take our time and sort through options before we send this mother to a bunch of specialists who may or may not help her.
For new lactation consultants feeling overwhelmed by this discussion here is how I handle things in my practice. Remember that lots of this is really grey and nobody knows for sure 100 percent of the time!
1) Evaluate the situation remembering that a lot of issues you see in the first couple of weeks may resolve spontaneously with time. Cracked nipples, mildly compressed nipples, vasospasms, reduced supply, slow feedings often resolve with tincture of time. Moms have heard over and over that if you are doing it right breastfeeding shouldn’t hurt. This has become a hospital staff mantra. So moms are anxious from the pain and feel like failures, “Obviously if i was doing this right it wouldn’t hurt” So they call us in and expect we have a magic wand that will make that come true.That we can just “Fix the latch” Reassurance that sometimes breastfeeding hurts in the beginning but it always gets better is really necessary for them to hear. Tell them that you will be there for them until it gets better and that there are lots of things you can try, but they are not a failure at this because it hurts and they are not necessarily doing something wrong. That in fact a lot of pain originates with the baby’s anatomy and not theirs. I remind them that birth hurts a whole lot and that nature is not a gentle mistress. And we also really need to be careful that body work and frenectomies don’t become our default advice because the mother is expecting something that will just get her to that place of pain free nursing and we don’t want to disappoint her. In the beginning breastfeeding hurts for many women and there may or may not be a latch adjustment you can provide that will reduce the pain. Those of us who have lead groups that go on for a year or so have seen many babies with mild or questionable tongue ties go on to become expert nursers, without any surgical intervention! Moving milk well and not causing pain to their mothers. Some of these mothers were told their babies were tongue tied and that they should get releases and are very angry. “See my baby was fine all along and that creepy lactation consultant in week 2 wanted me to cut his little tongue” We need to reassure these mothers that there was a very valid reason for the suggestion and that some nursing situations don’t improve spontaneously and the lactation consultant at the time was doing her best to help you get to a pain free state. And that we are all learning new things every day about how to help moms get to pain free nursing as quickly as possible.
2) if you are not sure whether a frenectomy will help in a specific situation engage the mother in a frank discussion of the pros and cons of options available to her. For instance, if nipples are damaged would she like to remove the baby from the breast for a few days to let everything heal up and pump and try again in a few days? For some moms this is all it takes. If a mom chooses this alternative, then I will tell her that after her nipples heal up and she returns the baby to the breast if things slide right back into the same level of damage that is an indication for a frenectomy. For many moms, once the milk arrives and is flowing out nicely and the nipples have returned to normal even some mild compression doesn’t do damage. Another option if a baby has a clampy latch but you are not sure if a frenectomy will help is a nipple shield. Sometimes this can take nursing from awful to wonderful without any surgery. But you absolutely must do before and after weights to figure out if a baby is transferring milk well. If it is not an anterior tongue tie or a very tight type 2 or 3, which are often no- brainers, explain to the mom that a frenectomy “might” help but that there are no guaranties. Sometimes you look at tongue and you are sure, but often it is confusing. As lactation consultants we have to be open to acknowledging that confusion. I will tell a mother that we are in murky territory and that I can’t promise anything.
3) Vasospasms are a huge problem in the early days especially with clampy latches and high levels of maternal anxiety, which I am convinced is a deadly combination for perfusing the nipples with blood! Mildly tongue tied babies will set off more vasospasms than their more agile tongued brethren. Vasospasms can be treated with heat and patience and will often resolve spontaneously as the hormones settle down and the baby’s mouth gets bigger and the latch improves. Do a thorough evaluation of whether the pain is worse when the baby is on the breast or off. If it worse when the baby is off, I tend to take a conservative approach about frenectomy because I find many of these cases resolve over time.Talk to the mother about heat heat heat. Often just a discussion of vasospasm helps reduce her anxiety and sense of failure that she isn’t doing things right and reduces the vasospasms!!!!
4) Interventions and finances. Many of my clients can drop 1000 on CST and not even feel it. But I think we all need to be cautious in recommending interventions which might or might not help. If I have a forceps or vacuum delivered baby, with torticollis and facial asymmetry I am going to be a lot more vigorous in my recommendation of body work than a mildly tongue tied baby where I can’t quite make the call. Unless finances are not an issue or there is a local practioner who takes insurance. Again, when I am not quite sure what is up and nursing is intolerable, I will often recommend removing baby from breast for a while, pumping and then sometimes a slow return. Nurse once a day, then twice a day then three times a day. Some moms would much rather do this than get a frenectomy. And I generally have not found bottles to be a problem under these circumstances. This is the parents call. And in my mind, should primarily be the mother’s call! Nothing drives me crazier than a mother who wants to get a frenectomy because she is intolerable pain whose partner won’t permit her to.
One thing I have discovered about my own practice is that my own confidence in frenectomies waxes and wanes with what is currently happening with my moms. If a questionable baby goes off and gets a release and things are wonderful then I am bolder in suggesting a release with the next baby. If I have an experience where it doesn’t help this seems to make me cautious for a while. I can’t believe after 10 years it is all so confusing still but it is!!!! So take heart keep your ears and mind open and let’s all keep learning together!
Kathy Lilleskov RN IBCLC
Practicing in Brooklyn NY where income inequality is rampant.
July 16, 2015 at 3:36 pm #5300Sonya MylesIBCLC
I have to agree with Kathy. As an aside, I have had a few older babies (older than a month) who have needed the procedure and then have been very angry with us. It is almost as if we broke trust with them. Remembering that what we do to babies has a psychological effect is important. We are lucky in the area where I live to have an excellent practitioner who does lazer frenectomy. She also does not do unnecessary procedures, and does an excellent evaluation. But some babies just don’t like having anything done to them. My go to options with these babies is:
1) Finish at the breast method of supplementation – baby gets a full bottle feed and then comes to the breast for cuddles and learns that a full belly and a breast go together. Also, mom and baby don’t stress about feeding and can learn to enjoy it
2) Osteopathy – I have seen it work miracles
3) Reiki – Japanese energy healing – again, I have seen it work miracles.
Sometimes babies just need to know we don’t do things to them to be mean, we do things to help them.
And I smile a bit on the inside sometimes, often my most horrified at the idea of a frenectomy parents are the ones who booked the circumcision before they even left the hospital.
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