Tongue Tie & Revision

Tongue Tie: The Revision Process

By November 28, 2017 No Comments

If there is a suspicion of tongue tie and or lip tie and the baby fails the HATLFF, I present parents with the option to have an evaluation by a revision provider.

“Revision” is a sweet term we use to describe the frenectomy procedure of cutting or lasering the frenulum under the tongue and/or upper lip.

“Revision provider” is the term we use to describe the medical professional who is qualified and skilled in the frenectomy procedure. This may be a pediatrician, dentist, or Ear Nose and Throat doctor.

The relationships I have formed with the revision providers in my area are similar to those I have formed with other referral partners. Since the mothers I work with are fragile, sensitive, and often scared, it is critical to me that whomever I send her to knows how to handle the new mother with care.

In specific, the revision providers I work with are very comfortable with newborn babies (and with having crying babies in the office) and are well versed in the collaborative care of the IBCLC, revision provider, and body workers necessary to yield the ultimate results after a revision.

Here is my current list of trusted revision providers in my area:

Pike Creek Dental

Lance Panarello, DDS

Andrew Goldstone, MD

Keith Hollander, DDS

Paul Bahn, DMD

 

Although I am only sending my client to the revision provider for an evaluation, the revision provider understands the time sensitivity of the situation and will often offer the revision procedure at the consultation if appropriate.

In case the parents opt to have the procedure performed, I am certain to provide anticipatory guidance about the procedure and the post care. This includes targeted sucking exercises, which may be helpful to the baby whether the baby is revised not.

Plan of Care for infant who fails the HATLFF

Quick look:

  • Schedule an appointment with the revision provider
  • Prepare for the procedure
  • Be prepared for the first 24 hours post-revision
  • Use comfort measures in the first 48-72 hours after the procedure
  • Start post-revision lifts and suck relearning 24 hours after the procedure
  • Follow up with your IBCLC three to five days after the procedure
  • Follow up with your revision provider as scheduled (usually two to four weeks after the procedure)

 Schedule an appointment with the revision provider, ideally within a week. If the office is unable to schedule and appointment within a week, let your IBCLC know. Sometimes we cannot afford to wait that long; other times we can.

Prepare for the procedure. Be sure you are comfortable using your breast pump and you have expressed at least once. Ideally, you will have two to three ounces of expressed breastmilk in your refrigerator in case your baby is too sore to latch at any point 24 hours after the procedure.

Prepare six to 12 “breastmilk popsicles.” Cut a clean, soft washcloth or receiving blanket into six-inch by half-inch strips. Soak the strips in breastmilk and squeeze out excess. Place the strips in a freezer bag or breastmilk storage bag and place in freezer.

Some parents feel more comfortable having medical gloves in the house for doing the post exercise lifts. Clean hands are certainly perfectly fine, but if you’d prefer, pick some gloves up at Walgreens.

Carve out three days after the revision when you will do little to nothing else besides snuggle with your baby.

What to bring to your appointment:

A support person

Snacks and water

Your breastfeeding pillow

Your insurance card

Practice lifts with your IBCLC (see below) before the procedure.

Be prepared for the first 24 hours post procedure. Oftentimes, baby latches well right after the procedure. It is the feedings subsequent to this first post-procedure latch that can be difficult.

Managing the baby who does not want to latch:

Pump in place of breastfeeding. Pump both breasts for 15 to 20 minutes.

Offer baby about two ounces of expressed breastmilk in a bottle. For babies two weeks or older, you can offer an additional half-ounce to one ounce of breastmilk if baby still seems hungry after finishing initial two ounces.

Don’t poke the wound! When bottle feeding, offering a pacifier, or offering the breast with a nipple shield, always take caution to first wait for infant to put his tongue down or else you may inadvertently poke the baby in the oral wound. If baby will not seem to put his tongue down, insert your finger into baby’s cheek and get on top of the tongue with the pad of your finger up. Encourage the baby to suck your finger. Once the suck feels organized, return to offering whatever it was you were trying to offer. Notice if baby puts his tongue down.

In the first 24 hours after the procedure, you do not need to do post revision lift exercises or suck relearning.

Be prepared for the possibility of post-revision remorse.

Infant Comfort Measures:

Breastmilk popsicles:

  • Remove a breastmilk popsicle from the freezer and allow to defrost to “slush” consistency. It should not be frozen when you put it in the baby’s mouth as that could cause cold burn or stick to the wound.
  • Offer baby a breastmilk popsicle three to four times a day for the first three days after the procedure. A great time to do this is before “lift exercises” or when baby seems to be feeling sore.

Skin-to-skin and decreased stimulation:

  • Baby will feel the most calm and the least sensation of pain when he knows his parents are close. Plan to spend first three days after the revision doing very little. Wear your baby in a wrap or carrier and spend plenty of time snuggling.

Tylenol:

  • Call your pediatrician to ask for the proper dose of Tylenol to give your baby.

Post revision lifts: In order for your baby’s revision to have the most benefit, we will be asking you to perform post-revision lip and tongue lifts. Starting at about 24 hours post-procedure, perform a lip and tongue lift before almost every breastfeeding session during the day, allowing for two to three skipped lifts overnight. Ideally, you will go no longer than six hours without performing a lift.

We do these lifts to help the wound heal open rather than closed, or to heal from the inside out.

Dr. Ghaheri has a really excellent aftercare instructional page with videos. Be sure to view these ahead of time and ask your IBCLC if you have any questions about how to perform the post-revision care.

Post-revision suck relearning: Now that your baby has a brand new tongue, we will be asking you to help her use it! Your IBCLC will provide you with a list and descriptions of various exercises that you or your partner will need to do with your baby to strengthen and organize your baby’s sucking habits.

Follow up care with your IBCLC: We prefer to evaluate your baby’s revision wound three to five days after the procedure, then follow up for a lactation consultation about a week after the procedure.

Follow up care with your revision provider: Even if breastfeeding has been going really well, be sure to keep your follow-up appointment with your revision provider, who will assess the healing process of the wounds and make recommendations if there is any further treatment needed.

Please remember that a revision of tongue and/or lip tie is not a magic bullet that fixes breastfeeding. You may or may not feel an immediate difference after the procedure. Oftentimes, it takes up to two weeks to fully appreciate all the benefits of this procedure. Like everything with breastfeeding (and parenting in general), this is a marathon, not a sprint. By preparing ahead of time and following the process, you and your baby will get the most out of this procedure.