Sometimes, the frenulum under the tongue can restrict movement of the tongue and cause breastfeeding problems.
- At Balanced Breastfeeding, Katie Madden used The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF). The Academy of Breastfeeding Medicine endorses the use of this tool for the identification of infant tongue ties.
- The HATLFF is a superior tool because it assesses not just how the tongue looks, but also how it works! I have found that using the HATLFF helps me to identify exactly which oral movements the baby is unable to perform properly so that I can customize my post revision suck training exercises. For instance, if baby is unable to fully extend her tongue before revision, I know to teach mom tongue extension exercises to practice before and after the revision to help baby learn this newfound skill.
- HATLFF + Feeding Assessment
- It is my job as the IBCLC to see the whole picture, not just the tongue. Tongue tie almost never exists in a vacuum of breastfeeding problems.
- A baby’s mouth must fit onto two particular nipples. We cannot only look to the baby’s mouth for answers to breastfeeding difficulties, we must also look at breast anatomy. An IBCLC is trained to assess breast anatomy in addition to evaluating the infant’s feeding needs.
- It is the role of the IBCLC to
- Address the parent’s suspicion of tongue tie and decrease self-seeking of revision, which may be unnecessary.
- Communicate her findings with the infant’s pediatrician.
- Refer the mother to a known and trusted revision provider (Dentist, ENT, oral surgeon, etc.).
- Treat underlying breastfeeding issues, such as low milk supply, nipple trauma, or infant’s poor weight gain, to name a few.
- Provide support, education, and anticipatory guidance before, during, and after the revision procedure.
- Provide follow-up shortly after the visit, including addressing all persistent breastfeeding issues, infant suck relearning, strengthening through tummy time, and emotional support.
- It is not the role of the IBCLC to
- Diagnose tongue tie. The IBCLC simply identifies limitations in oral range of motion. It is the revision provider who officially diagnoses tongue tie.
- Tell the family what she thinks they should do or make false promises that a revision will fix everything.
- If the infant fails the HATLFF, the IBCLC should refer to a trusted revision provider for evaluation and potential treatment.
- After evaluation with the revision provider, follow-up with IBCLC is critical.
Sometimes, the frenulum under the upper lip can also cause breastfeeding problems. This is as common as issues stemming from the tongue tie, but it certainly is part of the complete oral evaluation we complete. Again, it is less important what the attachment looks like and more important how the lip moves.
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 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.
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.
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 Revision 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.
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, get gloves.
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.
- In the first 24 hours after the procedure, you do not need to do post revision lift exercises or suck relearning.
Infant Comfort Measures
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.
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.
If you are finding performing the lift before feedings is affecting latch, experiment with doing the lifts after or between breasts.
Post-Revision Suck Relearning
Practice these exercises three to five times a day, before most daytime breastfeeding sessions.
- Always start with freshly washed hands and neatly trimmed fingernails.
- These exercises work well whether or not your baby has had his frenulums revised. Although frenulums themselves do not stretch, the tissues and muscles around the frenulums can.
- These oral exercises are designed to be gentle and fun. They shouldn’t seem to hurt or bother the baby. You may find that they annoy the baby, especially if he is hungry and you are attempting to do them before feedings.
- Try the exercises on yourself or your partner to try to identify and locate the targeted muscles. This will also help you understand which parts of the mouth are more sensitive than others. If any of these exercises make you uncomfortable, please don’t do them and let your IBCLC know.
Your baby may not realize how far her new tongue can stick out! Tap your baby’s forehead, nose, and chin. Hold your finger on your chin and she will start to extend her tongue. If she makes eye contact with you, stick your tongue all the way out and ask her to do the same; she may mimic you! Ideally, she will stick her tongue out past her bottom lip.
Sucking Tug-of-War with Palate Massage
- This exercise it to help strengthen his tongue muscle. Encourage him to suck your finger in, pad side up. As he sucks, resist him by gently pulling your finger out, allowing him to pull back. If he wasn’t extending well in the previous exercise, try applying gentle traction down with the nail side of your finger to push the rear of his tongue down.
- Using a windshield wiper motion, gently rub your finger back and forth over his palate.
- You can also encourage tongue extension by flipping your finger pad side down and pressing down while pulling forward while he sucks.
This exercise is to improve lateralization, or the side-to-side motion of baby’s tongue. Slowly trace her lower gum, from center to rear, with the pad of your pinky. Repeat on each side three times, then move to the other side. Repeat on the upper portions of her gum. Look for the tip of her tongue to follow your finger. She may rotate the side or the body of her tongue at first. As you practice this more and more, she should start moving the tip more.
Around-the-World Cheek and Lip Flanging
This will help him flay his lips out at the breast. Insert your finger between his gum and his lip. Trace your finger between his gum and lip, stretching his lip gently away from his gum. Do this under the top lip and bottom lip.
It is fairly common to have regret in the hours and days following a revision procedure. It can be a sickening feeling.
- Remember that having your baby’s tongue and/or lip revised was not a mistake.
- You made this choice not only to help your baby to breastfeed, but also to improve your child’s airway, dental health, and future speech.
But you feel unsure about that choice because:
It is hard to see your baby in pain. Make sure you are using comfort measures to help decrease your baby’s pain.
It can be discouraging if you are noticing your baby’s latch isn’t any better, or maybe it seems even worse! It’s okay. It is really common for babies to have a disorganized suck in the days after the revision procedure. Remember, your baby has a whole new ability to move her tongue!
That can be confusing!
It can be common for babies to sometimes refuse to nurse at all for hours or days after the revision procedure. This is also okay! Just feed your baby and protect your milk supply. You will work with your IBCLC to get the baby back to the breast.
It can be upsetting to perform the post-care lifts. If you are uncomfortable performing them, call your revision provider or your IBCLC and ask for help. Your IBCLC should see you three to five days after the procedure and she may be able to do the lifts with you.
Remember that you made an informed decision to give you and your child the best chance at meeting your breastfeeding goals. Sometimes you will encounter bumps on the road to those goals, but with perseverance and the right support network, you will get that much closer to reaching your destination.