Breastfeeding, holidays, and alcohol.

Breastfeeding and Alcohol

We know that there can be many barriers to breastfeeding success, perceived dietary and lifestyle restrictions can be one of these. Dr. Jack Newman, IBCLC, has this to say about alcohol and breastfeeding: “Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers.”

An Alberta Health Service publication quotes the Canadian Paediatric Society recommendation: “that mothers who drink only occasionally should still breastfeed their children.” It goes on to propose limits on the amount a mother can “safely” drink before she discontinues breastfeeding. “However, breastfeeding is not recommended for women who regularly consume more than a moderate amount of alcohol (more than two drinks per day).”

Dr. Newman and others argue that these statements use inconclusive or limited research, and fail to factor in the risks of discontinuing breastfeeding to the baby and the mother, or even the risks of replacing just a few feeds with artificial infant milk.

What we do know about alcohol and breastfeeding?
ALCOHOL ENTERS THE MILK IN THE SAME AMOUNT AS IS PRESENT IN THE BLOOD STREAM.

What this means is that if a mother has reached 0.05% blood alcohol (the legal limit to drive in Alberta) her milk will have 0.05% alcohol. In other words 100 ml of this mother’s milk would have 0.05 ml of alcohol. Non-Alcoholic beer has 0.5% alcohol. Valencia oranges have about 0.09% alcohol when they are harvested. After 8 weeks of storage they have 0.39% alcohol. There is more alcohol in a Valencia orange than in this mother’s milk.

When a mother’s blood alcohol level reaches 0.2-0.29%, she will be experiencing:
Stupor
Loss of understanding
Impaired sensations

Severe motor impairment
Loss of consciousness
Memory blackout

And yet, her milk will only have 0.2-0.29ml of alcohol in 100ml, still less than a Valencia orange after 8 weeks of storage and much less than a non-alcoholic beer. By the time she gets to 0.5 blood alcohol she will likely be dead, and yet her milk will only have the alcohol content of a non-alcoholic beer!

Impact of Mother’s blood alcohol level on the Mother
Mother’s Blood Alcohol level
Alcohol Content of Mother’s Milk (what baby is getting)
Compared to Non-Alcoholic beer 0.5%
Compared to Alcohol Content of Valencia Oranges (0.09% at harvest. 0.39% 8 weeks later)
Legal Limit
0.05%
0.05%
0.05%<0.5% 0.05% < 0.09% Stupor/loss of consciousness 0.2-0.29% 0.2-0.29% 0.2-0.29% < 0.5% 0.2-0.29% < 0.39% Possible death 0.5% 0.5% 0.5% = 0.5% 0.5% > 0.39%

La Leche League International says: “Adult metabolism of alcohol is approximately 1 ounce in 3 hours, so mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal.”
The bottom line is that if you are sober enough to parent, you can and should continue to breastfeed. The most important question is not whether you can drink alcohol and still breastfeed, the most important question is if you are going to drink alcohol to the point of impairment, who is taking care of the baby?
Full References will all be available at www.breastfeedingaction.ca shortly.

Here are the relevant links:

Alberta Health Services: http://www.albertahealthservices.ca/AddictionsSubstanceAbuse/hi-asa-women-effects-alcohol.pdf

Alcohol by volume: http://en.wikipedia.org/wiki/Alcohol_by_volume

Blood alcohol Content: http://en.wikipedia.org/wiki/Blood_alcohol_content

LLLI Alcohol FAQhttp://www.llli.org/faq/alcohol.html

Alcohol in fruit: http://quezi.com/14067

FURTHER STUDIES OF ETHANOL AND ACETALDEHYDE IN JUICE OF CITRUS FRUITS
DURING THE GROWING SEASON AND DURING STORAGE http://www.fshs.org/Proceedings/Password%20Protected/1971%20Vol.%2084/217-222%20%28DAVIS%29.pdf

RELATION OF ETHANOL CONTENT OF CITRUS FRUITS TO MATURITY AND TO STORAGE CONDITIONS
http://www.fshs.org/Proceedings/Password%20Protected/1970%20Vol.%2083/294-298%20%28DAVIS%29.pdf

Getting ready to go diaperless

elijah on the potty

Typically the best time to start getting ready is during pregnancy. Read a few good books on EC, and join a local support group. Watch a video or two as well. Like with breastfeeding, it really helps to see the mechanics of EC before you try it yourself. Notice how the caregivers respond to the baby and the different ways they may hold the baby at different stages. Ask lots of questions.

Before the baby comes, when you are feeling like nesting, get your supplies in order. You will need something to catch pee in, and something to keep you and the baby dry when there are “misses”. Many people pee the baby into a potty or other plastic receptacle. Some babies are peed in the sink, bath or toilet. Many enjoy using the great outdoors. Get a squirt bottle and fill it with vinegar and water or other gentle cleanser to rinse out the pee place after use. When you and your baby are starting out you will need something to keep baby(and you) warm and dry while you are both learning about elimination. Many people use a coverless cloth diaper or prefold when starting out so they can feel immediately when the baby is wet. There are many to choose from. The benefit of having at least a few prefolds is that you can lay the baby on the diaper as you carry him around, making it really easy to notice and respond to a pee. You might also want some thing to put wet and soiled diapers in as well. It is very handy to have some kind of absorbent pad to lay the baby on when he is diaperless, and under him at night.
Rather than setting up all of the diapering supplies in one place, think of having several toileting areas in your house wherever you and baby might be. A potty, a small change mat, a few clean diapers, and some small wipes in several areas of your home works well to avoid always having to rush off to the toilet as infants pee very often! You will likely do this with nursing areas too so you could set up both at the same time. Babies seem to nurse and pee in tandem and in clusters.

When the baby comes, you can choose to start right away, or you can wait while you rest and recover from the birth and get breastfeeding established. You will be learning a lot of new things very quickly and it is up to you when and how to start EC. Do consider that you will have to deal with your babies elimination needs no matter what you choose and it helps to have some of the EC basics in your mind even if you don’t plan to start for a few days or weeks.

Communication is the most essential part of EC so start by talking to your baby about what has happened, or is happening. “Oh look, you peed. Now your diaper is wet let’s get you warm and dry. It feels so nice to be dry.” Always try to keep your communication neutral. The baby will hear how pleased and excited you are in your tone, there is no need to overtly praise the baby for doing a normal bodily function. Conversely, avoid negatives around toileting. Don’t make the baby feel stinky, smelly or gross. No one wants to associate their most intimate body parts with something smelly, dirty or shameful. Elimination happens, and we parents have to deal with it. No one place to go is bad or good, it just is and in time all children master peeing in the toilet. Explain the toileting process to your baby. “I think you need to poop. Let’s go to the potty. I’m going to hold you so you can poop here. You will feel better after you poop.”

Observation is also key to learning about your babies’ timing and signals. Try to have some diaper free time in the early days so that you can notice what your baby does just before he pees, and also when he pees. You might notice a certain facial grimace, or a small sound that your baby makes.Popping on and of the breast or being restless or fussy during a feed can be a signal that baby needs to go. Just as you are learning about how your baby tells you that he is tired or hungry, he will let you know when he needs to go. This is where seeing other babies EC can be helpful, babies seem to have a range of signals they use but the themes seem to be common.

Timing is another useful tool for EC. Think about the times of day when you need to go. First thing in the morning, before and after naps, after play and after nursing. These are very likely times to catch a pee. Infants pee as much as 20 times a day in the first few months. Just as some babies cluster feed, they may also cluster pee. Don’t be alarmed if you find that your baby does nothing but pee and eat at certain times each day. This tends to slow down as your baby learns that you are responding to his needs, often around the third month. Pooping also tends to become more regular as you and your baby get the hang of EC, so if you offer regular pooping times, and hang out on the potty long enough for him to finish, you might have established a regular pooping habit by about six weeks.

When you and baby are very connected to each other, you may notice some of the intuitive EC cues. The feeling of a warm wet spot when you are hold the baby indicates the need to pee. Random thoughts of pee, or of your baby needing the toilet are common as well. Try not to ignore these intuitive feelings, or you may end up with a wet spot!
Holding on to a wiggly baby over the toilet can seem a bit daunting at first, but with practise you will find ways to hold your little one safely and comfortably. The EC books have good pictures, as do the videos. If you have a local Diaper Free baby group you will likely be able to observe mothers holding their babies to pee. Newborns might like to use a reclining cradle hold, and most babies are very comfortable being held with their back to your chest while your arms support their thighs holding the legs slightly apart. Both boys and girls can spray while they pee. You might have to experiment with your daughter to get the angle right to aim the stream right into the pot. Boys might need a finger to guide their penis down into the pot. Some parents find it is easiest to potty a child who sprays into the tub or shower.

It is important to remember that you don’t have to do EC full time, it is more important to establish a harmonious relationship that works for you and your baby. The communication is the most essential part, and you can do that whether your baby is in diaper full time or not. Don’t get stressed out about the results, EC is not a contest and there isn’t really a finish line, so take it easy and enjoy this precious time with your new little one.

Good Luck and Happy Pottying!

Lee-Ann Grenier

 

Breastfeeding, Holidays, and Alcohol

Breastfeeding and Alcohol

We know that there can be many barriers to breastfeeding success, perceived dietary and lifestyle restrictions can be one of these. Dr. Jack Newman, IBCLC, has this to say about alcohol and breastfeeding: “Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers.”

An Alberta Health Service publication quotes the Canadian Paediatric Society recommendation: “that mothers who drink only occasionally should still breastfeed their children.” It goes on to propose limits on the amount a mother can “safely” drink before she discontinues breastfeeding. “However, breastfeeding is not recommended for women who regularly consume more than a moderate amount of alcohol (more than two drinks per day).”

Dr. Newman and others argue that these statements use inconclusive or limited research, and fail to factor in the risks of discontinuing breastfeeding to the baby and the mother, or even the risks of replacing just a few feeds with artificial infant milk.

What we do know about alcohol and breastfeeding?

ALCOHOL ENTERS THE MILK IN THE SAME AMOUNT AS IS PRESENT IN THE BLOOD STREAM.

What this means is that if a mother has reached 0.05% blood alcohol (the legal limit to drive in Alberta) her milk will have 0.05% alcohol. In other words 100 ml of this mother’s milk would have 0.05 ml of alcohol. Non-Alcoholic beer has 0.5% alcohol. Valencia oranges have about 0.09% alcohol when they are harvested. After 8 weeks of storage they have 0.39% alcohol. There is more alcohol in a Valencia orange than in this mother’s milk.

When a mother’s blood alcohol level reaches 0.2-0.29%, she will be experiencing:

  • Stupor
  • Loss of understanding
  • Impaired sensations
  • Severe motor impairment
  • Loss of consciousness
  • Memory blackout

 

And yet, her milk will only have 0.2-0.29ml of alcohol in 100ml, still less than a Valencia orange after 8 weeks of storage and much less than a non-alcoholic beer. By the time she gets to 0.5 blood alcohol she will likely be dead, and yet her milk will only have the alcohol content of a non-alcoholic beer!

 

Impact of Mother’s blood alcohol level on the Mother Mother’s Blood Alcohol level Alcohol Content of Mother’s Milk (what baby is getting) Compared to Non-Alcoholic beer 0.5% Compared to Alcohol Content of Valencia Oranges (0.09% at harvest. 0.39% 8 weeks later)
Legal Limit 0.05% 0.05% 0.05%<0.5% 0.05% < 0.09%
Stupor/loss of consciousness 0.2-0.29% 0.2-0.29% 0.2-0.29% < 0.5% 0.2-0.29% < 0.39%
Possible death 0.5% 0.5% 0.5% = 0.5% 0.5%  > 0.39%

 

La Leche League International says: “Adult metabolism of alcohol is approximately 1 ounce in 3 hours, so mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal.”

The bottom line is that if you are sober enough to parent, you can and should continue to breastfeed. The most important question is not whether you can drink alcohol and still breastfeed, the most important question is if you are going to drink alcohol to the point of impairment, who is taking care of the baby? 

Here are the relevant links:

Alberta Health Services: http://www.albertahealthservices.ca/AddictionsSubstanceAbuse/hi-asa-women-effects-alcohol.pdf 

Alcohol by volume: http://en.wikipedia.org/wiki/Alcohol_by_volume 

Blood alcohol Content: http://en.wikipedia.org/wiki/Blood_alcohol_content 

LLLI Alcohol FAQ: http://www.llli.org/faq/alcohol.html 

Alcohol in fruit: http://quezi.com/14067

FURTHER STUDIES OF ETHANOL AND ACETALDEHYDE IN JUICE OF CITRUS FRUITS

DURING THE GROWING SEASON AND DURING STORAGE http://www.fshs.org/Proceedings/Password%20Protected/1971%20Vol.%2084/217-222%20%28DAVIS%29.pdf

RELATION OF ETHANOL CONTENT OF CITRUS FRUITS TO MATURITY AND TO STORAGE CONDITIONS

http://www.fshs.org/Proceedings/Password%20Protected/1970%20Vol.%2083/294-298%20%28DAVIS%29.pdf

Tongue Tie Release – My Story

 

A more clear view.

A more clear view.

Most of the information I had learned about adult ankyloglossia (tongue tie), was presented to me at the 2013 IATP (international affiliation of tongue tie practitioners) summit. There I learned that everyone with tethered oral tissue (TOTS) can compensate for the tension caused by tongue tie to varying degrees. For some compensation fails in infancy presenting as difficulty breastfeeding. As people with TOTs age compensation breakdown can look like feeding and swallowing difficulties (from infants to geriatrics), speech impediments, sleep apnea, as well as the symptoms I was presenting with. I became curious about my own oral function and learned a few of the criteria for diagnosing adult ankyloglossia. Which, as with infants, includes an assessment of symptoms, structure and function.

I was very curious about the effects revision might have in my daily life. I had many of the classic symptoms of problems relating to tongue tie: migraines, TMD, chronic sinusitis, fatigue during speaking. My tongue function was limited; I could not perform a full sweep of the inside and outside of my teeth using my tongue (this is called oral toilet). I could not open my mouth to a normal degree with my tongue elevated. I could not roll my r’s when speaking french. The structure of my lingual frenum presented as a class 3 attachment. I could feel the tension where it attached to the floor of my mouth, like a tight thin piano wire, it pulled and pinned my tongue down. I had had treatment to expand my high arched palate as a child.

I lost my ability to compensate for my oral restrictions in 2007 when I was involved in a minor car accident. I began to experience clicking and pain in my jaw. If I ate an apple or had some popcorn, I paid for it with a migraine the next day. I tried various treatments (chiropractic, cranio sacral therapy, acupuncture, dental devices) with no relief. It was at that summit that I began to wonder if the problems with my jaw might have been cause by tongue tie, and my bodies inability to compensate for that any more.

I spent the next two years becoming evermore immersed in the world of TOTs. Curiosity about my tongue function kept creeping into my thoughts, as I explained tongue tie to many anxious parents who were also curious about their own tongue function. I even accompanied a friend’s brother to have his frenum released.

In late 2014 I decided to undergo frenotomy. A friend and colleague wanted to have hers released too, so we decided to go together. We prepared by having bodywork a few days before the procedure. I had my revision on Friday January 22, 2015. Unlike the babies who undergo the procedure, I was able to have local anesthetic. Immediately after the procedure I noticed how high I could elevate my tongue, and sweep it across all of my teeth. As the numbing wore off I experienced pain, like the burn you get when you drink coffee that is too hot. It was intense. All I wanted was ice cream, it felt so good on the revision site! I took ibuprofen that afternoon and the next evening, and had minimal pain.

The next morning I took another dose and prepared for a long day of teaching (and lots of speaking). The stretches, to keep the wound from healing shut, were really hard to do to myself. The big upside was that I no longer had fatigue and soreness after a long day of speaking. This was amazing!

I followed up with body work, and noticed that for the first time ever a big release under my tongue and in my hyoid bone. The clicking in my jaw was gone, as was the migraines. My nose drained fully and it no longer hurt when I used my neti pot. I hadn’t known that I had difficulty swallowing pills until after the revision, when it was suddenly easy and not uncomfortable.

These small changes have really impacted my quality of life. I love that I can read to my children at bedtime without pain in the muscles surrounding my throat. It’s nice to be able to chew gum, eat popcorn and apples, without suffering for it. I find singing very different too, I no longer tilt my head back when singing. My posture has changed too.

Sometimes I feel things tightening up again, pain and discomfort returns. When it does, I go for cranio sacral therapy, and things improve dramatically and these changes last for months. I am very happy to have had the revision done.

Working and Breastfeeding!

Working and Breastfeeding

I often get email questions from parents, many of them have a similar theme, I’m going to publish a number of my responses here. This one was from a former client, who had questions about returning to work at the end of the Canadian maternity leave which happens around 12 months post partum. It was prompted by the 2015 World Breastfeeding Week theme: BREASTFEEDING AND WORK: LET’S MAKE IT WORK!


Q: Hi Lee-Ann! I was happy to hear that your theme of the year is about helping moms manage breastfeeding while working. I’ve started transitioning back to work & could definitely use some tips. Do you have any resources you could share?

A: Thanks for contacting me, did you have any specific concerns?

Q: Well one of my concerns is whether I need to leave milk for B at daycare. He’s 10 months old, still feeding on demand along with eating 2-3 meals a day. He’s in daycare starting next week for 6 hours/day, 5 days a week. I was at an LLL meeting last month; they mentioned that some moms don’t leave any milk (for a full 8-9 hr day) and the baby just makes up for it when they are with the mom. Is this more appropriate for babies a year and older? I only have a manual pump right now so it’s quite a lot of work to pump just a few oz.

A: This is true for babies of B’s age, and older. You will need to express at work for the first little while to help your body adjust and prevent engorgement.
So if you don’t want to pump to supply Blake with milk for daycare, you should just express to comfort and your production will down regulate to meet the changes.

Q: Ok thanks! Will he ultimately be getting less milk overall then he is now then? I was under the impression he would still get the same amount just during a concentrated part of the day. Do you recommend this method or is it best for him to get milk throughout the day?

A: Usually babies do what is called “reverse cycling” and get most of their milk through the night. This works well if you are co sleeping, as you can sneak in missed cuddles as well as feeds. If you are worried about his milk intake he can have cow milk at daycare. He is old enough to have a straw cup or regular cup and doesn’t need a bottle. Also calcium and    Vitamin D needs can be met without cow milk.

 

La Leche League Canada has an excellent blog post on this topic and can be a great place for support for parents returning to the workforce. ~Lee-Ann

Elijah Community Enhancement Fund

The Elijah Community Enhancement Fund

Elijah 5 months old

Elijah 5 months old

The Elijah Community Enhancement Fund was borne out of my difficulty finding excellent care to help Elijah as he struggled to breastfeed and grow during the first year of his life. His story was shared here (at 7:18) and continues here.

The Fund aims to fill the gaps in care that we experienced on our journey by providing access to high quality lactation support for those with a financial need. Lactopia will donate a portion of their services to match the contribution from the fund, providing breastfeeding couples with free or low cost breastfeeding support. Another gap has been in accessing current information and developing skills for lactation professionals. The fund will provide scholarship opportunities for professionals attending Lactopia’s training and continuing education services. The third gap we experienced was in community support for breastfeeding. The fund will  assist with projects providing community support for breastfeeding.
The first of these community support projects is our Ally to Advocate workshop happening on October 10th  at Grow Centre.

Visit our website for information on donating to the fund, or accessing it’s supports.

On Starting Solids

Elijah loves cherries!

Elijah loves cherries!

On Starting Solids

I was addressing a topic that comes up frequently on mom’s groups today, that of when to start solids. The poster wondered why her pediatrician now recommended starting solids at four months when she had recommended six months in the past. Several of the posters noted that Health Canada, the Canadian Pediatric Society, the World Health Organization, and La Leche League all recommend waiting until around the middle of the first year of a baby’s life.

So why the discrepancy, and does it make a difference anyway? The new research that was touted at industry sponsored conferences seemed to suggest that early introduction of solids might reduce the risk of allergy, type 1 diabetes, and celiac disease. Thorough reviews of these studies showed that finding were inconclusive as to providing any benefit from starting early solids, and findings did not address the known risks of early introduction of solids.

One rationale for early solids is low iron. Most babies have sufficient iron stores to six months and beyond. More if the cord was left to pulse at birth. Less in preterm births. Iron can be measured by a simple heel prick and a bio available (easily absorbed) supplement can be given. Early infant foods include purees of fruit and vegetables (not very iron dense) and iron fortified infant cereal. Iron in infant cereal is not very bio available and binds to the lactoferrin in human milk resulting in less total available iron and a resulting premature depletion of natural iron stores.

Another reason for recommending early solids is that baby will sleep longer at night. Not only is this reason untrue, and there is no evidence to back it up, there are many protective reasons for baby to wake and feed during the night. Night waking protects babies from SIDS, breastmilk has a higher calorie content at night and maternal prolactin levels are at their peak between 3:0o and 5:00am. Which means babies are safer, grow well, and mothers maintain a good milk supply when they are nursed through the night.

So the next question might be, is there any harm done by starting solids early? The easy answer is yes.

Infants drink (on average) the same volume of human milk each day during the period of one to six months of age. This is the peak of milk production which begins to slowly decline after six months postpartum. So any other foods consumed during this time replace calories and nutrients found in human milk. This leads to decreased milk production and potential early weaning as well as nutrient deficiencies.

The infant’s gut does not mature until after six months of age. Introducing other foods to the gut during this time causes damage to the gut lining and delays the maturation of the gut and digestive system. The presence of human milk in the digestive track protect against inflammation and confers antibodies that the baby does not begin to make on his own until the sixth month of life. This is protective against illness and allergy during this very sensitive period. It is sometimes referred to as the virgin gut.

By starting solids during the middle of the first year of life, one can avoid fortified infant cereal and pureed infant foods entirely, as baby is developmentally ready to pick up, chew swallow and digest solids which can be family table foods. These foods will be a compliment to breastmilk, not a replacement for it. Breastmilk continues to make up the bulk of babies caloric need for the rest of the first year of life.

From the kellymom website:

Signs that indicate baby is developmentally ready for solids include:

  • Baby can sit up well without support.
  • Baby has lost the tongue-thrust reflex and does not automatically push solids out of his mouth with his tongue.
  • Baby is ready and willing to chew.
  • Baby is developing a “pincer” grasp, where he picks up food or other objects between thumb and forefinger. Using the fingers and scraping the food into the palm of the hand (palmar grasp) does not substitute for pincer grasp development.
  • Baby is eager to participate in mealtime and may try to grab food and put it in his mouth.

Tongue and Lip Ties: Best Evidence

Ellie, intro
limited elevation in tongue tied baby

Tongue and Lip Ties: Best Evidence
By: Lee-Ann Grenier
Tongue and lip tie (often abbreviated to TT/LT) have become buzzwords among lactation consultants bloggers and new mothers. For many these are strange new words despite the fact that it is a relatively common condition. Treating tongue tie fell out of medical favour in the early 1950s. In breastfeeding circles, it was talked about occasionally, but until recently few health care professionals screened babies for tongue tie and it was frequently overlooked as a cause of common breastfeeding difficulties.
In the last few years tongue tie and the related condition lip tie have exploded into the consciousness of mothers and breastfeeding helpers. So why all the fuss about tongue and lip ties all of a sudden? Tongue tie seems to be a relatively common problem, affecting 4-11%1 of the population and it can have a drastic impact on breastfeeding. The presence of tongue tie triples the risk of weaning in the first week of life.2

Here in Alberta it has been challenging to find competent assessment and treatment, prompting several Alberta mothers and their babies to fly to New York in 2011 and 2012 to receive treatment. The dedication and persistence of these mothers has spurred action on providing education and treatment options for Alberta families.
In August of 2012, The Breastfeeding Action Committee of Edmonton (BACE) brought Dr. Lawrence Kotlow to Edmonton to provide information and training to area health care providers. The attendees included; nurses, midwives, doctors, lactation consultants, dentists, and doulas. This event was just the beginning of bringing more comprehensive treatment options to our province.
What is Tongue Tie?
Tongue tie, also known as ankyloglossia, is a remnant of embryological tissue (frenum) that interferes with normal oral functions and causes a wide range of symptoms affecting untreated babies, children and adults. Lip tie is an abnormal attachment of the lip (labial frenum) to the gums (maxillary gingival tissue), which causes restricted mobility, affecting the baby’s ability to create a seal around the breast. This attachment can result in maternal and infant pain, and symptoms associated with poor milk transfer. Treatment of tongue tie (frenotomy*, clip, release, revision) involves a division or release of the membrane from the floor of the mouth.
Although the history and treatment of tongue tie is well documented, lip tie is a newer area of study with emerging data.
History of Tongue Tie
Tongue tie is documented as far back as biblical times, but in the last 70 years diagnosis and treatment have fallen out of favour. As recently as 2011, the Canadian Paediatric Society (CPS) issued a position statement about tongue ties, discouraging treatment:
Ankyloglossia (or tongue-tie) is a relatively uncommon congenital anomaly defined by an abnormally short lingual frenulum. Associations between tongue-tie and breastfeeding problems in infants have been inconsistent, and are a longstanding source of controversy in the medical community. Definitions of ankyloglossia vary, and management suggestions are not based on randomized controlled trials. Surgical correction involves cutting the lingual frenulum (frenotomy). Based on current available evidence, frenotomy cannot be recommended. If, however, the association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed necessary, frenotomy should be performed by a clinician experienced with the procedure and with appropriate analgesia. More definitive recommendations regarding the management of tongue-tie in infants await appropriately designed trials.3
Historically, midwives would keep a sharpened fingernail and use it to sever any tongue tie an infant might have. More recently, when childbirth in North America was the purview of general practitioners (up to the 1950’s), frenums would be routinely cut during a baby boy’s circumcision, and all baby girls would have been checked for tongue tie, having their frenums released as well. Birth becoming the purview of obstetricians as surgeons, coincided with the appearance of formula sales representatives on labour and delivery units, and the skill of diagnosing ankyloglossia and performing simple frenotomy was not passed along to obstetricians.
Today, a few dedicated health care providers still perform frenotomy, but many more have never heard of it and others believe it is of no benefit to infants. It can be heartbreakingly challenging for a parent trying to find help for tongue and lip tied babies, and mothers know that this condition impacts breastfeeding despite the CPS position statement.
There are often questions as to why we are hearing about tongue tie so much these days. Breastfeeding initiation rates have increased, so more mothers are continuing to breastfeed through challenges. Mothers are seeking solutions to breastfeeding problems and are demanding that healthcare professionals don’t give up on them. Through social media, awareness about issues like tongue tie seems to be spreading even more quickly than before. When more women are breastfeeding and talking about it online, it increases the awareness of relatively common issues that can impact the breastfeeding relationship, even if there isn’t an increase in incidence.
There are some theories, and beginning research about environmental causes relating to tongue and lip tie, and other theories about gene mutation being involved. These are questions still awaiting answers.
There is renewed interest in research about tongue and lip ties and this is forming a body of knowledge that can support health professionals and parents.
The Research
Studies and scholarly articles dating as far back as 19484 document ankyloglossia’s impact on infant feeding. More recently, these studies show a host of symptoms experienced by mother and baby and go on to identify frenotomy as an effective procedure for correcting the structural element of ankyloglossia, improving maternal comfort and increasing breastfeeding competency.5
In a 2011 review of the literature the authors found that:
Generally, performing frenotomy for ankyloglossia was associated with improvements in breastfeeding characteristics. 67.2% (275/409) of infants were breastfeeding at three months post-frenulotomy. Maternal nipple pain was significantly reduced following frenulotomy in all studies at follow-up. A significant improvement in an objective measure of latch (LATCH** score6) was demonstrated in two of the three studies using this outcome measure.7
The authors of this review felt that a randomized controlled trial of the effectiveness of frenotomy through six weeks post procedure is needed.
A 2006 study randomized 25 infants to either: a) a frenotomy, assessment, sham (placebo) procedure, and assessment or; b) a sham procedure, assessment, frenotomy, and assessment. The study’s results concluded that there was a significant decrease in pain and an improvement in LATCH scores in all infants after frenotomy, but not after the sham procedure. They encountered no significant side effects and very little bleeding during frenotomy.8
Another randomized study, published in 2011, followed 58 infants who were initially randomized to two groups, frenotomy or sham procedure. The frenotomy group reported a significant decrease in nipple pain and improved infant breastfeeding scores, immediately after the procedure and again at two weeks post frenotomy. The sham group was offered frenotomy at their two week follow up appointment and all but one accepted the procedure. The babies were followed for a full year post frenotomy and continued to benefit from the reduction in pain and improvement in breastfeeding as reported in the study.9
A 1995 case report by Dianne Wiessinger is one of the earliest discussions of lip tie in the literature.10 It is also described, in 2004, in an article by Dr. Elizabeth Coryllos, as being one of many oral frenums that may interfere with lip flanging and may need treatment depending on the baby’s ability at the breast in relation to lip positioning.11 She noted that it appears in conjunction with tongue tie and may be part of a wider range of midline defects.
Dr. Lawrence Kotlow recently published a paper in the Journal of Human Lactation on “Diagnosing and Understanding the Maxillary Lip Tie as it Relates to Breastfeeding.”12 It is the first full paper to provide insight into the effect of lip ties on breastfeeding and their management. The paper also includes diagnostic criteria, a classification scale and a full explanation of the mechanics involved in upper lip flanging, gape and the impact on breastfeeding. Dr. Kotlow has performed revisions on over 1000 infants, starting treatment 40 years ago!
Long Term Implications for Not Treating
There are many potential consequences of not treating tongue and lip ties. It can be hard to foresee which problems the future may present to a tongue and lip tied individual. Because addressing the problems caused by tongue and lip ties crosses many disciplines, consensus about when to treat is lacking, and at times hotly debated. Some advocate for immediate infant revision, others encourage a wait and see treatment approach depending on how the ties impact breastfeeding, and further development. The relative skill and experience of the person performing the revision may be part of the decision to get immediate or delayed treatment. We know that all people with tongue ties are compensating for the lack of mobility (restricted function), to one degree or another, and over time the ability to effectively compensate can be compromised due to effects of aging, accident or injury.
Screening vs. Assessment
Many involved in the care and treatment of infants advocate for routine neonatal screening for tongue ties. A simple screen involves inserting a gloved finger in the infant’s mouth between the tongue and the floor of the mouth. The finger is positioned as far back along the gums as the space where the first molar will be, and then slid from one side of the floor of the mouth to the other. If any restriction is felt (wall, membrane, or “speed bump”) the infant would be referred for a more thorough and qualified assessment of tongue structure and function as well as breastfeeding assessment and support. This is important as it is reported that 25-50% of those with structural ankyloglossia will experience breastfeeding difficulties and may require frenotomy.13
A full assessment involves a detailed examination of the infant’s oral cavity. The practitioner will be knee to knee with the parent or assistant and place the baby’s head in their lap, with the baby’s feet pointing away from them. This knee to knee position provides for optimal visualization.
The assessment will look at structure, function and symptoms. The structural assessment tells the practitioner where the membrane under the tongue is attached to the floor of the mouth. However, it does not give any information about how minor or severe a mother’s and baby’s symptoms may be. There are several classification systems for tongue tie (only one for lip tie) and some controversy as to which one is the most effective to use and where to use it. The classification information about the structure is not typically relevant to parents, but the findings of a functional assessment can be quite helpful.
A functional assessment should involve observations of the infant at the breast, calm and awake, and while sucking on the examiner’s finger (with and without milk in the baby’s mouth). It may include pre- and post-feed weights and using a stethoscope to listen to swallow sounds at the baby’s neck (cervical auscultation) to assess milk transfer and the degree of ease with which the infant swallows (bolus handling). The examiner will look for range of motion and mobility of the tongue, how widely the baby can open his mouth at the breast (gape) and how well his lips seal to the breast (flange). They will also look for signs of feeding stress in the infant. This may include: splayed fingers and toes, hands up near the face in a “warding off” position, worried or wrinkled brow, and gaze aversion. How the whole baby moves and feeds as a whole will also be observed to rule out the involvement of other issues that may be affecting breastfeeding. This would include taking a detailed history. A good assessment will always begin with a firm grounding in the normal mechanics of breastfeeding with the assessor noting any deviations from the norm. You should be able to request a copy of your assessment for your records and to take with you to the treatment provider.
Treatment Options
Treatment of tongue tie (frenotomy, clip, release, revision) involves a division or release of the membrane from the floor of the mouth and can be performed by midwives, nurse practitioners, doctors (ranging from family doctors to ear, nose and throat specialists and plastic surgeons) and dentists. As the membrane is non-vascular there is very little blood, and the procedure itself is usually quick and straightforward to perform. Revision can be performed using scissors, scalpel or laser. Alberta Health Care covers scissor revision, but not laser revision. Release of lip tie can involve more blood and swelling as this tissue is more vascular. It can be performed by the same practitioners using the same instruments as for frenotomy.
When the practitioners are highly skilled, we see no difference in the treatment methods (laser vs. scissor). Laser treatment has been reputed to have an increased incidence of post revision oral aversion, but there is currently no research to back this up. Dr. Greg Notestine recently spoke at the International Affiliation of Tongue Tie Professionals (I.A.T.P.) 2013 summit, on “Laser vs. Scissor; Deep vs. Shallow; Anesthetic or None: What Frenotomy Treatment Decisions are Best?” He said that when a practitioner was already skilled with a laser, learning to perform a frenotomy with laser was easier and there is less difficulty in achieving a complete release. “Unfortunately,” Dr. Notestine says, “the learning curve is long. But until you treat a few and get a sense of the difference from the Mom, you don’t know if your treatment/release is successful. My real test, laser or scissor, is for me to swipe the wound while treating. If it still feels like a wall of tissue, I release a little deeper until the wound feels flat. With scissors, vision is obscured by blood but can still feel. With laser I can see AND feel, but it takes 10-30 seconds to complete versus two seconds with scissors. With a screaming, squirming kid 30 sec seems like an hour!”***
When practitioners are beginning their frenotomy practice we sometimes see incomplete revision as a result of conservative treatment. For those using scissors it can be challenging to gain the confidence needed to revise far enough without fear of excessive bleeding or damaging adjacent structures. A too shallow clip or incomplete revision can sometimes increase challenges as the mechanical force of the tongue has been transferred to a smaller load. This often means that part of the tongue has more range of motion, but further back it is still restricted, leading to further difficulties with normal function.
Since the understanding of a lip tie’s potential impact on breastfeeding is so new, many practitioners are skeptical about treatment, especially with scissors or scalpel, where bleeding would be more of a concern. There is significant anecdotal evidence to encourage this treatment and a need for further research into this area.
From a practical perspective, getting to revision can be challenging. Dentists remain the easiest self-referring care provider for parents to access province wide. The downside to this is that parents expecting a quick fix can get a revision without having any breastfeeding assessment, support, or follow up care or bodywork (craniosacral therapy, chiropractic or osteopathic care, which helps the baby learn to use his newfound mobility more effectively and quickly). This experience decreases the effectiveness of the revision (sometimes causing more problems than it solves) and gives the treatment a bad reputation, supporting the view of those who think this is unnecessary, or over prescribed surgery.
Without easy access to a supportive care provider, parents are often caught trying to navigate the public health system, fighting against the stigma of the CPS position statement. There are some self-referring breastfeeding clinics in Calgary and Edmonton that provide frenotomy and some are even revising lip ties as well. When seeking treatment options look for care providers that offer a thorough assessment and are interested in being a part of a comprehensive care team including the parents, breastfeeding support and bodywork.
This Isn’t Simple
Being a new mom, struggling with breastfeeding and trying to find care can be daunting tasks. Treatment of tongue and lip ties can be complex. As with many surgical procedures, treatment of oral ties, involves more than just surgery. Assessment and skilled (often ongoing) breastfeeding support are part of comprehensive care combined with pre and post revision bodywork, and post revision physical therapies for the babies.
All wounds are inclined to heal themselves closed and the frenotomy site is no different. In order to avoid healing reattachment, the parents need to commit to performing routine stretching exercises which can be stressful. This practice is hotly debated among professionals, but there is now some research coming to back up post frenotomy stretching.14 The person performing the frenotomy should provide a list of post-surgical care and stretching instructions, and the parents should be committed to performing the stretches before the revision is considered. We see improved results and less need for repeat revisions with stretching routines.
Some babies may need specific suck retraining exercises in order to relearn correct use of the tongue and other muscles used for feeding and swallowing. A skilled breastfeeding support person can determine the exact types of exercises need to achieve normal range of motion and effective nursing skills.
Bodywork: What is it and why is it important?
Babies can present with breastfeeding challenges as a result of a difficult birth (vacuum, forceps, Caesarean section, long or difficult pushing stage) or being constricted in utero (breech, transverse lie, posterior presentation, uterine scarring, multiple pregnancy), or a congenital abnormality such as tongue tie.
Bodywork refers to different types of gentle, non-invasive, manual therapies that can be used to help treat and correct breastfeeding problems with underlying structural causes. Practitioners can include: chiropractors, osteopaths, massage therapists, physical therapists, and craniosacral therapists. These manual therapies are particularly useful in helping to treat tongue and lip ties, before revision, instead of revision, and during recovery and healing after a revision.
As the tongue forms in utero it shapes the palate, which in turn shapes the sinuses. The rest of the craniofacial structures follow suit. A tongue that is restricted in utero by a frenum, does not allow for normal oral development, and tongue tied babies are often born with abnormalities of the palate and other craniofacial structures (i.e. narrow nasal passages). Torticollis (a muscular condition where the neck muscles are restricted causing the head to tilt in one direction) is sometimes seen in conjunction with tongue tie. The tongue tie often holds tight the surrounding muscles of the face head and neck.
Having bodywork prior to revision can loosen and normalize the surrounding structures to such an extent that the tie is no longer problematic. Allison Hazelbaker describes this phenomenon as “faux tie”, when constricted muscles cause the appearance of a significant frenum that reduces with bodywork.
Manual therapy can release the muscle tension and allow for more of the tie to “come forward” in the mouth, making it easier for the revising practitioner to get a complete revision. Some bodyworkers can provide a diagnosis of ankyloglossia that may be difficult to obtain in the conventional medical system. Pre-revision care often includes multiple visits close together (i.e. four to six visits, every second day) then decreasing over time when improvement is made.
One of the markers of a tongue tie in need of revision is that the baby does not improve with skilled bodywork. Following a course of bodywork treatment to see if the results of the treatment are lasting can sometimes be a test to see if revision is needed. The tongue tie requiring treatment will continue to pull the surrounding structures out of alignment over time. Babies who respond well to body work, but regress quickly might be good candidates for revision.
Post-surgical body work is important too. Manual therapy can help the body to adjust to its new range of motion, and even deal with some of the trauma associated with the revision process. Craniosacral therapy (CST) is particularly good for this and the CST practitioner will often treat the mother and baby at the same time allowing the mother to release trauma she may be holding relating to unsuccessful or stressful breastfeeding experiences.
Some bodyworkers recommend seeing the baby as soon as possible after revision, and again after a one to two day interval, decreasing treatments over time with improvement. The bodyworker can be an important part of the care team working in conjunction with, and as a complement to, services provided by a skilled breastfeeding support worker.
Healing and Relearning
The time post revision can be a trying one for parents, juggling appointments with bodyworkers and breastfeeding support, while re-learning to breastfeed and performing stretches. Some families treat this time as they would the immediate postpartum period and have a “lying in” or babymoon during the early recovery period.
In the first day after revision, many babies are in pain and upset. Some parents use an over the counter pain reliever. Others might opt for homeopathic pain relief. Some families provide comfort measures and wait it out. Be sure to check with your care provider for appropriate pain control measures. It is not uncommon for a baby to have a temporary and usually short lived nursing strike during this time. If this happens, the mother will need to maintain her milk supply by pumping or hand expressing, and feeding the baby by an alternate method. Although some mothers notice an immediate improvement in latch and pain, many mothers do not. Getting to normal breastfeeding can be slow. Often it is only one more good feed each day post revision. Most mothers see noticeable improvement in two to four weeks. The longer the baby had the restriction, the longer it may take to recover.
During this time a mom and her family need lots of support. She may appreciate having a meal prepared, help with older children, shopping or other household tasks being taken care of so that she may focus on caring for and learning to nurse her recently revised baby. This process can be very emotionally trying for the mother, as she begins to let go of the stress of struggling to get help and copes with the mixed feelings surrounding her expectations of herself, her baby and the revision process. She may have ongoing struggles with diminished milk supply, or need to heal damaged nipples. Emotional support during this time can be invaluable, and can come from partners, family friends and professionals.
Tongue and lip ties are a relatively common problem and revision is a relatively simple procedure. But for most parents, the journey from symptoms to successful and comfortable breastfeeding is complex and overwhelming. Building a team of professional support, appropriate pre- and post-care and community support are all a part of addressing this common problem. B
* Frenotomy is sometimes described as the release of the band of tissue, whereas frenectomy is the release and removal of the membrane. However both words (as well as frenulotomy) are often used interchangeably in the literature.
** “LATCH is a breastfeeding charting system that provides a systematic method for gathering information about individual breastfeeding sessions. The system assigns a numerical score, 0, 1, or 2, to five key components of breastfeeding. Each letter of the acronym LATCH denotes an area of assessment. ‘L’ is for how well the infant latches onto the breast. ‘A’ is for the amount of audible swallowing noted. ‘T’ is for the mother’s nipple type. ‘C’ is for the mother’s level of comfort. ‘H’ is for the amount of help the mother needs to hold her infant to the breast.” (Jensen D, 1994)
*** Personal communication October 13, 2013.
Symptoms of Tongue Tie and Lip Tie in Untreated Mother/Baby Dyad
• leaking or spilling of milk from breast (or bottle)
• sucking blister(s) or callous
• noisy feeds, clicking, snapping or slurping sounds
• maternal (and infant) pain
• reflux
• colic
• low, slow weight gain, failure to thrive
• infant slides off the nipple
• chomping or chewing on the nipple
• tongue and jaw tremors (indicate fatigue)
• falls asleep at the breast before fully fed
• baby exhibits signs of stress (during feeds)
• sputters, gags, chokes
• breast refusal
• picky nurser (will only nurse in certain positions or locations)
• nipples appear flattened, blanched or creased post feed
• cracked, bruised or chafed nipples
• bleeding nipples
• pain with latch or throughout feed
• incomplete breast drainage
• plugged ducts/mastitis
• thrush or bacterial infection
• lack of hormone surge
Symptoms Associated with Tongue and Lip Tie In Children and Adults
• persistent reflux
• snoring and sleep apnea
• difficulty with speech and articulation
• dental caries (cavities)
• problems with developing orthodontia
• narrow, high palate
• migraines
• TMJ disorders
• chronic pain
• chronic sinus infections (looks like allergy)
• feeding and swallowing problems
• diastema (gap between the upper front teeth)
Local Resources for Revisions
Resolving Tongue-Tie: One Family’s Journey
References
1. Hazelbaker, A. (2010). Tongue Tie: Morphogenesis, Impact, Assessment and Treatment. Aidan and Eva Press.
2. Ricke, L. A., Baker, N. J., Madlon-Kay, D. K., & DeFor, T. (2005, January). Newborn Tongue-tie: Prevalence and Effect on Breast-Feeding. Journal of the American Board of Medicine, 18(1), 1-7.
3. Rowan-Legg, A. (2011, April 1). Canadian Paediatric Society.

4. May, H., & Chun, L. T. (1948). Congenital Ankyloglossia Associated with Glossoptosis and Palatum Fissum. Pediatrics, 2(6), 685-687.
5. Coryllos, E., Watson Genna, C., & Salloum, A. (2004, Summer). Congenital Tongue-Tie and Its Impact on Breastfeeding. Breastfeeding: Best for Baby and Mother, pp. 1-6.
6. Jensen D, W. S. (1994, January). LATCH: A Breastfeeding Charting System and Documentation Tool. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 23(1), 27-32.
7. Constantine, A., Williams, C., & A.G, S. (2011). A Systematic Review of Frenotomy for Ankyloglossia (Tongue Tie) in Breast Fed Infants. Archives of Disease in Childhood, 96(Supplement 1), A62-A63.
8. Dollberg S, B. E. (2006, September). Immediate Nipple Pain Relief After Frenotomy in Breast-Fed Infants with Ankyloglossia: A Randomized, Prospective Study. Journal of Pediatric Surgery, 41(9), 1598-600.
9. Buryk, M., Bloom, D., & Shope, T. (2011, August). Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics, 128(2), 280-288.
10. Wiessinger, D., & Miller, M. (1995, December). Breastfeeding Difficulties as a Result of Tight Lingual and Labial Frena: A Case Report. Journal of Human Lactation, 11(4), 313-316.
11. Coryllos, op. cit.
12. Kotlow, L. (2013, November). Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. Journal of Human Lactation, 29(4), 458-464.
13. Segal, L., Stephenson, R., Dawes, M., & Feldman, P. (2007, June). Prevalence, Diagnosis, and Treatment of Ankyloglossia. Canadian Family Physician, 53(6), 1027-1033.
14. Demyati, S., Ankyloglossia in Breastfeeding Infants: Stretching Exercises Post Frenotomy and the Efficacy of the Procedure. In Press.
Lee-Ann Grenier is the mother of three breastfed children. She has been helping mothers breastfeed since 2005. After a ten month battle to get treatment for her tongue-tied baby, she flew to New York to see Dr. Kotlow, a pediatric dentist specializing in lip and tongue ties. She has immersed herself in the world of tongue and lip ties and her personal experience combined with her lactation expertise and holistic approach give her a unique perspective on this complex problem.
Photos by: Picture That Photography