This short summary of the Tongue Tie Study Day with Alison Hazelbaker was written with breastfeeding supporters and doulas in mind. If you are a parent hoping to learn more about tongue tie, you may like to start with this article and the articles on the Analytical Armadillo blog.
It heartened me no end to see so many interested parties at yesterday’s Tongue Tie study day at The Royal Free hospital in London. There were International Board Certified Lactation Consultants, Midwives, Health Visitors, Breastfeeding Counsellors, Doulas and I’m sure others. Some are dividing tongue ties in their communities; others, like me, notice, suspect and refer to expert diagnosis.
I was half expecting disagreement but the over-riding feeling is that we should all be working together, nation-and-world wide, to expand our knowledge and the evidence base around the issue of tongue tie, its impact on breastfeeding and the division of the frenulum if necessary.
Of course, the day wasn’t all consensus, but Alison Hazelbaker, who came to share her tongue tie knowledge with us, handled disagreement with dignity and assertiveness. Her message was clear – our practice and the support we offer parents much be guided by the evidence. Where evidence does not exist yet, we need to share our experience and anecdotal evidence and support new research and lines of enquiry.
We began the day by reminding ourselves of the importance of the infant suck. Suckling at the breast with a tongue which functions correctly influences a child’s lifelong health and wellbeing through its intimate connection with:
Breathing, articulation of speech, chewing, swallowing, digestion, oral health, kissing/relationships, the ability to benefit from breastmilk, the enjoyment of nursing, sleep quality, the hormonal bond with the mother, bone and cranial alignment, hormone release, brain growth/development, development of the social nervous system to name just a few we thought of!
I, for one ,heard her say a few things that gave me ‘a-ha moments’ – for example, I’ve always known that one element we’re looking to observe in an effective latch is the bottom lip flanged outwards. She asked us to draw in our lower lip over our bottom teeth and notice where our tongues went – of course our tongues where nestled behind our bottom gums…no baby will be able to draw in and cup the breast with a tongue hidden down there! When you stick your tongue forward over your lower lip, over and out that lip curls.
I also found it interesting when she reminded us that infant sucking is a brain-stem moderated issue. Therefore, any stressor can cause a sucking issue. If there does appear to be an issue with a baby sucking in a disorganised way, she underscored the notion that we must pay attention to it, because these problems tend not to resolve on their own. To help and support the dyad, we need to determine the cause of the problem, make an assessment of the baby’s ability to suck, swallow and breathe in rhythm and whether it is a motor or sensory problem whilst keeping the baby fed! This reminds me of the golden rules for that I always remind mothers who are having breastfeeding problems: Feed the baby, protect your milk supply, find the cause, work on a solution and have patience.
Alison classifies sucking problems into 4 groups:
1. Simple/Transient oral motor disorganisation
This is when the baby may have a problem latching and suckling well due to a transient cause, such as breast engorgement.
2. Oral Motor Disorganisation
We recognise this for example when the baby takes long and frequent pauses during suckling and is often agitated at the breast. Often these babies are slightly premature, or have muscular issues from mode of birth (c-section or instrumental delivery, for example) or have a structural issue, like tongue tie. These problems may also be caused by removal from the mother before the first feed, suctioning, dummy or teat use, illness or infection, like Thrush.
Some start the feed well and get increasingly agitated as the feed goes on; others start badly and get better as the feed progresses.
So what can be the solutions? Well Biological Nurturing often helps (and I’ve definitely seen this myself!), skin to skin and keeping things calm and quiet for the baby seem to be the main keys here.
3. Sensory Based Disorganisation
Many babies with this kind of problem have structural problems: the way they were lying in the womb, resulting in twists or tension. They may have cleft lip or palate, tongue tie or have been suctioned at birth. They may also have infection, reflux or allergies.
4. Sensory Based Disfunction
This baby may not be latching at all or opening mouth over nipple but still rooting and never creating a seal around the breast. These babies cannot feel the breast in their mouths!
We then moved on to specifically talk about tongue tie. As a birth doula, I was interested in Alison’s opinion that there are some tongues which APPEAR to be tied but are not. This can be due to the tongue being pulled back into the throat due to tension in the fascia caused by something like a tight nuchal cord or locked hips (perhaps due to the baby being breech).
Where tongue tie is present, the issues for the mother can be severe – frustration, milk stasis, resentment, helplessness, lack of self-confidence, nipple compression and damage and of course, pain.
The impact it has on breastfeeding can include impaired milk transfer, shallow latch, a continuous feed cycle, compromised supply, nipple compression, breast/nipple damage, weight gain issues and premature weaning.
When assessing how the tongue functions, Alison’s Assessment Tool encourages practitioners to assess how the baby can lift his tongue, how far it can extend, how he can spread it out (she showed us a photo of a peacock fanning out its tail to help us visualise how this looks as the tongue gets thinner at the edges as it prepares to latch), how the tongue creates a ‘cup’ to ‘scoop’ up the breast tissue and peristalsis (or how the tongue makes progressive contractions in a wave-like motion).
She also describes what she calls ‘snap back’ – something breastfeeding supporters often call ‘clicking’ at the breast. The tongue tries to extend forward but a tight lingual frenulum ‘snaps’ the tongue back – every few sucks or even every suck and makes a characteristic ‘clicking’ noise.
I have another interesting titbit in my notes: for babies whose mothers have had narcotics during the birth, apparently large amounts of vitamin C in the mother’s milk will help break down these effects in the baby. When asked how much Vit C the mother should take, she said “to bowel tolerance” – in other words, if she gets diarrhea she should take a little less! Apparently, she uses this technique a lot in her practice – as her local hospital has a 99% epidural rate!
She also threw in a fact I didn’t know about US breastfeeding rates – that the figure of 75% breastfeeding we are familiar with is actually 3/4 of mothers expressing the intention to breastfeed. By one week, breastfeeding is down to 5% – yes 5%!
A lot of what Alison had to say would be seen as controversial in the UK, especially outside the breastfeeding support community. When she told us she is working with an increasing number of mothers with over supply issues because they are taking their placenta pills – many of the NHS workers in the room were surprised, confused or a little revolted! Of course, I wasn’t surprised at all as this practice is well known in the doula world!
Personally I’ve come away with loads of food for thought and some techniques I can begin to experiment with when supporting mothers and babies. And if Alison’s work can help tongue tie dividers around the world standardise their practice, she will have done the world a favour!
My only regret is that her book was on sale for the discounted price of ‘only’ £45. Shame. Maybe Santa will be be kind to me this year…