An Enhanced Model of Care for the Breastfeeding Dyad: Proficiency in Tongue and Lip Restriction Assessments
An Enhanced Model of Care for the Breastfeeding Dyad: Proficiency in Tongue and Lip Restriction Assessments
by Christine Staricka, BS, IBCLC, RLC, CCE
The privilege and responsibility of providing excellent, evidence-based care of the breastfeeding dyad in today’s culture falls on the shoulders of many: physicians, IBCLCs, nurse practitioners, registered nurses, dentists, occupational therapists, chiropractors, speech pathologists, trained volunteer breastfeeding supporters, and many who are cross-trained in those and other specialties. The evidence base grows rapidly, and staying current is a welcome challenge for most. In the field of human lactation, the knowledge base about tongue and lip function is particularly rapid in its growth and expansion, and the number of healthcare providers who are proficient or expert in handling these situations is growing daily. How can you participate?
Begin by assessing your comfort level with the topic. Which of the following applies best to you?
- I know I need to learn about this but I haven’t figured out how.
- I know a little but it’s really intimidating and I am unsure about how to apply what I know.
- I am learning more every day — this stuff is fascinating and it’s why I love working in lactation! It is helping me connect the dots on many past cases of unsuccessful breastfeeding.
- I already have my lactation niche, and I’m not interested in making changes.
Next, complete the following:
Personal Checklist for Comprehending Tongue Restriction and Lip Tie
- can identify red flags indicating to check for Tongue Restriction and Lip Tie
- can visually assess infant oral anatomy
- can digitally assess infant oral anatomy
- can functionally assess infant oral anatomy during suckle
- can identify mispatterned or dysfunctional suck/swallow/breathe rhythm
- can explain ideal tongue mobility and function
- can explain positioning and purpose of lip placement during latch
- can identify patterns of nipple trauma indicative of tongue and lip restriction
- can identify other infant indicators of structural dysfunction related to Tongue Restriction and Lip Tie
- can identify priority of revising tongue/lip function in an overall bf improvement plan for a specific dyad
- can understand why Tongue Restriction and Lip Tie are poorly understood and often dismissed
- can properly document observation and assessment of tongue function during breastfeeding to facilitate reporting to other healthcare providers
Proficiency in these standards ensures that the breastfeeding dyad is receiving care from a provider who is assessing their situation from multiple angles and with regard to the most current knowledge base. The standards directly reflect and relate back to all other functions required of the IBCLC in particular, and they strengthen the IBCLC’s ability to perform according to their Scope of Practice. If you feel you are unable to meet these objectives, it would benefit you to ally yourself closely with and begin making referrals to someone who is proficient in recognizing tongue and lip restriction issues.
Adopting standards such as these is inevitable for the IBCLC profession. Creating an expanded circle of many types of healthcare providers proficient in recognizing and addressing these issues will greatly enhance our society’s ability to properly and fully support the health of infants and their mothers through normal breastfeeding.
After completing the above inventory of current knowledge, skills, and motivation, in order to learn more about Tongue Restriction and Lip Tie, you may wish to familiarize yourself with the following rich resources. Each of these links will also connect you to additional valuable resources and published research on infant tongue and lip restriction.
www2.aap.org/breastfeeding/files/pdf/BBM-8–27%20Newsletter.pdf
nurturedchild.ca/index.php/breastfeeding/challenges/tongue-tie-and-lip-tie/
holisticibclc.blogspot.com/2014/03/tongue-tie-clips.html
*You are highly encouraged to get involved with your local breastfeeding coalition or task force to network with other breastfeeding professionals and volunteers who have experience in this area. *If you are already proficient at assessing and helping dyads experiencing these issues, make sure your local coalition or task force knows what you can offer so they can include you on their list for referrals. *
Finally, if you have doubts about how complex this issue is, please consider the following:
We know that sub-par breastpumps don’t work well. Why? Because inconsistent vacuum creates problems with seal, causes nipple damage, and provides incomplete milk removal from the breast. Guess what (who) else does that? Babies with tongue restriction and lip tie. Why do high-quality breastpumps work? They create a seal and use perfectly rhythmic and timed pressures which allow the mother’s nipple to maintain a stable teat throughout the process and which do not cause friction/nipple damage. With these factors in place, complete milk removal is accomplished and milk supply can be sustained over time. Why do babies with normal tongue function and normally flanging lips breastfeed efficiently? They create a seal and use perfectly rhythmic and timed pressures which allow the mother’s nipple to maintain a stable teat throughout the process, they do not cause friction/nipple damage, and this permits complete milk removal for long-term milk supply stability.
Similarly, we know that one of the reasons premature infants can be ineffective at feeding from the breast and ineffective at complete milk removal is that they are unable to maintain a seal due to low muscle tone; thus, retaining the mother’s nipple in the oral space is a challenge (this has been the primary reason given for experimenting with the use of nipple shields for premies!)
Why do nipple shields work? They create a constant and unchanging teat for the baby who is unable to maintain that himself. In some cases, we have historically thought this was because the mother’s nipple protractility was low (described as short, flat, or inverted nipples.) In other cases, we attributed it to baby’s inability to latch deeply enough, blaming it on latch technique or baby “needing to learn.” The theory of the learning curve is not biologically realistic. Sucking is a reflex, and babies practice it thousands of times before they are born. (Establishing a normal suck/swallow/breathe pattern does indeed involve a short learning curve; thus, milk flow during the colostral phase is slow, building gradually as the baby practices frequent suckling in the first few days of life, coordinating an efficient pattern for managing the flow of milk within days of birth.)
But what if one of the real reasons babies ever needed nipple shields to successfully breastfeed was that their tongue function was restricted, and/or their lips were unable to flange properly? What if nipple shields have been masking these problems all along? Why would a baby “need” a piece of plastic to improve their ability to breastfeed? Even if a mother has nipples which do not evert easily, shouldn’t a normal baby have the ability to hold a teat in their mouth by creating the appropriate vacuum and alternating pressures during suckling? Have we not used breast shells for many years on pregnant women with shorter nipples in a (usually successful) attempt to create a continual vacuum which improves nipple protractility prior to the baby’s birth? Shouldn’t the normal vacuum of a normal baby during breastfeeding, occurring multiple times over the course of days, also provide gradual increases in protractility and allow for effective breastfeeding?
Accounting for the experience of breastfeeding dyads who did successfully breastfeed for any amount of time in the presence of tongue and/or lip restriction, it is also possible that in some cases, an overabundance of milk or high number of milk ejection reflexes per feeding were able to partially or completely compensate for the anatomical restrictions of the baby. In light of this, there is a theory that it is perhaps better to take a “wait and see” approach to an early observation of tongue and/or lip restriction. However, it is not possible to predict the likelihood of oversupply or the number of milk ejection reflexes a mother will experience, nor the likelihood of pain or nipple trauma. The risk of the poor outcomes associated with tongue and lip restriction is high, early weaning being the most critical negative outcome.
Copyright 2014, Christine Staricka, BS, IBCLC, CCE
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