1) How can an ENT be part of a breastfed baby’s healthcare team?
Successful and efficient breastfeeding requires the tongue and lips to have adequate mobility (structure) to stably maintain an airtight seal between the tongue, lips, palate and nipple during the process of extracting milk, as well as proper strength, coordination, and movement (function) of these tissues. This is why optimal treatment of breastfeeding problems may require a team effort between the pediatric ENT to address the structural concerns, and a lactation consultant and/or occupational therapist to address the functional concerns.
2) Is tongue tie a fad diagnosis? Why has there been such an increase in tongue tie revision in the last decade?
Tongue ties have always been around, but the increase in emphasis on benefits of breastfeeding, and less willingness to accept the advice just to bottle feed if breastfeeding is difficult, have led to an increased exploration and awareness of tongue tie as a treatable structural concern that may improve the comfort and efficiency of feeding.
3) What is the reason for controversy about tongue tie? Why do so many healthcare providers disagree on this diagnosis?
There is a spectrum of ways in which the tongue can attach to the floor of mouth, and some tongue ties, particularly those that are anterior, are more obvious than others. The presence of a tongue tie that is less obvious is diagnosed by the feeding pattern more than the exam. Those who do not have a good understanding of the ways in which the relationship between the tongue, lip, jaw, palate and nipple can affect breast feeding, may not be willing or able to recognize a functionally significant tongue tie if it is not readily visible. The tongue-tie feeding pattern is a consequence of inability to maintain an airtight seal due to an imperfect relationship between these structures, which leads to a cascade of potential issues including shallow latch, frequent separation/repositioning, nipple pain/cracking/blistering, plugged ducts or mastitis, clicking/air swallowing which makes the baby gassy and fussy after feeds, biting or chomping behaviors (as the baby works as hard as they can to maintain the latch given the structural limitations), leading to fatiguing during feeds before obtaining adequate milk intake, resulting in frequent, inefficient cluster feeds. If these symptoms are present, it should prompt evaluation for an oral tie.
4) Do all tied babies need a frenotomy? Are there evidence-based non-surgical options to resolve this issue?
How likely the frenotomy is to be helpful for breastfeeding problems depends on how much tethering tissue can be released, relative to how restricted the movement is. If the baby has feeding issues suggestive of tongue/lip restriction, then a frenotomy is likely to be helpful. Beyond breastfeeding, the frenotomy is particularly recommended for babies with anterior tongue ties, which are more likely to affect speech articulation.
Non-surgical treatment cannot address the structural restriction of the tongue and lip. Although some babies may gain more strength and coordination, and be able to compensate better, the structural relationships do not change. Toddlers will often fall and lacerate the labial frenulum, but it’s not exactly a workable treatment plan.
5) What is the role of the palate in diagnosing tongue tie?
The tongue must have enough mobility to rise up and pin the nipple against the palate to maintain an airtight seal. If there is a high arch to the palate, then the tongue has to elevate further in order to achieve enough surface contact to achieve this seal. So it is often more the relationship between the tongue and palate, rather than the tongue itself in isolation, that determines whether the baby will have a tongue-tie feeding pattern.
6) Plenty of moms are posting photos on Internet forums asking if their babies have a tie. Can you make a diagnosis from a photo? Is there a difference between form and function when diagnosing ties?
Anterior tongue ties, where there is an obvious tethering band restricting movement of the tongue tip, can be diagnosed from a photo or examination alone, although the history is still helpful in determining how much it is affecting feeding. Less obvious tongue ties are diagnosed much more by the feeding pattern than the exam. There is not always a good correlation between form and function, because there are so many other factors beyond the visible structure of the tongue and lip which may affect the latch. My approach is that the feeding pattern (function) tells you that a tie is present, while the exam (structure) tells you how much of a target you have to improve the situation.
7) What are the long term consequences of untreated oral ties? Is there a way to predict if a tie will be problematic down the road?
Untreated oral ties can contribute to feeding problems with handling certain textures of solid foods, dental hygiene problems including cavities (imagine not being able to use your tongue tip to dislodge crumbs caught between the gum and cheek), and speech difficulties (try to talk while holding your tongue tip against the inner surface of your lower teeth, and you will hear the effects on articulation).
Again, since form and function do not always correlate, it is difficult to predict for sure how much these effects will occur if the tie is untreated. As a rule, the closer the tie is to the tip of the tongue, the more likely it is to affect speech. As the procedure is easier and better tolerated in younger infants, and it is better to prevent the speech problems than to treat later and need speech therapy to re-learn articulation, I am in favor of early treatment once a tie is identified.
8) Why do so many healthcare providers seem to miss this diagnosis? Many moms report being told the latch looks great even though they experience pain. What should they be looking for instead?
Again, this comes back to frequently poor correlation between the exam and the feeding pattern. Many providers are trained only to recognize the structurally obvious anterior ties, or may have even been taught that tongue ties do not affect breast feeding, because some babies with visible tongue ties are able to breast feed without difficulty. (This is like saying that smoking does not cause cancer, because some people smoke their entire lives and never get cancer). Recognition of the tongue tie feeding pattern (see #3) should help determine when a baby could benefit from tongue tie evaluation and/or treatment.
9) Other than oral ties, what other conditions do ENTs treat that may require special breastfeeding support?
Conditions that affect the tongue, jaw and palate, such as cleft lip and palate, Pierre Robin and other craniofacial syndromes, or tongue cysts, may make breast feeding difficult or impossible and require special support.
10) Laser vs scissor: any truth that one is better?
There are no head-to-head studies comparing them, although some providers are laser proponents because there may be less bleeding, which potentially allows the procedure to be done without a local anesthetic (numbing injection), or because it may allow for a more precise cut. On the other hand, laser is possibly more dangerous if the baby moves, certainly requires more setup time and precautions, and is a much more expensive piece of equipment. So I see no convincing evidence to prefer laser over scissors, especially for office-based procedures.
Bonus question 11! Share a memory or reason breastfeeding had a positive health impact for your family.
When my wife and I were in residency and she was on call, I would pick up my son from daycare and bring him to her to breastfeed, then pick up all the bottles she had pumped during the day so that I could feed him overnight. It was nice for them to have that bonding moment in the midst of her busy day, and put him in a better frame of mind to come home with me for the evening.
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From very early on, Dr. Erik Bauer has been fascinated with language and communication, which led him to an interest in hearing and speech, and from there to the versatile specialty of pediatric otolaryngology. Born and raised in Chicago, Dr. Erik Bauer graduated from Harvard University magna cum laude before enrolling at the University of Michigan Medical School. He went on to surgical internship and residency in Otolaryngology-Head and Neck Surgery at Washington University in St. Louis, Missouri, then stayed on for the Pediatric Otolaryngology fellowship at St. Louis Children’s Hospital. This fellowship prepared Dr. Bauer to recognize and treat a full range of pathologies including pediatric hearing loss, cochlear and BAHA implantation , chronic ear disease, congenital and acquired airway problems, foreign bodies, and sinus disease.
Dr. Bauer joined Pediatric Ear, Nose & Throat of Atlanta in September 2006. In practice, Dr. Bauer has developed a special interest in tongue and lip ties, especially as they affect infant breast feeding. He feels fortunate to have learned a lot about this previously under-recognized issue, and to have the opportunity to help many infants and moms navigate this challenging territory. Allowing babies to feed more comfortably and effectively has turned out to be one of the most rewarding aspects of his practice.
Outside practice, Dr. Bauer does his best, along with his wife Mandy, a breast radiologist, to keep his two active boys entertained, between helping with science fair projects and social studies homework, shuttling to soccer and chess tournaments, and attempting to make sense of their video games. He also enjoys travel, dining, live music, and trying to teach himself languages with varying degrees of success.
Dr. Bauer is a diplomate of the American Board of Otolaryngology, having received his board certification in June 2006, and a fellow of the American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Pediatrics. He practices at our Main Office, Alpharetta, and Marietta locations.
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