Ankyloglossia and Breastfeeding

From Santa Barbara Lactation: Anterior tongue tie.

By Glenni Lorick, IBCLC

Ankyloglossia is the medical term for tongue tie. It simply means that the little piece of tissue which attaches the tongue to the floor of the mouth is preventing the tongue from moving enough to nurse effectively. I've been a lactation consultant for nearly 20 years, and clearly recall the first time I really identified it as a problem for a mom and baby. It was 1998, and we were serving as missionaries in Lima, Peru. A friend who knew that I had worked a lot with breastfeeding moms called me to see if I could help a new mom with their mission organization. The mom was trying desperately to nurse her baby, but he just screamed and cried. He would try to nurse, but kept losing weight.

As soon as he opened his mouth, it was very clear to me that he had a classic tongue-tie. The frenulum was attached just below the tip of the tongue, and his tongue had a "heart-shaped" appearance. I had already been in touch with Nair Carrasco from CEPREN in Lima, so I called her to ask if she knew of anyone who might be willing to clip it. She referred me to an absolutely amazing pediatrician named Dra. Sicilia Bellomo. Dra. Bellomo was able to see her very quickly and clipped the baby's frenulum in her office right away. Immediately he was able to latch on and effectively nurse. He went on to gain weight very well, and his mom's sore nipples healed up nicely.

Posterior Tongue-tie

I was so excited to see such immediate results, so from that point on, I was careful to look for that kind of tongue-tie if there were a breastfeeding problem. I had learned early in my lactation career that some babies had a difficult time getting their tongues over their gum lines, and I had successfully helped numerous babies learn to suck more effectively using a suck-training technique. However, I found that some babies still had a difficult time, some moms nipples still ended up looking sort of flattened or ridged, and sometimes we still had some clicking that just wasn't normal.

Fast forward to the International Lactation Consultant Convention in 2008. For the first time I
learned about 4 different types of tongue-tie and how they can affect the breastfeeding relationship. As I began to apply this new information to my practice, I found that I was seeing more and more babies with tongue-tie issues. I worried for a while that I was "tongue-tie crazy." I quickly found that although our local ENT's would readily clip anterior or classic tongue-ties, nobody was willing to clip a posterior tongue-tie. In fact, the mother would often be told that her baby just had a "short tongue."

A tongue-tie that has just been clipped.

I began sending patients out of state when I knew that we had a posterior tongue-tie problem. At first I had to send them to Mississippi to Dr. Becky Saenz. Then the pediatric ENT practice at Vanderbilt began performing this procedure. I also discovered the importance of checking for upper lip tie at this point. The relief for our moms when they could nurse pain-free and begin making more milk was palpable!

Just a few weeks ago we had a La Leche League Gold Standard mini-conference at Calhoun College in Decatur. One of the topics there was tongue-tie. Several of my colleagues and I began trying to locate a provider who will use a laser to correct the tongue-tie and upper lip tie. Just this week I discovered that at Children's in Birmingham they will use a laser for the upper lip frenulum, but not the frenulum under the tongue. I hope that will change soon!

Appearance after a laser release of tongue-tie. 

Symptoms of tongue-tie include the following:

• Pain when nursing
• Poor milk supply (although some mothers actually end up with oversupply because their bodies are over-compensating for baby's weak suck)
• Excessive gassiness and reflux
• LONG nursing sessions (usually mothers with tongue-tied babies will complain that it takes baby 45 minutes or more to nurse.)

If you suspect that your baby is tongue-tied, you need to see a lactation consultant who has experience in identifying tongue-tie. She should also discuss post-frenotomy care with you. Dealing with your baby's tongue-tie just might be the key to preserving your breastfeeding relationship!

Yeastie Beasties

Candida A. is a nasty little fungal infection that likes to move in and take over, Unfortunately it makes breastfeeding very uncomfortable. We see lots of moms with sore nipples that can be attributed to a yeast infection. Sometimes the baby may have thrush in his mouth, but not always!

Symptoms

• New nipple pain after pain-free nursing
• Deep shooting breast pain. It may present as extremely painful let-down but will usually also occur 1/2 hour to 1 hour after nursing
• Purplish-red color on the nipples OR shiny nipples OR whitish dry looking skin on nipples
• White patches in baby's mouth that won't scrape off or an angry red bumpy diaper rash.

Diagnosis

If you're not sure whether you're dealing with thrush or not, but you have some (or all) of these symptoms, then see a lactation consultant or La Leche League leader. There is no diagnostic test. Sometimes a doctor may think everything looks normal (after all, aren't all nipples kind of pink?) However, when the mom is treated for thrush, the pain resolves! So if you have an International Board Certified Lactation  Consultant who can contact your doctor with her evaluation of your condition, that may help since IBCLC's are generally recognized as the true experts on all things related to breastfeeding.

Treatment

• Dr. Jack Newman has a terrific protocol for the treatment of Candida. We have had great success with it when it is followed to the T!  
• The first step is the APNO (All Purpose Nipple Ointment) available at local compounding pharmacies like Sterling Pharmacy, Madison Drugs or Huntsville Compounding Pharmacy. You have to have a prescription from your doctor. Ask that they compound it with Flucanazole instead of Micanazole. 
• Several local pharmacies actually compound Lactation Consultant Nipple Ointment which is not quite prescription strength but still very effective. You will find it at Sure Save Pharmacy, at County Line and 72, Madison Drugs and Sterling Pharmacy.
• Gentian Violet, is messy, but very effective. It is available locally in Huntsville at Madison Drugs, First Pharmacy or Sure Save at County Line and 72.  
• Be sure to ask your baby's pediatrician to treat your baby with either oral Nystatin or oral Diflucan (preferred) if you don't use the Gentian Violet.
• If you do end up needing Diflucan (Flucanazole) be certain that your doctor understands Dr. Newman's protocol. You need a 400 mg. loading dose and 100 mg. twice a day for at least 2 weeks or until you are symptom free for a week.
• Be sure to keep your nipples dry. Bra pads with any plastic may aggravate the problem. If you use cloth pads, change them frequently. This is a good time to switch to a pad that wicks the moisture away from the breast.
• Keep everything that comes in contact with baby's mouth clean - lots of moms actually boil pacifiers etc.
• Wash bras and pads in hot water
• If yeast persists, check out a Candida Diet.  Some mothers finally find relief when they take this step!

If you think you may have a problem with Yeastie Beasties, give us a call! We're the Yeastie Beastie Busters!