Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

What Is Appropriate Aftercare Following Tongue Tie Treatment? PART 2

Part 2
You can get up to speed with Part 1 here.

Today I'm going to assume full on aftercare works and is 100% effective, guarantees no regrowth/further frenulum problems (we know that this isn't true but let's run with best case scenario).

Does that automatically mean we should recommend parents do it?

Perhaps this sounds like a ridiculous question to some - if the aim is to remove a frenulum and aftercare guarantees success, it's a no brainer.  But for me, tongue tie treatment is not just about removing a piece of skin; it's one part of the "resolving feeding issues, big picture".

Some people have asked what "rigorous aftercare" is, so to clear that up first of all this is a pretty standard example from youtube (note this clip originally had the sound of a baby crying hard, but sound now appears to have been removed).

If you've never seen an area post frenulotomy, ie the area that parents are to rub and stretch - click here.  I think this bit is quite important.

How often seems to depend upon who you ask, from 5-7 times per day for a week, up to at every feed for 2 weeks.

Many babies hate the above process (funnily enough), so you're in effect asking a mother to cause her baby distress numerous times per day.  I meet mums simply unable to perform the aftercare, and should we be surprised?  The maternal bond is one of protector - the "mamma bear" instinct, and for me we should be supporting continued development of this connection.  Breastfeeding is an intimate bond between mother and baby, and suddenly pain/discomfort comes before or after the breast?

It's interesting many treating tongue tie will not allow/do not recommend parents to be in the room when the tie is treated, yet then expect them to cause and be resilient to such distress on a daily basis.

Others manage to follow through because they're so concerned as to what will happen if not, but it is often a very negative and emotive experience when recounted.

As a lactation consultant this bothers me greatly - nurturing the dyad is key.  Furthermore we are taught a baby's mouth is sensitive, and that babies who have had more oral interventions are already at increased risk of oral aversion (this is one reason I have issue with the claim all infants should be checked at birth for tongue tie).

La Leche League sum things up:
"Infants are incredibly oral creatures."
"The mouth is the most sensitive organ and the one over which the infant has the most control." As needs are met, a budding mastery over the environment emerges, and newborns learn that the world is a good place and they are safe. Thus, newborns' mouths provide the key first step to learning about love and trust."
"Klaus and Kennell state that "affectional ties can be easily disturbed and may be permanently altered during the immediate postpartum period."
"Because of this, a newborn's mouth and feeding behavior must be treated with the utmost respect. And while any oral intervention is less than ideal, a procedure that is roughly done, however inadvertently, qualifies as an invasion. 
The article also discusses how a very real consequence of "any type of poorly tolerated oral contact" or when the mouth has been traumatised, can be oral aversion.

Wolf and Glass state that oral-tactile hypersensitivity and aversive responses can be caused by "unpleasant oral-tactile experiences."
"Oral aversion leaves the baby in actual danger. An infant with oral aversion may not take anything into the mouth;not the breast, a pacifier, bottle nipple, spoon, or finger. Some infants also will not tolerate anything touching their lips, such as a cup. Infants with an aversion response go through a period of relative oral deprivation until the aversion subsides. This is a serious situation, and an ounce of prevention is worth far more than a pound of cure. The infant's oral aversion may also adversely affect the mother's perception of her abilities. The infant's strong negative response to oral stimuli may lead the mother to feel that her baby is rejecting her. The intricate bonding feedback process in which mother and newborn learn to recognize each other via oral, tactile, and olfactory modes is short-circuited. Klaus and Kennell note that these disruptions to mother-infant bonding may affect the mother's behavior for the first year of the infant's life, even when the infant's aversive behavior has ceased.
Read the whole article here

This knowledge is not new, here is a quote from Klauss1976:
The mouth is his avenue for food and love, communication and comfort. This sensitivity is the reason a baby is so acutely affected by anything he experiences with his mouth. If his mouth is hurt, especially before he establishes a secure breastfeeding relationship with his mother, he may respond by refusing to breastfeed. In addition to the loss of the breastfeeding relationship, the overall mother-child relationship may be disrupted, even after oral aversion ends (Klaus 1976).
This may sound dramatic, but there has been several  mothers who have reported oral aversion in their infants post "aftercare", including one older baby who required admission to hospital for nasogastric feeding.

It's also worth noting that some babies feed poorly for a few days following treatment, because the area is a
little sore when the tongue is used, babies may choose not to use the tongue fully until it has healed somewhat. "Wound disturbance" can cause continued sensitivity in the area, because you are in effect preventing healing.  I know of numerous mums who found feeding improved tremendously as soon as they abandoned the "aftercare" and the tongue stopped being sore!

Rub and stretch your own untreated lingual frenum, it's not the most comfortable thing; that is with you in control of what is happening in your mouth.  Now imagine someone doing it to you.

An adult I spoke to who had hers treated said the pain of rubbing/stretching the blister was intense - and certainly this seems to be the experience for some babies.

And we don't even have any evidence it works any better than either doing nothing, or watching and lifting the tongue once if it does start to tighten (done by practitioner rather than parent).  

I would like to close with a comment from a mum who would like to remain anonymous (due to a complaint underway):
"My baby had her tongue tie released 3 times, not because it “reattached,” but, to go deeper and her lip tie was released twice (reattached both times) and broke its own once (did not reattach). 
We handled aftercare differently each time (from not touching the revision site at all to aggressive stretching), I can say with confidence that in our case it made no difference in regards to reattachment. 
The aggressive aftercare felt wrong, but, I was scared into doing it by one of the many professionals we saw. After 14 weeks the dentist who released the ties and I both agreed that I needed to stop. It took 2 weeks to heal after I stopped touching it (and only the lip reattached, not the tongue), within 4 weeks she was actually breastfeeding better than she had since the first feed following the procedure . . . I think she had been in too much pain to feed well. 
My heart broke when my baby showed the same expression of terror that I have seen on the face of people drowning – and it did not stop when the stretches stopped, it was every time I put her in “stretching” position for nearly a year. 
Her brother ask her recently (17 months post release) if she remembered getting her tongue tie cut off and stretched, I was shocked and saddened when the terrified expression returned followed by absolute sobbing . . . she still remembers.
I deeply regret using aggressive aftercare; I wish I had listened to my heart and my baby instead of fear."