Upper Lip Tie Treatment in Infants - Informed Choice, Risks & Efficacy

In all the noise about lip ties, is there risk of misdiagnosis?  And are parents really making an informed decision?

We acknowledge there are risks to most things - from getting out of bed, to taking a paracetamol or treating a tongue tie. We typically weigh up what the benefits may be, what risks are involved and we (hopefully) get the chance to make an informed choice. 

When it comes to treating tongue ties, we have (thanks to diligent practitioners and researchers) over 20 years of studies under our belts.  NICE have explored the research, discussed this with experts in the field and drafted guidelines.  These tell us (among other things) that frenulotomy (treatment for tongue tie), is a procedure of minimal risk for most healthy neonates.  

Risks & Benefits need examining both short and long-term.

Short-term risks of tongue tie treatment would include for example infection in the wound site, baby bleeding more heavily then expected following the procedure or perhaps later in the day after the event.  Long-term risk may include say keloid scarring at the wound site, if you're genetically predisposed.

In short - aside from discussing the potential benefits and effectiveness of tongue tie treatment, we've also established what the potential knock on associated effects may be, and we can examine rates to discuss risks.

Recently some seem to have made the leap of logic to assume it's also therefore safe and beneficial to release other oral frena babies have too - if it is considered "tied".  Tied means that the frenulum is shorter, thicker or placed abnormally compared to a typical frenulum.

So here are the things I think we need to know:

1)  What is a normal infant upper lip frenulum & what is its function?
2)  How do we diagnose an abnormal infant upper lip frenulum?
3)  What problems can an abnormal upper lip frenulum cause?
4)  When & how should we treat it?
5)  What are the benefits, risks and outcomes of treatment?

Language that features below:

Frenulum/Frenum/Frena/Frenula:  The "string" that attaches to the top lip or tongue (or bottom lip/ cheeks)
Maxillary/ labial fraenum: Upper lip frenulum
Diastema:  Gap in the front teeth

Babies should have an upper lip frenum that attaches to the gum or palate.  Seriously I want to drive round with a loudspeaker on the top of my car simply repeating this phrase.

These pictures below show you normal infant placement.  Infant upper lip frena are supposed to be "low sitting".

SOME EXAMPLES OF NORMAL UPPER LIPS.

These babies had no feeding problems, reflux, wind or any other issues.

The confusion as to why everyone at the moment thinks these are ties, is I believe is explained well here.  It's because they can see the low sitting frenum.  As I discuss in this piece 93.4% of babies do, as the frenum attaches to the gum or palate.

Why?

People are concerned their child has a gap in their teeth, and yet this is exactly as it should be.  

Here we can see a normal ADULT MOUTH:

image pocketdentistry.com

In contrast let's look at the ideal INFANT MOUTH:

Image Glenn Carty Orthodontics 

See how different it looks?  And note the low sitting frenulum. Glenn Carty Orthodontist tells us:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth"

The frenulum moves up the gum-line in the first 10 years of life, until it sits in the adult position. The gap closes as second teeth align - as per the photo below.

Same child: shows normal frenulum regression and appropriate dental development during childhood

This spacing also makes teeth easier to keep clean.

A 2011 paper states:

The superior labial frenum is triangular in shape and attaches the lip to the alveolar mucosa and/or gingiva. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration. [1] Taylor has observed that a midline diastema is normal in about 98% children between six and seven years of age, but the incidence decreases to only 7% in persons 12-18 yrs old. [2] But in some instances, the infantile arrangement is retained.

So normally they regress but sometimes this doesn't happen and the frenulum remains lower on the gum. Sometimes a gap (or a diastema) can be seen.  A very famous example of this being of course, Madonna:

Diastema is heavily prevalent in some cultures - for example Nigeria has incredibly high rates.  In turn it's considered extremely attractive and surgery exists to create the gap.  In contrast it's very uncommon in other areas such as china.  

What criteria are we using to diagnose tied versus normal?  How was this established and is it reliable?

When it comes to tongues we look at what normal presentation and function is, and we establish (or we should) how far away from that each baby is.

When it comes to lips, there seems to be a lot of confusion and inaccurate information shared.

The advice many are given is to push the lip back and see if there is blanching, that if it pulls tight and there is a "notch" this will create a gap - and as such removing the frenulum prevents the risk of a diastema.  

But is this true?

It's not just as simple as the skin you can see...

Initially it was assumed the frenulum caused the gap, it seems obvious - we can see a thick meaty piece of skin between the teeth, thus it was assumed that the frenulum not regressing at the expected age, was the root cause of a persistent gap into adulthood.   Interestingly as researchers began exploring further, they discovered it wasn't quite so clear cut.

Some concluded that when the normal regression of the frenulum didn't happen, it wasn't the frenulum causing the gap, but the gap that resulted in the frenulum remaining low.   Another study found a cleft in the bone was associated with some gaps, and others found removing the frenulum did not alone, appear to make a difference to the gap compared to those that remained untreated;10 years later there was no identifiable differences between he two groups.   Some theorised certain types of frenulum could cause a gap, but researchers decided ultimately this wasn't so.  They noted gaps with frenula and frenula without gaps.  They also noted wide variance in the normal frenulum in terms of visual presentation - thickness and so on.

A 2012 review outlines the evidence concerning the cause of a persistent gap, and the possibility of closing it by removing the frenulum:

"At the beginning it was thought that the labial fraenum interfered with the closure of the midline diastema. This belief resulted in misdiagnosis and unnecessary surgical intervention of the fraenum 13,14.

They then outline all the papers and their findings - I've linked below if you want to look in more detail.

They continue:

"Since there is no evidence concerning the fact that the maxillary labial fraenum is the main causative factor for a midline diastema, some orthodontists propose the following therapeutic methodology 37,45: Initially, it is necessary for the dentist to make a diagnostic trial, in order to find out whether the fraenum is implicated in the pathogenecity of the diastema. 

1. Positive “blanch test” of the incisal papilla, when pulling the lips forward. By pulling the upper lip and exerting pressure on the fraenum, if there is a blanching, it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion; 

 It is important to emphasize the fact that frenectomy has clinical validity only after the eruption of all 6 permanent teeth if it failed to close the diastema, and then only in conjunction with orthodontic treatment. So after the eruption of all 6 permanent teeth, 9,14,16,20,34,36,37 orthodontic appliances are used to close the diastema. A frenectomy is carried out, so as the scar tissue will hold the teeth together 16,20,27,33,37,39,48. During the primary dentition phase, surgical intervention of the labial fraenum is not recommended7."

This clarifies blanch tests etc are a tool that may be useful as a diagnostic tool once 6 permanent teeth are in.  They weren't designed for, nor tested in terms of accuracy or reliability, in babies and young infants who are expected to have a low sitting frenulum.

The above paper continues to explain the different opinions held by dentists and oral surgeons.

Surgeons tend to prefer removing the frenum and following immediately with orthodontics (so they have good, clear access to the tissue), some dentists agree; other dentists feel a better result is obtained by pushing the teeth together first with orthodontics, and then removing the frenulum, or only removing it if the teeth "drift" back apart again - so any resulting scar tissue holds the teeth together. The last group don't feel there are any benefits to frenectomy.

What all seem to agree on, is the risk of removing tissue from the gum when there are no teeth to push together, suggesting that this may at times result in scar tissue on the gum that makes it impossible to completely close the gap. They continue:

"In the orthodontic community there is unanimity on this issue 37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema 9,16"

"Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected 9,2 "

So the "unanimous" view is that 6 permanent teeth should be in before the frenulum is removed - ie this is the optimal time for removal along with orthodontics.

What are the risks and benefits therefore to removing it earlier than this, or before the top teeth have even appeared?

I couldn't turn up any studies exploring this.

Here we can see the progression of teeth following lip tie removal in a child who should still have a low sitting frenum, as they do in the first picture:

We can see the child has typical spacing in the first picture, similar to that we saw above.  These pictures have been shared as evidence removing a tie removes a gap - and in this instance it seems clear that removal indeed rapidly resulted in adult dentition and lack of spacing between the teeth.

However we know already this is what happens in the majority of people with time, so what benefits and risks of hastening this process?  How will this impact on adult teeth spacing long-term?  

Interestingly we can note the top lip still looks thin and pinched.  There also appears to be slight yellowing between the teeth on the last photo, although I'm not sure whether that is just this particular photo and the light.

One mum has expressed concern her child's top teeth have come in crossed following his upper tie removal (he had no teeth at the time of the procedure):

Will this self correct as other teeth align and a correctly functioning tongue exerts appropriate pressure? Is this linked with premature removal of the frenulum and something parents need to factor their decision making process?

Without studies we're working from anecdote, which is non-transparent and unreliable.

Mr Sheehan (ENT) Manchester, proposes that as part of the role of the upper lip frenum is to stabilise the top lip, removal of the upper lip tie may also allow over extension when smiling in some people, perhaps those with naturally longer gums.

Helen Marshall (IBCLC) shares similar concerns:

"I had my upper tie removed at around 10 or 11 years old because of a gap in my teeth.  My lip pulls higher up and exposes more of the gum when smiling, and which started post-revision. You can see where it attached to my lip and gum, and my smile would not be the same if it hadn't been cut - --my lips wouldn't be able to ride up and uncover my gums"

Assessing an infant for lip tie.

Even if we were to establish the blanch test above may accurately determine the lip is tight, does that mean we can assume the cause is the length of the frenulum?  We talk about assessing function not appearance, but even this isn't straightforward.

Tongue ties can cause tension through the lips that makes them tight:

The above baby had incredible tension pulled through his mouth by his tongue tie. When we "flipped his lip", it didn't flip at all - instead it blanched and felt incredibly tight.   His parents commented they didn't know where he got his mouth shape as they both had full, plump lips. After the tongue was released and baby turned to his parents, the first thing they both noted was the phenomenal difference in his lips and mouth shape.

The little girl below didn't just have her lips bound down by her tongue tie, her whole chin and jaw was pulled back too.  We saw her chin move forward when feeding immediately post revision, and function was completely changed.

Something as simple as being hungry can cause a baby to tighten their lips. When we assess hungry infants post feed and note tightness, this often presents different when baby is full and relaxed.

Therefore in order to accurately hope to assess function, don't we need to release the tongue first?

What people also often don't understand is that if baby is in a shallow latch on the breast or bottle, the top lip can sometimes curl under when feeding, appearing as though it can't do anything but - to try and compensate.  

Image Milk Matters - tongue tied baby compensation

This is extremely common in tongue tied babies as this post demonstrates. However as anyone who fully understands the mechanics of milk transfer and has observed thousands of dyads will know - it is not desirable for the top lip to flange outwards when feeding either -  it should be neutral as the post above highlights (and the image below shows), flange suggests anything from slightly shallower to very shallow latch.

Below is the same breastfed baby as above with the curled under top lip, immediately after tongue tie release:

Image Milk Matters 

If we just treat the lip, do we sometimes just allow for more or better compensation?

"The added ability to fully flange the top lip will allow a baby to compensate for continued poor positioning or tongue function issues. But of course this is treating a symptom and not the underlying cause. Improving positioning, tongue –tie division, tongue exercises and suck training to promote effective tongue mobility would be more appropriate. "(Oakley 2016)"

And of course, again without studies - what about possible negative consequences? 

One mum on Facebook explained how her journey developed.

Her son had a tongue tie, he had learnt to feed gripping extra hard with his top lip - just like the babies above.  However they were unable to find anyone who would release the tongue and so only the lip was treated.

Following this, he was no longer able to adequately grip with the excess force he had been doing to compensate, and was no longer able to breastfeed.

This proved an extremely traumatic time for all involved and mum feels more studies are needed.

Lack of Guidance

We have no NICE guidance pertaining to lip tie, nor recommendations from any other recognised authority.

Nobody has (in any official capacity), questioned whether the procedure is beneficial to infant feeding, or for the prevention of diastema; whether it has the desired outcome or when the best time for treatment is. Whether the area needs numbing and if pain relief afterwards is required.  Whether both tongue and lip should be released together, given not only the change in presentation post tongue tie release, but because of the difficult or discomfort baby may have feeding with two sore areas in the mouth.

At the moment different practitioners use different lasers (some use heat to cauterise the area, others use intense water jets to vapourise tissue).  This paper discusses that scarring can occur, and describes a surgical technique combining the frenectomy with a "laterally positioned pedicle graft", to give the best aesthetically pleasing response- are infant frenectomies different?  Which method is safest, most effective?

Best practice should surely be based on best for baby, not "we've travelled a long way so may as well just do both..."

Perhaps most importantly,  nobody seems to have explored whether there could be any unintended risks associated with the procedure.  Some argue those who treat would have observed problems should that be the case - however long-term risks can be very difficult to identify in practice rather than research, especially if we're approaching with a bias, and we're not clarifying what "normal" is.

Abnormal lip frena of course exist, and whilst those promoting removal of the ULT claim we in the UK are "behind" and "ignorant" when it comes to diagnosis and treatment, I'm not entirely convinced.

I've found when there is truly abnormal presentation (such as a excessively wide, tight frena that have bound down the lip) the NHS have treated.

Interestingly they tend to release the tissue up where it is attached to the lip, not touching tissue on the gum margin.  In the private sector I have seen both methods used, suggesting we also need assessment and standardisation of this area too. 

However, when presented with normal low sitting frena being called a tie, the NHS (as evidence supports), recommend reassessing again age 8-10 and treating if appropriate.

This is why controlled studies are key.

We need to start asking questions, so that we continue to push for studies and evidence to support guidance for practice.  Simply accepting the word of those performing the procedure is not enough.

Some charge as much as £500 for a consult and release lasting around 15 minutes, enabling them to see 4 per hour.  A 7 hour day that's potentially £14,000, or £70k per week, 280k per month, and so on. Further charges may be applied for feeding support, which many parents report is often needed. 

That's of course not to say there aren't situations where removal may be beneficial - lack of evidence isn't lack of efficacy, but we need to know more!

Parents need facts on which to base a decision, as do those supporting infant feeding.

MUST READ LIP TIE LITERATURE:
The Maxillary Labial Fraenum -A Controversy of Oral Surgeons vs. Orthodontists

The midline diastema: a reviewof its etiology and treatment 

Upper Lip Tie – 4 Facts About Breastfeeding And Upper Lip Ties

Breastfeeding - Certainties V Risks

When discussing the implications of not receiving human milk, it never ceases to amaze me how many rush to answer with details of how they didn't breastfeed - yet them/their child doesn't have XYZ (whatever is being discussed); thus they can conclude the study/discussion in question is "rubbish".

Generally no other supporting evidence follows, the conclusion is reached purely based up on their personal experience.

This is quite typical of human nature I think.  We base our "norms" on what we see around us, we are less likely to believe negative implications of something unless we see/experience it first hand.  Furthermore it's very difficult for a mother to begin to contemplate negative implications that may relate to her own child - believing it's rubbish is an inherently more comfortable position.

But it doesn't take a genius to establish this logic is fatally flawed.  If you don't know anyone who smokes and has died of lung cancer, is it accurate to conclude smoking doesn't cause harm?  Many of us were raised without booster seats in the car for older toddlers/children - I didn't come to harm in a crash therefore does that mean nobody else has?  That we can abandon safety in the fact of anecdotal evidence?

The reality is that when discussing infant feeding, we are talking risks not certainties.

Risk

Noun: The possibility of suffering harm or loss; danger.

Cer·tain·ty
Noun: Firm conviction that something is the case.

Saying not breastfeeding is linked with increased risk of obesity or SIDS or diabetes does not, I repeat does not, thrice I will say does not mean every non breastfed infant will turn out fat, suffer SIDS or end up diabetic.  Nor does it mean no breastfed baby will become overweight, not become a victim of SIDS or develop diabetes.

What it does mean is if you take two groups - one breastfed and one not, those not breastfed would be more likely or have a higher chance of developing XYZ.  Sometimes this risk is slight, other times more significant - but it remains a risk not a given.

If we can maintain this perspective, perhaps it may lead to more progressive dialogue whereby instead of debate over whether one has/hasn't had experience something that tallies with what evidence is telling us - we could instead move on to discuss how to reduce whatever risk is in question.

5 Reasons Infant Formula Isn't The Lazy Option

I seem to have come across loads of comments recently suggesting formula is an easy/lazy option, both from parents using formula and those who don't. And I have to be honest and say it really baffles me.

Sure I can see how in the very early days if a mum has breastfeeding problems, is getting passive support and has problems nobody can seem to resolve - formula is easier in comparison.  Pain stops, a baby who hasn't been feeding well is likely to look more settled when given a bottle, anyone can make up the bottles and feed the baby, mum can sleep!

But let's be honest, this time is but fleeting.  Relatives who may flock to see the new arrival, soon head home.  Partners return back to work, often far less agreeable to making and delivering night feeds when they have a full day of work ahead compared to mum who is at home and can sleep when baby does.  For many, especially if family and friends work - by 3-4 weeks postpartum the days (and often the nights) are mum's alone; yet baby will need milk feeds for a further 11 months +.

Take out these early few weeks and directly compare breast and bottle feeding (in this sense to mean formula), and let's compare how easy it is:

1.  Making A Feed
Bottle:  
1. Clean the surface thoroughly on which to prepare the feed  
2. Wash hands with soap and water and then dry.
3. Boil fresh tap water in a kettle.  Alternatively bottled water that is suitable for infants can be used for making up feeds and should be boiled in the same way as tap water.   
4.  Important:  Allow the boiled water to cool to no less than 70º C.  This means in practice using water that has been left covered, for less than 30 minutes after boiling.
5. Pour the amount of boiled water required into the sterilised bottle.
6. Add the exact amount of formula as instructed on the label. Adding more or less powder than instructed could make the baby ill.
7. Re-assemble the bottle following manufacturer’s instructions.
8. Shake the bottle well to mix the contents.
9. Cool quickly to feeding temperature by holding under a running tap, or placing in a container of cold water.
10. Check the temperature by shaking a few drops onto the inside of your wrist – it should feel lukewarm, not hot. 
11. Discard any feed that has not been used within two hours (Department of Health & Food Standards Agency).  Note the Infant Feeding Council recommend feeds are discarded within 1 hour.

Breast: 
1.  Lift/open shirt/top
2.  Unclip Bra

2.  Night Feeds
Bottle:
1. Get up and go to kitchen
2. Follow guidance as above
3. Try and pacify baby whilst waiting for feed to be ready
4. Go back to bed
5. Sit up and feed baby
6. Wind baby
7. Settle baby back to sleep

Breast:
1.  Roll over before baby fully awakens
Optional stage 2: open nightclothes if wearing

3.  Out And About
Bottle:
Option 1 - Ready to use liquid feeds are sterile and are the safest option.  However, they are a more expensive option and therefore may not suit all parents.

Option 2 - Take & make as required, next safest from microbial contamination/infection point of view
1.  Put boiling water in a sealed vacuum flask and use this to make up fresh formula milk when needed. 
2.  Pack large bag with powder, pre boiled water in a flask & pre sterilised bottles.
2.  Find somewhere to mix and serve.

Note:  Ensure you've packed sufficient bottles/powder/water for the duration of your outing, plus extra in case of travel delays/unforeseen circumstances.  Care should be taken to avoid scalding when making up the feed.

Option 3 - Preparing powdered feeds for later use.  It is the length of time for which the reconstituted formula is stored that increases the risk of bacterial growth. Reducing the storage time will therefore reduce the risk.  

1. Prepare feeds in separate bottles, not in one large container (e.g. a jug)
2.  Follows steps above ‘Making a feed".
3.  Store the feed in the fridge at below 5º C. Prepared bottles are best kept in the back of the fridge and not in the door. 
4.  The temperature of the fridge should be checked regularly.   A fridge that is opened frequently may need to be set at a lower temperature to ensure that it does not rise above 5 ºC during times of frequent access.  The thermostat in older fridges without temperature settings may need to be adjusted to ensure that the temperature is below 5º C. 
5. The risk of infection to a baby will be lower if the feed is only stored for a short time. Feeds should never be stored for longer than 24 hours and this length of time is no longer considered ideal especially for young babies.  

Because of the potential for growth of harmful bacteria during transport, feeds should first be cooled in a fridge (below 5º C) and then transported.

1. Prepare feed(s) and place in the fridge as outlined in section ‘preparing feeds for use later’.
2. Ensure feed has been in the fridge for at least one hour before transporting.
3. Only remove feed from the fridge immediately before transporting.
4. Transport feeds in a cool bag containing a frozen ice brick.
5. Feeds transported in a cool bag should be used within 4 hours.
6. Re-warm at the destination as in section ‘Re-warming stored feeds’.
7. Alternatively if you reach the destination within 4 hours, feeds transported in a cool bag can be placed in a fridge and kept for up to a maximum of 24 hours from the time of preparation - this is not ideal as the risk of illness increases the longer it is stored.

Rewarming stored feeds:
1.  Re-warm using a bottle warmer, or by placing in a container of warm water (if out and about you also need to find somewhere to access this if not carried).
2.  Microwaves should never be used for re-warming a feed.
3.  Never leave a feed warming for more than 15 minutes.
4.  Shake the bottle to ensure the feed has heated evenly.
5. Check the feeding temperature by shaking a few drops onto the inside of the wrist - it should be lukewarm, not hot.

Breast:
1. Lift/open shirt/top
2.  Unclip Bra

4.  Cleaning
Bottle:

1. Wash hands thoroughly before cleaning and sterilising feeding equipment
2. Wash feeding and preparation equipment thoroughly in hot soapy water
3. Bottle and teat brushes should be used to scrub inside and outside of bottles and teats to ensure that all remaining feed is removed
4. After washing feeding equipment rinse it thoroughly under the tap
5. If using a commercial steriliser, follow manufacturer’s instructions.  If your bottles are suitable for sterilising by boiling: fill a large pan with water and completely submerge all feeding equipment, ensuring there are no air bubbles trapped; cover the pan and boil for at least 10 minutes, making sure the pan does not boil dry.
6. Keep the pan covered until equipment is needed.
7. Wash hands thoroughly and clean the surface around the steriliser before removing equipment.
8. It is best to remove the bottles just before they are used. If the bottles are not being used immediately, they should be fully assembled with the teat and lid in place to prevent the inside of the sterilised bottle and the inside and outside of the teat from being contaminated.

Breast:
Shower/Bath/Wash as desired.

5.  If Baby Needs To Be Left With Friend Or Relative
Bottle:
1. Give baby, formula powder, equipment and full guidelines above about preparing formula safely.
2.  Ensure caregiver understands failure to make appropriately could lead to serious illness for baby.

Breast:
1.  Express and give fresh breastmilk or frozen previously expressed and relevant feeding equipment (bottle, cup or syringe) with guidance that fresh breastmilk is fine at room temperature for 6 hours, frozen can be stored in the fridge until needed and gently warmed in warm water before use (or is fine served room temp)
2.  Reassure caregiver that breastmilk is antimicrobial and antibacterial and doesn't need high heating to kill bacteria.


Now really - still think formula is a lazy option?


References:
http://www.food.gov.uk
The Breastfeeding Network: Expressing & Storing Breastmilk

Yoomi Feeding System - Genius or Germ Fest?

Discussing "feeding systems" isn't typical fodder on this blog, but the reason I decided to cover it now will become clearer when I post the next entry.  I was tempted to roll the two together, but I thought discussion of this product deserved its own entry, in case you get asked about it...

So for those who haven't heard of Yoomi, it is according to the manufacturers a bottle and warmer in one.   You pop in the milk, add a warmer,  press the button and bingo - 60 seconds later it's ready to drink.  Sounds genius right? 

Don't get me wrong I can totally understand the demand and market for something such as this.  Formula feeding is a lot of faffing about; there's a shed load of work involved washing, sterilising and making up each meal as required - something that can make the middle of the night feeds quicker has to be a winner right?  Who wants to be stood in the kitchen at 3am with a crying baby waiting for its bottle to be made up and warmed?

I was therefore a bit confused to read the Yoomi only heats the bottle to 32 - 34 degrees.  In fact what Yoomi actually say is:

"Your yoomi warmer gives you perfect breast-milk temperature feed in 60 seconds."

And yes the "breastmilk temperature" is emboldened on their website, nice marketing Yoomi!

But you can't make powdered formula at 34 degrees....

  

I assumed I was missing something obvious, after all Yoomi's homepage boasts a "Mother & Baby Best Buy" badge (Best Product for Bottle Feeding, twice) and the following comment from a Health Visitor:

"Congratulations on a very clever product. I have been a health visitor for the past 15 years and this is exactly what is needed"

Ann Guindi, Health Visitor and mum of 4

Which is interesting given the NMC state:

"You must ensure that your registration status is not used in the promotion of commercial products or services"


Whoops looks like someone forgot to read their code of ethics.

A click later I discovered Yoomi is literally just a bottle warmer and a bottle in one, it doesn't do anything more exciting - and how many people do you know bought a bottle warmer and never used it?  

"Perfect to warm expressed breast milk (ebm) and pre-mixed formula. We always follow DOH guidelines on how to prepare and store feeds."

Interesting choice of language. Pre mixed isn't the same as "ready to use" (RTU) is it?  As Yoomi refer to RTU further down the page.    Yet the DOH guidelines Yoomi themselves link to state:

"To reduce the risk of infection, make up each feed as your baby needs it, using boiled water at a temperature of 70oC or above. Water at this temperature will kill any harmful bacteria that may be present."

So if Yoomi always follow DOH guidelines about preparing feeds as required - why would one need this "perfect" item to warm it back up?

Under FAQ Yoomi then state:

"How can I prepare and store feeds in advance safely?"

If ready to use formula feed is not practical, the FSA suggest you prepare feeds in separate bottles and store in the back of the fridge at below 5°C. Feeds should never be stored for longer than 24 hours. The feed can then be warmed gently and safely using the yoomi bottle and warmer.

So if you can't follow the guidelines, shrug and hurrah for the Yoomi?

For the system you need a Yoomi bottle, A Yoomi teat and a Yoomi warmer - you can remove the warmer and use like a normal bottle.  However you have to "charge" the warmers before use, and then again before each subsequent use.  You can do this by putting in a pan or steam steriliser for 25 minutes, or using the new "pod" that can go in the microwave for 2 mins - however you then need to wait 75 minutes for it to cool down... 


Yoomi state it is cost effective as it can be recharged 150 times - but as young babies take 8-12 feeds per day, if we consider an average of 10, this gives 15 days use.  Each warmer costs £16, which equates to £32 per 30 days for "warming".   Of course having to charge the warmer, wait two hours before use etc before each feed isn't really practical - so you really need multiple bottles and warmers if you want to consistently use the system, then factor in time at the end of the day to prepare them all for the next.


Cost effective compared to what?


Eg the "Momma By Tomy" bottle warmer costs £29.99, takes 1 min 45 seconds and doesn't need replacing monthly..  OK so it isn't portable, but if out and about with baby - the guidance is to use a flask and make up feeds as required.  Breastmilk or RTU is just fine either chilled or at room temp - and so is formula, if there has been some reason it is essential to premake.

Lane Franche, pediatrician says:

"Warming baby formula is something we do out of habit rather than for any medical or safety reason.  Warming a bottle can be a real hassle, especially if you're traveling. Instead, take away the chill by holding the bottle of formula in your hands for a few minutes. Chances are your baby will never notice the difference."

Bet Yoomi aren't keen on that plan...

On "Circle of Moms", some agree:

"My children are 6 and 4 and neither one would take a bottle from day one unless it was straight from the fridge."

and

"Neither of my daughters care if it is warmed up or not. Both have had it ice cold straight out of the fridge if they are really hungry and I haven't had a chance to warm it, but they prefer it room temperature or cool."

and

"my daughter HATED her milk warmed and wouldn't drink it"

So before splashing out it may be worth seeing whether you can avoid the expense and hassle heating altogether!

A bit more digging revealed that "Yoomi's midwife" is not a registered midwife, but a retired one - I bet you will be shocked by this, no really try not to fall off your chair:

"Many of my new mums and dads who are out and about get in rather a panic about how to transport the milk, how to warm it up, how to store it and so on. A bottle like the yoomi, which enables one to be self-sufficient - heating it easily and rapidly in under a minute - is all you need."  Clare Byam-Cook, Former Nurse and Midwife, Independent Breast Feeding Counsellor and Author

Mums get in a panic about carrying a bottle of breastmilk or a carton of ready made formula and either taking the lid off or cutting the top off and tipping it out before use?  Yikes best fasten seatbelts for toddlerhood!  Isn't transporting, storing it "and so on" identical whichever bottle you use for your breastmilk or ready to use formula?  It's purely the ability to heat to body temp that makes this product any different?


I can understand mums getting in a panic about travelling with powdered formula, when the guidelines suggest each bottle should be made as required with water that is at least 70 degrees.  I see mums juggling containers of powder, flasks of water sitting in insulated pockets to try and maintain temperature etc - but this product really the ideal for addressing that dilemma is it?  Well unless you ignore guidelines and make bottles in advance.


Given we are still in a position of some mums using microwaves to nuke bottles of powder mixed with cold water, it concerns me that mums could be under the misconception a system like this is as safe as mixing when required - that carrying a flask of water and pressing the Yoomi button are comparable:

From Netmums:

"I make up 2 feeds in advance, put them in the fridge and warm them up in the yoomi bottle - takes 60 seconds .. just press the button, wait and feed. Has made night time feeding much easier! great for out and about too - saves carrying a flask of hot water"

From Mumstreet:

"The Best Bits: Warms the bottle in 60 seconds so you don’t need to worry about being near a bottle warmer or carrying boiling water around in a flask."

 Something else that really grates, and what probably provoked this piece -  is the constant associations with breastfeeding.  Why can the bottle not just be marketed upon it's own merits, why do manufacturers need to make constant links with breastfeeding (that's rhetorical by the way, clearly I know why £$) but ethically it sucks.

• "Makes combining breast and bottle easier" - How? How does a bottle that replaces a bowl of hot water make combining feeds easier
• "Breast-like anti-colic teat" - Huh?  My breasts aren't silicone?  Furthermore nipples are pulled back towards the point the hard/soft palate meet, this short silicone teat wont and will land much further in the mouth.  Something which can encourage "humping" of the posterior tongue - a technique that doesn't work at the breast.  Medela attempt to combat this with their Calma bottle and a longer teat and you can see how short the Yoomi is in comparison.  Are there clinical trials showing the yoomi is "anti colic"? 
• " Yoomi bottles have a clever breast-like anti-colic teat for easy latch on, perfect for bottle only, combination feeding or transitioning your baby from breast to bottle." (on their site the "easy latch on" and "transitioning from breast to bottle are bolded".)
• "Yoomi warms baby's feed to the natural temperature of breast milk at the touch of a button"
• " We both feel that yoomi made the transition from breast to bottle possible."

And from the "Read what parents say" section (ie posted by Yoomi as "testimonials")

• " Harry was a breastfed baby so it was a real challenge to find a bottle that he would take" Lots of breastfed babies take bottles no problem, so why the implication that it was challenging because he was breastfed - I see lots of bottle feeding parents who have a challenge trying to find a bottle baby can use well!
• "Conrad had his first bottle feed last night and my wife, Natalie was a bit upset… he was quite happy to take yoomi without any problem whatsoever! However, I’m sure she will appreciate the extra sleep now I can do the late night feeds"- cos that's what every good dad  does right?  Never mind Natalie was upset,  he's sure she will appreciate the sleep...
• "Although my daughter is only 7 weeks old, I wish I would have had my Yoomi from day one. This bottle is a must for breastfeeding moms on the go!" - a bottle is a must for a breastfeeding mum?  Er nope, breasts are pretty perfect for mums on the go, no heating elements required ;)  Plus advice isn't to introduce a bottle from day one if you are establishing breast feeding.
• "I only introduced Harry to a bottle around 6 months and I was concerned that he would reject the bottle as he was so used to being breastfed. Thankfully he took to the yoomi straight away and I have been able to combine both bottle and breastfeeding really successfully. I find the yoomi especially handy during the day when I’m out and about " - Yes SO much handier than putting baby to the breast - or are we supposed to be re-emphasising the message it's good to breastfeeding at home but use a handy bottle in public?
• The transition from breast feeding to a bottle can be a difficult one, but the clever design of these bottles solves many of the common problems.  But does it?  Really?  Or did you just buy the marketing?

Those familiar with the marketing of breastmilk substitutes will recognise much of the above feels familiar - the baby market is so lucrative, but what do you think?  Another flash in the pan trend or a practical product?

Should all newborns be checked for tongue tie & treated ASAP?

Updated: 21.1.17

Recently there has been lots of talk about tongue and lip ties - I've been known to blog about them myself a time or three.  But recently tongue tie talk has taken a turn that has left me feeling a little uncomfortable - a call for every baby to be checked at birth for tongue tie, and divided if identified.

Logically this appears to make sense - snip them all and things will be well with the world, but I fear in practice the reality is not so.  For me there are really important issues that we could focus on first, should we want to promote a change in the current standard of care offered.  This means starting at the beginning, not halfway up the ladder.

First, many many mums with nipple pain/cracking/bleeding/feeding problems are not even getting this flagged as a problem - no really.

They are told positioning and attachment look great, perhaps their nipples are just more sensitive, their hair is too fair, baby has a "hoover suck"or it too big/small/hungry/lazy, it takes time for them to learn how to feed well.  After all, not all women can breastfeed and don't feel bad if you're one of those that can't.  The passive support I wrote about 5 years ago is still alive and well.  In some areas, breastfeeding support still means grabbing mum's boob, baby's head and plugging the two together...

Secondly. the reality of our current care system means that many midwives are already so stretched that there are ongoing campaigns and petitions about the continuity of care women receive, quality of antenatal information, how many midwives are looking after each labouring mum.  Midwives themselves talk about how little time they have to spend with each new mum, 6 hours in hospital pre discharge for some straight forward births and community visits are shorter.

Just this week the news headlines just this week read:

"NHS midwife shortage leaves women in labour feeling ‘LIKE CATTLE’, new report claims A CHRONIC shortage of midwifes in British hospitals leaves women feeling ‘like cattle’ or as though they are ‘on a conveyor belt’ during childbirth, a new report warns."

On top we now want them to be trained, and to implement effectively, checking every new baby for tongue tie?

OK.

Let's pretend that the government announce they've found a secret pot of cash, and run with it.

How will they check?

A sweep underneath the tongue?  Elevating it to look?  Checking function and running a Hazelbaker assessment or other similar tool?  Sitting down and observing a feed and using the above to create a big picture?

Are we checking babies solely for ties that sits right on the tip, or a restriction anywhere down the tongue?

Using method one, the sweep - we're going to potentially identify those ties on the tip, and easily palpable at the front or middle of the tongue.  Those near the tip are often already diagnosed in many areas - a midwife notices the baby crying, or during the NIPE and a good number of parents are indeed told at birth or very soon after.

Great they should have no problems then?

A diagnosis is great - but it doesn't help feed said tongue tied baby, nor does it resolve the tie.

• Many people have a frenulum(s) that does not impede tongue function - a tongue is only "tied" if that frenulum is too short and tight to allow proper function.  Simply seeing a piece of skin between the tongue and the floor of the mouth, or the lip and the gum means nothing.
• Parents are often told there's a tie, sometimes that they will be referred for treatment in the community and off they go.  Night two or three, baby with a tie in a shallow latch won't settle, nipples can be painful and because they weren't given any support in feeding a tied baby - a bottle of formula is introduced.  Even if parents plan to get back to breastfeeding, or get through the first few days with relatively few problems - they could then face an 8 week wait in their area for treatment.
• Once in the community, parents may be told unless there are weight concerns or nipple trauma, the tie isn't causing problems and so won't be treated.  If mum has switched to bottle feeding they won't even assess the tie in some areas, stating it doesn't cause problems with feeding.
• I see parents who have the tongue tie diagnosis clearly stated in their notes and yet it has been dismissed as not causing the problem.  
• I see parents who have been told their baby is tied, but there's nothing in their notes - meaning nobody else is aware.
• Associated symptoms like colic, wind and reflux aren't recognised by many NHS areas as linked to the tie.  Despite the fact NICE guidance recommends feeding is assessed, we know in practice this doesn't happen.  Instead guidance such as infacol, gripe water and reflux medications are widely recommended to parents.
• It's very difficult for midwives to diagnose, and then have a substandard referral pathway. Imagine the scenario - you see a newborn with a tie, struggling to latch.  You explain to parents their baby has a tongue tie, something they might never have heard of.  This needs explaining fully to parents, who understandably may be anxious or concerned about what is wrong. We should give all the information for an informed decision - except there's only 3 of you covering 9 beds, you haven't had chance to even get for a pee in the last 4 hours and you're already working half an hour beyond your shift with no breaks - so you probably skim through key info as quickly as possible.  You then have to follow that up with the above information regarding an 8 week wait, and I'm sure you can imagine the response from parents?  

"So my baby has a tongue tie that is causing her to struggle to feed, but you can treat this?"
"That's right, it's a very simple procedure in newborns."
"OK, so when will that happen."
"The current wait is roughly 6 weeks...."
"So how do I feed my baby until then?", "Why is the waiting time so long?", "So he can't breastfeed well until this happens?" 

A diagnosis means nothing if effective and informed care doesn't also happen alongside being told what is wrong. 

Now let's also consider that by using criteria such as breastfeeding, slow gain, nipple trauma, ties only at the front - the pool of babies diagnosed with a tie, but eligible for treatment is already significantly reduced (thus saving money).  I'm not suggesting for a second this is how it should be, but in a system that has to allocate funding on a priority basis, it's how it is.

Even with this "filtering", demand is such that even those eligible often aren't able to access treatment in an acceptable time frame.

Treating all the ties already diagnosed would create a huge increase in babies waiting for treatment.

We then diagnose even more by checking all babies (including those that weren't causing any problems) and we're going to refer them into the system too.  This would create a further dramatic increase in service demands, that the system has absolutely no hope of meeting in the current climate.

Even if we say we're not going to treat those not causing a problem, it still means said busy hospital midwife needs to sit and explain fully what they've found, why it doesn't need treating at the moment, what the implications may or may not be - and what will happen moving forward. This then needs to be accurately conveyed to the community team taking over their care, so it's clear from their notes that there is a tie, in case potentially associated problems do arise.

Many, many, many parents who do get early diagnosis of a tie - are reassured it's mild, slight, insignificant, despite the fact that their symptoms are not.  Yet severity seems to be gauged only on how close to the tip of the tongue it sits, which makes no sense if we consider a tight short tie that is hard to see near the back, can be more restrictive and cause more problems than a long stretchy one at the front...

If parents have been told it's "mild" and not going to cause a problem - they may never make the link between that and their 3 month old baby's reflux!  It happens often that after a long discussion I ask if anyone has checked their baby for a tie, oh yes I'm told, they said that early on but that it wasn't severe enough to need treating....

Then we may have the problem of getting ties treated that aren't on the tip of the tongue, but can still be easily felt.  Some areas are still calling these a "fad" or "trend" 

One honest midwife once told me:

" I see them on the ward, but our service won't treat them if not on the tip of the tongue and so it becomes a very difficult situation.  I can diagnose it, but where do we go from there?  I have nowhere to refer them for treatment other than privately."

Then we have the question of how do we diagnose ties that aren't easily palpable or visible? 

This is where we'd need someone:  "Checking function and running a Hazelbaker assessment or other similar tool?  Sitting down and observing a feed, and using the above to create a whole picture?

Who will do this?  The midwife?  What training will she receive in this?  Where will the time and hours come from for her to do so?

What's more newborn oral anatomy can change in the early days as they recover from the birth, pregnancy, labour and delivery can all impact - whilst an anterior tie isn't going anywhere, posterior tongue function CAN change with healing, one has to be able to identify whether the birth impact to affect tongue function and try other measures first.  Sometimes babies that are a little bruised from birth feed totally differently 48 hours after birth than they did hours after.

Checking effectively for  tongue tie - involves tongue function as part of a much bigger assessment and skill set.  We need to establish whether baby's suck is organised, what else apart from the frenulum may be impacting? What impact has labour and delivery had? Is baby struggling one side more than the other and if so what is causing this? What does baby do at the breast during the whole feed?  How does this tie in with an oral assessment of baby's sucking skills?  The skill is piecing together all the information, to understand the big picture.

Midwives would also need to be fully educated to provide enough information to facilitate an informed choice.  We're not even there yet with breast v substitutes, let alone how a restricted frenulum can impact on feeding.

If we then consider that even if we only increase rates of diagnosis by 20% (of 50/50 problematic and not if we're checking all), on top of the surge we've already established would hit the system - we're now talking an exponential increase.  What measures will be put in place to fund this?

Wouldn't it make more sense to:

1. Ensure all parents are given information antenatally and again at birth to empower them to be active participants in their feeding journey.  So they feel confident identifying the early indicators of a problem, where to go, who to see and what they can do.
2. Ensure those at the first point of contact can recognise a problem; including key indicators of tongue tie that can be apparent without fingers ever going in a mouth.  Appropriate referral pathways need developing alongside so they can refer to someone with relevant expertise in that area?
3. A peer supporter allocated to every mother, co-ordinated by a breastfeeding counsellor (BFC) to whom the supporter can refer mums.  An IBCLC or equivalent lactation consultant co-ordinates the BFC and so on, to create the breastfeeding support pyramid.

Whilst anyone and everyone has an opinion on breastfeeding, like podiatry, osteopathy or a speech and language therapist - lactation is a specialist field and indeed a pretty sound science.

Why can't parents expect qualified help? 

 As someone a few years ago said (and I'm sorry I can't recall who) You wouldn't expect to go to the hospital with a broken ankle and instead of seeing a qualified doctor, be referred to someone who had broken theirs a few years ago and done a few weeks training.  Feeding is the cornerstone of longterm health! Peer Supporters have a significant and valuable role to play - but this isn't in the role of someone providing all the lactation education and support both pre and postnatally, diagnosing tongue ties because they are significantly cheaper to employ than someone appropriately trained and experienced.

In a city close to me recent economic changes have meant the NHS no longer provides three full time Lactation Consultants, instead it employs one part time with a Peer Support network.  One LC for a whole city with many more unsure where future cuts will leave them.

A mum on Facebook today said:

"We are losing our NHS lactation consultants from 3 counties in South Wales this year and they won't be replaced. Other than Health Visitors, a couple of Breastfeeding Counsellors and the Peer Supporters, that is it for breastfeeding support" 

Without the whole system to support feeding in place, a diagnosis is just words.

Magic Bullet
The trouble with perceiving anything breastfeeding related as a magic bullet to all problems, is that for many it simply doesn't work like that.  Years ago thrush (Candida) was trend, and everyone and anyone with nipple pain (which extended to deep breast pain too) was diagnosed and medicated for thrush.  Even now we see women who don't have any risk factors for thrush, no visual presentation - medicated due to pain with similar presentation..

The fact there can be numerous causes of pain both during and after a feed beyond fungal.

Tongue tie just like thrush treatment for some women is the magic bullet - if that is the only cause of their problems, dividing it often resolves.

We need to assess the quality of the treatment.  

We diagnose the tie, we get a referral, we get a date for treatment - and only half the tie is released.

These mums will often note only some or short-lived improvement post division, and at times things can even get worse as the baby can no longer use the compensatory skill they have been using.

Tongue ties all have the ability to reattach - yet this isn't regularly checked for on the NHS, some surgeons will readdress if it happens and mum goes back, (if she has been told this can happen) others don't acknowledge they can reoccur and there's a good chance mum can come away thinking division didn't work.

Thinking a diagnosis in the current climate is going to make any sort of difference, expecting the funding to be found to run all the essential associated training and support to happen, when my midwife colleague is still using a PC system that's 15 years old and some areas have run out of red books due to budgets - is frankly delusional.

Mums need more than a pair of scissors  - we need to be campaigning for them to have access to qualified, effective, timely, evidence-based, non-judgemental infant feeding support.

In areas that employ effective support systems, some have developed tongue tie clinics as part of their remit.  The procedure isn't undertaken by surgeons and consultants, instead the infant feeding lead who is assessing feeding or a key midwife,  can treat when appropriate.

This means those who have problems are flagged early by the peer supporters or "breast buddies", they're not expected to diagnose, assess or work beyond their remit - instead they work alongside those who can so mums are quickly seen.  More in depth feeding support is given, and if appropriate, treatment can often be arranged much more rapidly.

The problem we have on focusing solely on the frenulum, is that we risk what has happened in one area.  They had very long waiting times to see one consultant at the hospital, mums were complaining and thus a quick fix was needed.  The answer was to train a large number of midwives to treat tongue tie.  Problem one was that the person who did the training, only treats the anterior portion of a tie - so now we have an army of people copying that technique in the community.  Problem two is that there has been no increase of hours for the midwives to provide feeding support alongside the procedure, because as long as we remove the frenulum we're good right?