I am having pain when breastfeeding, but my baby is gaining weight. Why?
This phenomenon could be occurring for a few reasons, but the best place to start is your lactation consultant to make sure your technique is correct. The mother’s supply can fluctuate with time, changing hormone levels and stimulation or lack of stimulation from the baby. The mother may have an oversupply and be compensating for the child’s inability to effectively nurse and empty the breast. This oversupply will allow the child to obtain enough calories and gain weight with very little effort. The poor or ineffective ability to latch and nurse can lead to frequent feeds, long feeds, frustration at the breast when not satisfied and the baby can start to chomp or bite the mother. At some point the lack of effective stimulation to the mother can cause her milk supply to start dropping and potentially leading to a more frustrated baby, drop in the baby’s weight beyond acceptable levels and more discomfort for the mother.
The baby must have the ability to have a properly functioning tongue and oral motor coordination to efficiently breastfeed. Once a lactation consultant has properly assessed you and your baby and a suspected functional issue exists, you should consider looking further into a tongue or lip tie issue.
Why are my nipples misshaped after a feeding?
If the nipple has a flattened, creased or looks like a new tube of lipstick after feedings the child may not be properly latching and nursing. Misshaped nipples can be caused by the child biting or compressing on the nipples, rather than sucking and drawing the nipple into the mouth. This can be caused by a host of reasons from a high palate in the child, a poorly functioning tongue, a tongue with limited mobility or anatomical issues with the mother.
The nipple should be drawn into the mouth and the tongue should be able to elevate upwards against the palate and express the milk from the mother. If the tongue cannot fully elevate or wrap around the nipple, the child may resort to chomping down on the nipple to express milk, leading to the misshaped nipples.
After revisions of the tongue, the nipple shape may improve to a more ideal form, or still have some distortion. Fixing the tongue to allow for improved range of motion can improve nipple shape, but the high palate may be causing some of the distortion. The palate will start to level with time and become more flat, but this can take months to occur.
What is the white coating on the center of my baby’s tongue?
The white coating on the center of the tongue is most likely residual milk left on the tongue and in rare cases, it could be thrush. The “milk tongue” is typically only found on the center portion of the tongue and not the perimeter of the tongue. This can occur because the tongue cannot fully elevate against the roof of the mouth and “self-cleanse” against the palate. The perimeter, or outer border of the tongue, will be the normal pinkish color, because the upper and lower jaws help clean off the perimeter. The presence of a milk tongue is one reason to suspect or further investigate a potential tongue tie which is not allowing for ideal movement and elevation of the tongue.
In cases of thrush, the white coating typically can be wiped off and the tissue under the coating is very red and sore. White patches in other areas of the mouth, typically the cheeks, can be another sign of thrush. Thrush can affect the mother and child, and if properly diagnosed, both individuals should be treated with appropriate anti-fungal medicines.
Why does my baby have an upper lip / sucking blister or two tone lips?
The upper lip blister, or sucking blister, can result from the inability of the upper lip to flange out while breastfeeding. This inability for the upper lip to flip or flange out and remain flanged out at the breast can lead to the upper lip blister. The blister can result from the upper labial or lip frenulum being too thick, attached to the inside of the lip or a combination of factors. By releasing the upper lip frenulum, it can allow for a wider mouth opening or gape for the child, help improve the depth of the latch, reduce air intake during nursing and help improve the seal to reduce milk leakage.
The two tone lip appearance, or blister that goes around the entire circumference of the mouth, typically is caused by the lips pursing down on the breast. The pursing down of the lips can be uncomfortable for the parent, cause the latch to become shallow and can lead a provider to believe the tongue is not fully functioning. In these instances, the lips are trying to hold onto the breast and compensate for the tongue’s inability to maintain the deep latch properly. These baby will use more facial muscles to nurse and does not allow for efficient or comfortable breastfeeding. These infants may also fatigue sooner at the breast and leading to longer feeds.
Why does milk leak out or air getting into the sides of my baby’s mouth?
The tongue is needed to make a primary seal and the lips help make a secondary seal. The inability of the upper lip to properly flange out does not allow for the baby to make a good seal at the breast. When the upper lip is curled in and remains curled in, this can allow for milk to leak out of the sides of the mouth or for air to be swallowed by the baby. You may notice small, darker triangles in the corners of the mouth if the lip is not fully flanged. The parent will need to typically flange and adjust the upper lip manually to properly place the upper lip. Even after a revision, the upper lip may need to manually be displaced until more muscle control is gained by the infant.
The tongue also plays a part in the maintenance of a seal because it pulls the nipple into the mouth and enables the baby to latch. The tongue needs to extend, cup and bowl around the nipple to pull it into the mouth. If a tongue has limited ability to extend and elevate or cup around a nipple, or the finger when examined, this may also contribute to milk leakage and excessive air intake.
Why is my baby having excessive gas, hiccups, fussiness or reflux?
Reflux, hiccups, gas and spit up are all normal for a newborn or infant, but the cause can be for a host of reasons. These issues may be due to gastrointestinal issues, normal variations in muscle development and tone of the GI system, food sensitivities associated with the mother’s diet or from excess air intake during breastfeeding. If excess air is ingested, it must exit the body either as gas or burping. If the air is burped up, it can bring up stomach acid and cause discomfort and mimic reflux. The excess air can also distend the stomach and cause fussiness and irritation with the child, too. The child’s stomach may be distended or appear more full when filled with excessive air after a feeding.
An excessive amount of very frequent hiccups can be the result of excess intake while feeding, too. The air intake will distend the stomach and it pushes on the diaphragm, which is the muscle used to fill and empty the lungs. When the stomach places pressure on the diaphragm, its rhythmic cycle can be broken and lead to hiccups, especially after feedings.
Why can’t I see the tongue tie?
Tongue ties come in assorted varieties, shapes, sizes and make-ups. Some are very easy to see and others are much more difficult to see and need to be physically felt and examined by someone with experience in diagnosing and treating these issues. Some ties are very thin and attach to the lower jaw and the tongue will have a small indent at the tip. Ties can appear further back in the mouth and when the tongue is lifted a webbed appearance may be seen behind the bottom jaw. This webbed appearance resembles the Eiffel Tower and restricts the full range of mouth of the tongue. The most difficult types of ties to diagnose and treat are posterior or even further back in the mouth and under the tongue. These ties are not easily seen and almost exclusively need to be felt to appreciate. These ties are typically thicker and denser in these posterior areas, as opposed to the more thin anterior variety.
Why do tongue ties occur?
There is some scientific evidence that tongue ties may have a genetic correlation and occur more frequently within certain families. These cases can be easier to diagnose given the familial history.
When the tongue is developing in the first months in utero it is originally attached to the floor or bottom of the mouth. As the oral structures continue to develop, the tongue separates from the floor of the mouth and becomes free to move around. It is like the top layer (the tongue) peels up and off of the bottom layer (floor of mouth) to become less attached. In most individuals, the front of the tongue becomes free first and proceeds towards the back of the tongue to become released from the floor of the mouth, almost like a zipper. In some individuals, this process does not occur at all and leads to an anterior tongue tie. The same process occurs to varying degrees in other individuals. They may have a portion of the frenulum remaining that start half way under the tongue and continues back. Again, the frenulum length and thickness can vary, depending on how it developed in utero.
Won’t the tie just stretch with time?
The frenulum is made up of fibrous tissue that is equivalent to a rope. This tissue will stretch only about 3% and it is NOT a rubber band or elastic. The tongue will grow, gain more strength and mass as it is used after birth, but a restricted tongue will not typically compensate. Each frenulum will have varied lengths to it and a longer frenulum can allow a tongue to partially function, but a short frenulum can have a detrimental effect on tongue mobility and function.
What is all this reattachment talk?
Once a tongue or lip is properly revised a diamond shaped wound will remain. Think of the diamond as a baseball diamond. Typically over the 2 weeks following the revision the diamond will shrink towards the pitcher’s mound. The wound is a 3-dimensional area that also has a depth component. Think of this as ground underneath the pitcher’s mound. Again, over the 2 weeks of typically healing, the diamond will shrink in and fill in from the deepest part to the most superficial part. The diamond will fill in and slightly constrict and tighten in the 2-3 weeks to following the revision.
Some individuals will have a tendency to form thicker collagen or a denser scar. This is not reattachment, but healing of a wound and pulling the tissue tighter from the original margins or edges of the diamond. The tissue may feel slightly thicker in the revised area and will smooth and soften over time.
What about transitioning to foods in the future?
The tongue is important in moving food around the mouth so it can be properly chewed and broken down into smaller pieces. The food is formed into a bolus, or ball, that then can be swallowed. Swallowing requires that the airway is protected and a rhythmic and fluid motion occurs to smoothly push food down into the stomach. Infants with a tongue tie cannot always move the food around easily and chew it up into small pieces. These individuals may gag frequently, ingest large amounts of air due to poor coordination and appear to be choking and overall struggle with solids.
I am worried about the dental and speech issues that may occur
When a baby’s teeth start to normally erupt after the 5th month, and this can vary greatly when they erupt, spaces may occur between the teeth. As a pediatric dentist, baby teeth with spaces between them are much easier to keep clean for the parent and will allow for space for the wider adult teeth to fill in when the child is older.
As the child’s teeth erupt and daily brushing is needed, the child may not always cooperate for brushing. An important aspect of cleaning the upper teeth is to gently move the top lip upwards to expose the entire upper front row of teeth. You need to focus on brushing at the gumline and this can be challenging for some children, especially if they have a lip tie that is contributing to the problem.
Speech is a very complex task that involves the brain, many neural pathways and facial muscles to produce speech and allow one to articulate. Restriction of the tongue can make certain letters and sounds more difficult (th, d, l, n, r) and a restricted or very tight upper lip can affect the ability to produce other sounds like B’s and P’s.
If you are treating your infant, I strongly advise you weigh your decision on the breastfeeding relationship and your goals in regard to breastfeeding. If a speech issue is a problem as your child becomes older, it is advisable to have a speech therapist involved to properly diagnose and understand the cause of the speech problem. If some form of a restriction is determined to be part of the problem once a speech therapist has helped with a diagnosis, we can address this at a later and more appropriate time.
Is this going to be an instant fix for my baby and myself if we do the frenulectomy revision?
In some instances, depending on how poorly the tongue or lip tie initially are functioning, you may notice an instant improvement immediately after the procedure. Other variations of tongue and lip ties will require patience, a relearning period for the infant, suck training and follow up with your lactation consultant. The infant will also play a key factor in to how quick they are able to adjust, relearn and adapt to the newly revised lip and/or tongue. I encourage all patients to follow-up with their lactation consultants a few days post procedure to help work through new latching challenges and retraining.
What other issues could be contributing to our breastfeeding issues?
Many others aspects of the mother and child could be complicating the breastfeeding relationship.
Anatomical issues (nipple shape), milk supply challenges and other physiological issues with the mother can all contribute to obstacles. Having a well-trained lactation consultant can help work through some of these issues.
The infant can have a much longer list of potential issues. The relationship of the upper to lower jaw can impact the positioning of the tongue. If the lower jaw is recessed or set back, this will place the tongue further back and add to the challenge of latching. Babies with a lower muscle tone or hypotonia may have more issues extracting breastmilk from the mother. Birth history, delivery method, gestational age of the infant at birth (premature babies) and other issues can add to the challenges of effectively and efficiently breastfeeding.
How do I manage pain or discomfort for my infant?
The day of the revision and the following day or so after the revision you may notice your infant is somewhat fussy or irritable. I strongly advise the use of Tylenol and the appropriate dosage will be provided to you the day of the procedure. DO NOT use Motrin or Ibuprofen in any infant under 6 months of age. Staying ahead of the discomfort and being proactive with pain management is a good practice. Other methods to soothe the child can include, skin to skin contact, more frequent nursing, and a warm bath to name a few.
What is the hardest part of the entire experience?
The day or two following the procedure your infant may be more fussy and irritable then normal. These first few days will require frequent stretching exercises that the parent needs to perform. These stretches will likely be the most challenging aspect of the entire experience and the infant typically will not care for these to be done. It is suggested to gently stretch the revision area and surrounding tissue prior to feeding the child and then nurse the child to calm them back down.
The stretching exercises will be reviewed in person with you once the revision is complete.
How is the best way to get pictures under a tongue or of a lip?
This is tricky. The pictures below are good examples of pictures of a tongue and lip tie. Your child’s will not necessarily appear the same way and that does not mean there is or is not an issue. Appearance is part of the puzzle, function is a bigger part of the puzzle of figuring out if a tongue or lip frenulum is causing issues.
Lay your child down or swaddle them and place both index fingers under the tongue and gently guide it upwards. Have another person take the picture from the angle depicted below. For the lip, take both thumbs and gently roll the upper lip towards the nostrils or gently grasp the upper lip and reflect it up and towards the nostrils. Do your best, they can be tricky.