Tongue Ties – what’s it all about?

Tongue Ties – or ankyloglossia – just what are they and why do they cause problems for some mothers and babies, and not others?

As soon as you start to talk to people about tongue ties you realise that it’s a bit of a contentious topic; some people think they are over-diagnosed, others think they don’t exist, others have never heard of them.  So why the confusion?

What is a Tongue Tie?
Between the 4th and 7th weeks of development a baby’s oral cavity develops and tissue in the mouth (and other areas of the anatomy) goes through a process of growth and regression.  During this process the tongue forms and separates from the floor of the mouth leaving the frenulum – the piece of skin that attaches the tongue to the bottom of the mouth.  In some babies the frenulum doesn’t separate as much as it could do, causing a possible tongue tie.

If the frenulum is too tight  it impacts the baby’s ability to use his tongue to feed effectively – this can impact breastfeeding and and to some extent bottle feeding, as well potentially causing future problems with oral health and development, speech, digestive problems, and others.

Some babies have an obvious frenulum but it does not cause any problems – every baby and mother needs to be assessed on an individual basis.

Why do they occur?
There doesn’t seem to be a consensus of opinion on this.  There has been discussion about a gene that may be responsible, and whether or not folic acid has a role to play.  There does seem to be a higher chance of a baby having a tongue tie if there is a family history of tongue tie though, and often if one child in the family has a tongue tie, it’s not uncommon that their siblings do too.

What does a tongue tie have to do with breastfeeding?
When a baby breastfeeds he needs to be able to keep his tongue forward over the bottom gum, use the tongue to cup and grasp the breast, bringing the breast tissue far enough back in the baby’s mouth to ensure that the nipple is not squashed between the tongue and hard palate, and create the vacuum in the babies mouth that results in the milk flow from the breast.  If the movement of the tongue is compromised in any way then some or all of these activities can be more difficult.  The baby’s tongue should be able to work in a rippling type of movement that carries the milk from the front of the baby’s mouth to the throat for swallowing.

If a baby is tongue tied some mothers experience pain that cannot be managed by improved positioning and latching, the nipple may be squashed or grazed by the tongue causing bruising and/or bleeding, cracked nipples; the baby may not gain weight well as he is unable to remove milk efficiently from the breast, leading to low weight gain, or a sleepy baby due to insufficient calorie intake.  Sometimes the baby may not gain weight well, but the mother may not experience any pain.  In some cases all seems well for the first few weeks.  The mother naturally has an abundant milk supply and the baby is gaining weight well.  However, as supply becomes dependent on the baby removing milk from the breast well (rather than hormonally driven as in the first few weeks), the baby’s weight gain starts to drop and the mother notices a decrease in milk supply.  All of these things COULD be an indication that the baby has a tongue tie.

How do you know if there is a tongue tie?
If a mother is having problems with painful breastfeeding, or the baby is not gaining weight sufficiently, then the first thing to do is check that the baby is positioned well at the breast and is latching well.  Many painful breastfeeds can be rectified by improved position and/or latch.  However, if things cannot be resolved this way, then the possibility of tongue tie should be investigated.   Tongue ties are generally deemed to fall into one of four classifications:  I, II, III and IV.  The first two tend to be easier to see and involve the tip of the babies tongue being restricted.  These are often called anterior tongue ties.  However, tongue ties are diagnosed by both appearance and function – some tongue ties just don’t cause problems for feeding and can be left alone.  Many practitioners use the Hazelbaker Assessment Tool as a consistent and reliable method of checking both appearance and functionality of the tongue in a breastfeeding baby.

Why are tongue ties more common these days?
It’s not clear why tongue ties seem to be occurring more often, or even if they really are more common – it could be that we are just hearing more about them than we used to.  You may have heard stories about midwives in the past keeping a finger nail long to cut them as soon as the baby was born.  As formula became more of the “norm” for babies and, for a while was believed to be scientifically superior, it was easier to switch babies to bottle feeding and the tongue tie was less of an issue.  It is likely that due to more mothers wanting to breastfeed again, and generally having access to better and more easily available breastfeeding help, tongue ties are again being recognised and dealt with.

How do you fix a tongue tie?
The procedure of dividing a tongue tie is called “frenotomy”.   There are a number of ways of carrying out a frenotomy – laser, scalpel, diathermy.  Laser is expensive and is deemed by some as unsuitable for use in babies.  Some midwives and lactation consultants perform frenotomies, in other areas GPs who carry out minor surgeries will do them.  A frenotomy involves the tight frenulum being cut in one or two places to relieve the tongue and allow normal movement.  There is usually very little bleeding – the risk of excessive bleeding and infection is deemed to be very low.  Usually a small piece of gauze will be placed against the cut area for a few seconds and then the mother encourage to feed the baby.  The baby is often not upset by the procedure itself, but often doesn’t enjoy adult sized fingers being poked in the mouth and under the tongue during the process.  Most of the time, mothers report immediate improvement, however some babies have got used to using their tongue in an inefficient manner and take more time to get used to the new mobility of their tongue.  In these cases tongue exercises may help:  http://vimeo.com/55658345

Some mothers find that these tongue exercises can help the baby use their tongue better while waiting for a tongue tie to be checked, along with using nipple shields (to prevent further damage to the nipples), or expressing and bottle feeding until the tongue tie can be divided.

Once the tongue tie has been divided, it’s always worth going back to your breastfeeding support person to ensure positioning and latching is optimal.

References/further reading:

Is my baby getting enough milk?

This is a question that many mothers ask themselves at some point during the time they are breastfeeding their baby.

Often the frequency of a baby’s feeding habits can be a surprise for new parents and without the right support and information it’s easy for a mother to feel she hasn’t got enough milk for her young baby’s growing needs.  Many women I speak to worry about not having enough milk, and I often hear that well-meaning friends and relatives have commented on how the baby should be made to wait for 3 hours, or sometimes longer, or to top up with a bottle of milk after a breastfeed.  Unfortunately this advice, if followed, actually has the opposite effect on the mother’s milk supply, and therefore the baby’s growth too.

On average, a baby born at around 40 weeks of pregnancy can only fit around 5mls (a teaspoon) of milk into his or her tummy in the first 24 hours of life.  This increases to around 25/30ml by about day 3, and 60/80ml by about day 10.  Even though a baby only drinks small quantities of milk, it can still take them 20 minutes or more to finish feeding.  Just like adults, each baby is unique and some eat more quickly than others, so it’s important to let the baby decide when he or she has finished; that way babies will drink until they are full, ensuring they get enough calories to grow well, and stimulate the mother’s milk supply adequately.

Every time milk is removed from the breast, more is made.  However, if milk is left in the breast then a protein called FIL (Feedback Inhibitor of Lactation) increases, which slows milk production.  Therefore, the more often a baby feeds at the breast, the more milk a mother is able to make.  Most people are not symmetrical and this applies to breasts too.  A lot of women have breasts that vary slightly in size, this is quite normal.  The size of a woman’s breasts bears no relation to the quantity of milk she will make.  Large breasts may contain a small amount of glandular tissue and vice versa.  It is not possible to tell!  By allowing a baby to feed as often, and for as long, as he or she needs to, most women’s breasts will make enough milk for their baby.  If you think of the breast as a glass, it doesn’t matter how big the glass is – you can still drink lots of water in a day from a small glass, you just need to drink more often.

So even if you feed your baby for as long and as often as he or she wants, how do you know it’s all working?  Weight gain and growth is something that can be measured, and certainly in the first couple of weeks your baby will be checked to ensure that by around day 10 your baby is at least still at birth weight.  Many babies lose a little weight in the first few days and this is completely normal.  If the mother has had IV fluids during labour then the baby’s weight can be slightly inflated at birth and this can mean the baby loses a little more weight than otherwise as they lose the excess fluids taken on during birth.  On average, a baby will gain anything between around 110g-220g a week in the first four months.  As you can see there is a wide range of “average” and at different times babies put on different amounts of weight.  It can be important not to weigh a baby too often as some weeks babies won’t put on much weight which can cause unnecessary worry.  It’s better to look at the overall pattern of growth, taking into account growth in head circumference and body length as well as weight gain, and to ensure that the overall trend is upwards on the growth chart, and that the baby is staying more or less on their percentile line on the chart.

However, in between your baby being weighed you’ll want to feel confident that things are going well.  One of the easiest ways to do this is to check what’s coming out the other end :-)  If milk is going in at the top, then something will be coming out the other end.  It’s amazing how important the contents of your baby’s nappy becomes!  When your baby is born his bowel contains meconium.  This is the first poo you baby will pass and breastmilk helps your baby’s digestive system start to work; the colostrum works a little like a laxative helping your baby pass meconium – a sticky, black/dark green bowel motion.  In the first 2 days your baby should produce one or more poos a day, and two or more wees a day.  On days 3 and 4, your baby will produce three or more poos a day, which will become more green coloured and possibly a little softer, and three or more wees a day.  On days 5 and 6, your baby will produce three or more soft yellow poos.  The poos change to yellow as all the meconium has been passed and your baby starts to drink and digest more milk.  By now you will notice that you are producing more milk.  From day 7 onwards, your baby will produce at least two soft yellow poos, possibly a lot more, which is quite normal.  They may also look a little “seedy”, which is fine.  Your baby should also be producing six or more heavy wet nappies a day.

It can be hard to feel confident of something that we haven’t done before, and having a baby that seems unsettled or unhappy is enough to make any mother concerned.  If you are worried about your baby’s behaviour, development, or health then you should always seek advice.  A mother’s instincts are often right and sometimes it can take a while to get to the root of the issue, so keep asking and talking to people who have been well trained and have good experience until you are satisfied.

You can find some great information here about how milk production works, and on this page for what to expect in the early days of breastfeeding.  If you are worried about how often your baby is feeding, you might feel reassured after reading the information on this page.

Please feel free to comment on this post, or ask questions.  You can also contact me directly vie email:  bfc.denise@gmail.com

Is breastfeeding a contraceptive?

I couldn’t help but smile to myself as I wrote that… only today someone was talking about this and said that the chances of sex happening again in the foreseeable future was slim – the process of labour and giving birth was enough to ensure there was little chance of any pregnancy-inducing behaviour happening in their house :-)

However, the question of the contraceptive effect of breastfeeding does come up quite often so I thought I’d put some information here.  Breastfeeding as a way of avoiding pregnancy is referred to as the Lactational Amenorrhea Method, or LAM.  This method has only a 1% to 2% failure rate providing all 3 of the following are true:

  • the mother’s period have not returned since the birth of her baby (spotting or bleeding during the first 56 days does not count) AND
  • the mother is breastfeeding her baby on demand day and night, with no other regular drink or food substitutes AND
  • the baby is less than six months old

If any one of these is not true then the chance of LAM being effective is reduced, and at the point that any one of the above conditions changes, the couple should use other methods of contraception if they are keen to avoid pregnancy.

Return of Menstruation – during the first 56 days after a woman has given birth, spotting or bleeding does not count as a period.  However, after the first 56 days, spotting or bleeding of 2 days or longer duration should be considered as a period, or any other bleeding that the mothers feels is a return of menstruation.  This would mean that LAM may no longer be effective and other contraception should be used.

Breastfeeding at Night – for the second condition to be considered effective, the mother should be breastfeeding at least once during the night as well as on demand during the day.  Prolactin levels are higher at night thus having a greater impact on fertility.  If the baby goes longer than 4 hours during the day or 6 hours at night without breastfeeding, the effectiveness of LAM may be reduced and other contraception should be considered.

The Baby is less than 6 months old – once a baby reaches 6 months old it is common for other foods to be introduced and for babies to go longer between feeds.  Due to less breastfeeds taking place from 6 months old, LAM may become less effective and other contraception should be used.

Methods of contraception that will not impact breastfeeding are barrier methods such as condoms or diaphragms, spermicides, or non-hormonal IUDs.  Natural family planning methods can be hard to use at this stage due to the impact of breatfeeding on the signs of fertility.

After the first six weeks, progesterone only methods such as the mini-pill, injectable contraceptives, and other IUDs may be suitable.  Progesterone only methods are unlikely to have an impact on breastfeeding, but it is advisable to wait until six weeks or so has passed to allow breastfeeding to become more established.

For more information about LAM and contraception, check out this very useful website:  http://www.waba.org.my/resources/lam/#LAM

Holidays interrupting breastfeeding?

As the holidays start and visitors arrive many people find their normal “routine” goes out the window and you seem to spend time rushing around after everyone else more than usual.  It’s easy with all the festivities and visitors to attend to, to find that you just don’t have as much time to sit down with your baby/child to cuddle and breastfeed as you would normally.  It’s often a time when children don’t behave in the way the would do at any other time of year and older babies especially, get very distracted by all the interesting activity around them.

Most babies will breastfeed beyond a year old; if a baby suddenly stops breastfeeding before a year old it is quite likely to be a “nursing strike”.  A nursing strike doesn’t mean your baby necessarily wants to stop breastfeeding but it does mean something has got in the way of, or made him want to stop breastfeeding right now.  Sometimes it’s not possible to ever find out exactly what caused it, but time and patience will often solve it.  It might be a sore ear, stuffy nose or something else physical that is making breastfeeding uncomfortable, or it might just be that there are so many distractions and delays in breastfeeding for a couple of days that your baby just stops asking.

So what can you do if it happens?  Well, as this most often happens to babies from 7 months upwards, there is no rush to replace the lack of breastfeeding with lots of other drinks and foods – your baby is probably quite a strong little thing by now and eating some solids.  You can express your milk and give it to him in a cup if he wants it – expressing will also help to maintain your milk supply and prevent engorgement, blocked ducts etc.  Avoid bottles and pacifiers though as these will just satisfy the urge to suck with something other than your breast.  Some mother’s find that trying to feed when their baby is sleepy or drowsy works, others find feeding in the bath, while standing or rocking, trying a totally different position than your baby is used to, and sometimes just leaving it for a day or two so there is less tension and anxiety around breastfeeding.  Usually after a few days, but sometimes as long as a couple of weeks, things return to normal for no apparent reason.

Finding time out for peace and quiet with your little one can be hard though at this time of year, and can lead to frustration and worry.  Over the holidays most organisations are closed so don’t forget to check out where your local La Leche League leaders are.  You can also check whether there are Peer Counsellors in your area, national breastfeeding helplines and lactation consultants.  There’s nothing worse than feeling you are on your own with a problem and there is no one available to listen or help… and sometimes the “help” and “advice” from visiting relatives and friends is, well, unhelpful :-)

The Breast Room specialists are available all through Christmas and the new year holidays.  You can find their details on Facebook https://www.facebook.com/TheBreastRoom.  You can contact them on breastroom@gmail.com or 027 938 6955 and 027 938 6956.

Check the Links on the right hand side of this page for some other ideas of where to get some help over the holidays.

Happy Holidays every one!  :-)

 

Breastfeeding… it takes time

The other day a mother said to me that she wished someone had told her that it would take time to get breastfeeding “right”.  She’d done lots of research prior to having her baby – read books, spent time on google, talked to people – but she didn’t recall anyone telling her that it would take time.

The thing is, for some people it doesn’t feel as though it takes very long for breastfeeding to feel natural, and “right”.  Others feel that it takes them ages to get to the point where it all feels ok.  Just because breastfeeding is what our bodies are designed to do, doesn’t mean it will just work straight away.  There are a lot of things we do, that are “normal” or “natural” for humans… walking and talking for example.  However, these things that we take for granted have to be learned before they are automatic or natural, and take a fair bit of time to master.  Breastfeeding is just the same.

People learn a lot by watching others, so surround yourself with people who do, or have, breastfed.  Find out where you can go to talk to women who breastfeed, women who are having the same experiences as you, or have already been through the stage you are at.  Stay in touch with the women you meet at antenatal classes – it’s amazing how much moral support you can get from these people, and sometimes they become life long friends :-)

But just as important, give yourself and your baby time.  Be kind to yourself.  It can take a few weeks before you feel completely comfortable about breastfeeding – and that’s just fine.  Sometimes babies need a bit of time to get the hang of it all too!  If you don’t feel that things are improving, or working the way they should, then ask your midwife, a lacatation consultant, or other breastfeeding specialist or supporter for some information.  They can talk to you, find out what’s happening, and often share information and ideas that will help.  If you don’t want to talk to someone face to face, there is lots of support online;  Facebook has some great groups too – look out for Breastfeeding NZ, The Breast Room in the House, LLL NZ, and Kelly Mom to name a few!

 

 

World Breastfeeding Week

The 20th World Breastfeeding Week is almost upon us – the first week of August every year.  Each year there is a different theme and this year is Understanding the Past, Planning the Future.  20 years ago, WABA launched the first World Breastfeeding Week with the theme Baby Friendly Hospital Initiative.

Has a lot happened in the last 20 years?  What should we do in the next 20 years?  Some believe that we should just be quiet and stop going on about it.

In 2005, Women’s Health Action in New Zealand organised the first Big Latch On as part of World Breastfeeding Week.  Each year the numbers of women breastfeeding at the event has grown, helping to increase awareness and support for women breastfeeding outside their home.  We too often hear new mothers worrying about whether or not they will get asked to leave somewhere simply for breastfeeding their baby.  Human milk is made for human babies.  The World Health Organisation (WHO) recommends that babies receive only breastmilk for around the first six months of their lives and that breastmilk should then be continued alongside other foods for 2 years or beyond.  Surely no one expects a mother to only feed her baby within her own home for 2 years or more?  But perhaps the people who disagree with breastfeeding in public also disagree with the WHO recommendations…

Of course, breastfeeding for 2 years or beyond isn’t for everyone, and that’s fine too.  It’s all about making informed choices – they key word being INFORMED.  Being informed about choices means knowing both sides of the story, having enough information about the whole picture before making a decision.

I wonder, is there more information available now, to help people decide whether or not to breastfeed, than there was 20 years ago?  Is the information easy to find, complete, unbiased, presented in a way that is easy for all audiences to understand?  Have things changed for the better or worse in the last 20 years, or is it just different?  What needs to happen next?  What do you think?

Either way, look out for the Big Latch On in your area.  Maybe you will learn something new :-)

 

 

 

 

Breastfeeding and bras

One of the things I always think is great about breastfeeding is that it doesn’t require the purchase of lots of equipment.  I know there are cushions, covers, special breastfeeding t-shirts etc – but none of those are actually necessary, they are a choice.  However, there is one thing that needs to be correct if you are to purchase one, and that’s a nursing bra.

Not everyone wears a bra when they are nursing, it is absolutely personal choice.  If you are comfortable then that’s all good.  BUT, if you are going to buy a nursing bra you need to buy one that fits properly and is a suitable style.  Over the last few years I have seen many women who have run into problems caused by an ill fitting bra.  In the first few weeks after your baby is born, your breasts will fluctuate in size as your breasts fill with milk.  After the first few weeks your milk supply and your baby will be a bit more in tune and the change in breast size will be less noticeable.  Therefore, the first nursing bras you buy need to be a suitable style to deal with this.

There are two main styles really.  One has a cup that unclips and leaves the breast free, the other has a cup that unclips to reveal an inner cup that has a hole in it allowing the nipple and areola to be exposed.  Both are fine when you have been breastfeeding for a while, but experience has shown me that the second style (with the inner cup) can sometimes be less suitable in the first few months.  This is because the edges of the inner cup can put pressure on the breast causing restricted milk flow, blocked ducts and ultimately mastitis.  Not all do this as some are softer, less rigid inner cups, but some are very firm and not appropriate.  I have heard bra fitters say that the inner cup is required for support during breastfeeding.  I do not agree.  A well made bra will give support without needing two layers of cup, and when you are actually, physically in the process of feeding your baby, you are unlikely to be doing start jumps or any other physical activity that requires extra support – you will probably be sitting down quietly somewhere!

This type of style (click here) is the type that I would always suggest for a new mother.  You can see from the picture that from the top of the breast downwards is uncovered, leaving the breast free and without pressure.  The other style looks more like this but you can see in this picture that the piece that stays in place at the top of the breast is soft and stretchy, which may be ok for some women.  Some manufacturers use a more rigid piece of fabric here that would potentially cause problems.

A bra provides good support mainly from a wide band, so you will find that the band on a nursing bra is usually wider at the back than a fashion bra, and may well have 3 or even more rows of clips.  Wide, adjustable straps will also help to ensure good fitting and comfort.

It is best to get your nursing bra fitted close to the end of your pregnancy – definitely not before 36 weeks, and preferably from 37 weeks onwards.  When your bra is fitted you should find that the band around your ribs is a little tighter than you would normally wear.  This is because your at this stage of pregnancy your baby is pushing your rib cage up and out.  Once your baby is born your rib cage will go back to it’s usual position, making your bra fit less tightly.  The cups should feel a little large at the time of fitting, allowing you to easily fit your flat hand in the top of the cup with some room for movement.  This allows for the increase in breast size once your baby is born and your breasts are making milk after the first few days.

If you choose to use breastpads at night then you might also need a bra for nighttime.  A soft, unstructured bra is best for nighttime.  A supportive, day time bra has too many seams and structure for nighttime and you may find that the seams and edges of the bra dig in when you are sleeping causing discomfort or other problems.

It is important that you feel comfortable in your nursing bras.  If the person doing your fitting doesn’t seem to understand how breastfeeding works and how a poorly fitting bra can impact breastfeeding, then ask for someone more experienced to help you, or try a different store.  It is not ok to wear a bra that is too small – even when you are not breastfeeding.  If the store does not stock a decent range of sizes, then go to a different store.  Remember – in the old days breasts were bound tightly to stop women producing milk…