Alison Hazelbaker, PhD, IBCLC, FILCA, CST, RCST

spiritofhealingllc@gmail.com (614) 326-3504

Dr. Hazelbaker specializes in cross-disciplinary treatment and to that end has taken training in several modalities to best assist her clients. She is a certified Craniosacral Therapist, a Lymph Drainage Therapy practitioner, and an International Board Certified Lactation Consultant.

See a Bully. Stop a Bully. Make a Difference!

By now, you have either heard about or read both the Breastfeeding Today Blog Post and the protest letter that was published nearly immediately after its release.

The blog post can be found at www.Breastfeedingtoday-llli.org/tongue-tie-lip-tie-diagnosis-treatment-aftercare/ and the letter could previously be found at www.facebook.com/groups/lactnet/ (23rd Nov.) and www.facebook.com/kellymomdotcom/?fref=ts (23rd Nov.) However, I can no longer find the letter on either site.

The protest letter is another example (out of many) of the bullying that accompanies any attempted rational discussion regarding tongue-tie and other oral restrictions, and their proper assessment and treatment. The signers take exception to it because the blog does not conform to their particular rhetoric. Some of the signers you will recognize as people who have a low tolerance for anyone who disagrees with them. The others have surprisingly chosen strange bedfellows!

I think if one is going to criticize someone else in scientific circles, they ought to have solid methodological and research ground on which to stand. In this case, the ground on which these signers stand cannot support their collective ego weight.

For those of you who doubt that I have done my research, and for those of you who simply want more background information for the blog post and my other writings, please find my list of references below.

Before you go, let me just share a few stories that prompted the writing of the blog post:

Hundreds of babies have undergone both lingual and maxillary frenectomy to resolve breastfeeding problems only to experience no resolution. The stories of these babies are the garden variety stories. The stories I tell here are not so garden variety. I daily receive emails from scared, disillusioned and angry parents.

A woman brought her baby into our free bodywork clinic and told us her baby had been refusing the breast for weeks. She had heard that craniosacral therapy would finally resolve her breastfeeding problems. She wanted us to check her baby to see if his frenulum had “regrown.” I checked his tongue underside and examined him for tongue function: he had massive scarring attaching his tongue to the floor of his mouth and significantly compromised tongue function. I asked her what had happened. Her baby had received not one, but four lingual frenectomies and one labial frenectomy! Each frenectomy was followed by excessive new scarring. Had she been doing the aftercare protocol? You bet she had!

She reported he screamed each time she did the “exercises,” especially when she rubbed the wound the way the dentist showed her to. With every new frenectomy, he became more and more orally defensive until he just stopped going to breast…

She showed me the before pictures and video. He had a normal maxillary frenum before revision with perfect range of motion. His tongue was retracted making his lingual frenum appear tight. What was his real problem? He had a severe torticollis that no one ever assessed let alone addressed.

What did we do? We did craniosacral therapy, chiropractic, OT, and some PT. The baby eventually latched on again but his willingness was still reserved. Did we treat the scar tissue? Yes, with a scissors frenotomy; No diamond-shaped wound; No aftercare stretches; No new scar tissue and we were able to normalize his suck.

In an Eastern state, a mom took her baby for both maxillary and lingual revision. The baby aspirated her blood and ended up in a medically induced coma. When she posted on Facebook for support, her posts were removed and she was accused of fraud.

In a Western state, a mother took her baby to see a local lactation consultant who took a quick look at her baby and told her the baby had both a tongue-tie and a maxillary lip “tie.” No history was taken, no care plan other than frenectomy by laser was recommended. When the IBCLC found out the mom took the baby for a second opinion, she called the mom and browbeat her for not getting the frenectomies done, as she had told her to do.

A baby in Canada received 6 frenectomies with no change in his suck-swallow-breathe coordination.

A mom in my practice brought her baby in for assessment and treatment. Her baby was popping on and off the breast and not gaining sufficiently. The baby had an obvious anterior-tie and what the dentist classified as a class 4 maxillary tie. The baby underwent laser revision for both tongue and lip. The mom brought the baby in for her second visit with me directly after the revisions. The baby’s upper lip was so swollen she could not close her lips. She certainly couldn’t breastfeed. We tried everything to get the baby as comfortable as possible and keep her fed. We ended up dropping expressed breastmilk into the baby’s mouth one drop at a time. It took more than an hour to get the baby to calm down. The mom continued the dropper feeds for 36 hours!

Why did the lip swell so badly? The dentist accidentally lasered the lip muscle. This was the last baby I sent for maxillary lip revision.

The stories I have in my archives exceed the number of signers on this ridiculous protest letter. The stories many of my colleagues have to tell do as well. To the signers I say: Pull your heads out of your collective arse: there’s harm being done!

Stay tuned for my upcoming blogs on maxillary lip “tie,” wound healing and torticollis! Until then, keep protecting our babies!



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Messner, A.H., & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology-Head and Neck Surgery, 127, 539-545.

Meyer Palmer, M.,  & VandenBerg,  K.A. (1998). A closer look at neonatal sucking. Neonatal Network, 17, 77-78.

Meyer Palmer, M. (2002). Recognizing and resolving infant suck difficulties. Journal of Human Lactation, 18, 166.

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Miller, M.J., Martin, R.J., Carlo, W.A., Fouke, J. M., Strohl, K.P., & Fanaroff, A.A. (1985). Oral breathing in newborn infants. Journal of Pediatrics, 107, 465-469.

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Pransky, S.M., Lago, D. & Hong, P. (2015). Breastfeeding difficulties and oral cavity anomalies: the influence of posterior ankyloglossia and upper-lip ties. International Journal of Pediatric Otorhinolaryngology, http://dx.doi.org/10.1016/j.ijporl.2015.07.033

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Thomas, J. & McClay, J.E. (2015). Breastfeeding: what to do about ankyloglossia, lip-tie. AAP News, 36(6):11

Todd, D. (2014). Tongue ties: Divide and conquer? To divide and prevent an interruption in breastfeeding. Australian Breastfeeding Association Seminars for Health Professionals.

Todd, D., & Hogan, M.J. (2015). Tongue tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeeding Review, 23(1):11-6.

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Woolridge, M. W. (1986).  Aetiology of sore nipples.  Midwifery, 2, 164-171.

Woolridge, M. W. (1986).  The anatomy of infant sucking.  Midwifery, 2, 164-171.

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Infant Trauma

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Karen, R. (1998). Becoming attached. New York: Oxford University Press.

Levine, P. & Kline, M. (2007). Trauma through a child’s eyes. Berkeley: North Atlantic Books.

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Page, G.G. (2004). Are there long-term consequences of pain in newborn or very young infants? The Journal of Perinatal Education, 13(3): 10-17.

Porges, S. (2011). The Polyvagal theory: Neurophysiological foundations of emotions, attachment, communication and self-regulation. New York: W.W. Norton & Company.

Rothschild, B. (2000). The body remembers. New York: W.W. Norton & Company.

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Siegel, D. (2012). The developing mind. New York: Guilford Press

LASER

Cobb, C.M., & Vitruk, P.(2015). Microbial decontamination of three different implant surfaces using a super-pulsed CO2 (10,600) laser: An in vitro study. The Academy of Laser Dentistry Meeting, Feb. 5-7, Palm Springs, CA.

Convissar, R. (2011). Principles and Practice of Laser Dentistry. St. Louis: Mosby Elsevier.

Kaplan, M., Hazelbaker, A.K. & Vitruk, P. (2015). Infant frenectomy with 10,600 nm dental co2 laser. WAGD Newsletter, April.

Vitruk, P. (2014). Oral soft tissue laser ablative & coagulation efficiencies spectra. Implant Practice US, November.

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Waynant, R.W. (2001). Lasers in Medicine.  Boca Raton:CRC Press.

Zeinoun, T., et al. (2001). Myofibroblasts in healing laser excision wounds. Lasers in Surgery and Medicine, 28:74-79.

Maxillary Frenum and Lip tie

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Chan, L., & Hodes, D. (2003). When is an abnormal frenulum a sign of child abuse? Arch Dis Child. Doi: 10.1136/adc.2003.031534.

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De Carvalho Stroppa, S., et al. (2014). Surgery management of rare hypertrophic frenum in an infant: a case report. Case Reports in Dentistry. http://dx.doi.org/10.1155/2014/168192.

De Morais, J. F., et al. (2014). Postrentention stability after orthodontic closure of maxillary interincisor diastemas. Journal of Applied Oral Science, 22(5):409-15.

Delli, K., Livas, C., Sculean, A., Katsaros, C., & Bornstein, M. (2013). Facts and myths regarding the maxillary miline frenum and its treatment: A systematic review of the literature. Germany Quintessence International, 44(22):177-87.

Desai, A.J., et al. (2015). Bilateral pedicle approach for esthetic management of upper labial frenum. Journal of Interdisciplinary Dentistry. 5(1): 27-30.

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Dewel, B.F. (1966). The labial frenum, midline diastema, and palatine papilla: A clinical analysis. Dent Clin North Am. 10:175-84.

Diaz-Pizan, M.E., & Lagraverere, M. O. (2006). Midline diastema and frenum morphology in primary dentition. J Dent Child, 73: 11-14.

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Flinck, A., Paludan, A.,  Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr 4(2):67-73

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Hazelbaker, A. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Columbus: Aidan and Eva Press.

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Jenista, J.A. (2001) Mandibular frenulum as a sign of infantile hypertrophic pyloric stenosis. 2001;138:447. J Pediatr.138:447–7. 

Kaimenyi, J.T. (1998). Occurrence of midline diastema and frenum attachments amongst school children in Nairobi, Kenya. Indian J Dent Res. 9:67-71. 

Kakodkar, T., et al. (2008). Clinical assessment of diverse frenum morphology in permanent dentition. The Internet Journal of Dental Science. 7(2). http://ispub.com/IJDS/7/2/4074.

Kotlow, L.A. (2004). Oral diagnosis of abnormal frenum attachments in neonates and infants: Evaluation and treatment of maxillary frenum using the Erbium YAG Laser. J Pediatr Dent Care. 10:11–4.

Kotlow, L.A. (2010). The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: Prevention, diagnosis, and treatment. Journal of Human Lactation, 26(3):304-08.

Kotlow, L.A. (2013).  Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding.J Hum Lact . 29(4): 4458-464.

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Maguire, S., et al. (2007). Diagnosing abuse: A systematic review of torn frenum and other intra-oral injuries. Arch Dis Child. 92:1113-7.  

Martin, R.A., & Jones, K.L. (1998). Absence of the superior labial frenulum in holoprosencephaly: A new diagnostic sign. J Pediatr. 133:151–3. 

Mazzocchi, A,& Clini, F. (1992). Indications for therapy of labial frenum. La Pediatria Medica e Chirurgica, 14(6):637-40.

Mintz, S.M., Siegel, M.A., Seide,r P.J. (2005). An overview of oral frena and their association with multiple syndromes and nonsyndromic conditions. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 99:321–4.

Mohan, R., et al. (2014). Proposed classification of medial maxillary labial frenum based on morphology. Dent Hypotheses; 5:16-20.

Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.

Noyes, H.J. (1935). The anatomy of the frenum labia in newborn infants. Angle Orthod, 1:3-8.

Paramala, B.K., & Prithviraj, D.R. (2012). A comparative study of mandibular incisor relation to the lingual frenum in natural dentition and in complete denture wearers. J Indian Prosthodont Soc. 12(4):208-15.

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Priyanka, M., Srithi, R., & Ambalavanan, N. (2013). An overview of frenal attachments. J Indian Soc Periodontal. 17(1):12-15.

Pushpavathi, N., & Nayak, R.P. (1997). The effect of mouth breathing, upper lip coverage, lip seal and frenal attachment on the gingiva of 11-14 year old Indian school children. J Indian Soc Pedod Prev Den. 15:100-3.  

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Suter, V.G., et al. (2014). Does the midline diastema close after frenectomy? Quintessence Int. 45(1):57-66.

Teece, S. (2004). Torn frenulum and non-accidental injury in children. EMJonline. Doi: 10.1136/emj.2004.022079.

Townsend, J. A., et al. (2013). Prevalence and variations of the median maxillary labial frenum in children, adolescents, and adults in a diverse population. General Dentistry. March/April; 57-60.

White, J.A., Bond, I.P., & Jagger, D.C. (2013). A novel solution to the fraenal notch of maxillary dentures. Eur J Prosthodont Restor Dent. 21(3):120-6.

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Torticollis, Plagiocephaly and Brachycephaly

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Ardran, G. M., Kemp, F. H., & Linda, J. (1958).  A cineradiographic study of breastfeeding.  British Journal of Radiology,  31, 156-162.

Arvedson, J.C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. (2nd ed.). Albany: Singular Publishing Group/Thomson Learning, Inc.

Atmosukarto, I., et al. (2009). Automatic 3D shape severity quantification and localization for deformational plagiocephaly. Proc SPIE, Jan1, 7259(725952): doi:10.1117/12.810871.

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Boiron, M., Da Nobrega, L., Roux, S., Henrot, A., & Saliba, E. (2007). Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in infants. Developmental Medicine & Child Neurology, 49, 439-444.

Bosma, J.F. (1985). Postnatal ontogeny of performance of the pharynx, larynx, and mouth. American Review of respiratory Disease, 131 (supplement), S10-S15.

Bosma, J.F., Hepburn, L.G., Josell, S.D., & Baker, K. (1990). Ultrasound demonstrations of tongue motions during suckle feeding. Developmental Medicine and Child Neurology, 32, 223-229.

Breastfeeding and birthing: do birthing practices affect breastfeeding?  (2007). INFACT Newsletter, Winter, 1-2.

Brookes, M., & Zeitman, A. (1998). Clinical embryology: a color atlas and text. Boca Raton: CRC Press.

Broussard, D.L.; & Altschuler, S.M. (2000). Central integration of swallow and airway-protective reflexes. American Journal of Medicine, 108, 62S-67S.

Bruneteau, R. J. &Mulliken, J. B. (1992). Frontal plagiocephaly: synostotic, compensational or deformational. Plast Reconstr Surg: Jan: 89(1): 21-31.

Bystrova, K. et al. (2007). The effect of Russian home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Hum Dev, Jan:83(1): 29-39.

Cabrera-Martos, I., et al. (2013). Clinical profile and evolution of infants with deformational plagiocephaly included in a conservative treatment program. Childs Nerv Syst: Oct: 29(10): 1893-1898.

Cavalier, A., et al. (2011). Prevention of deformational plagiocephaly in neonates. Early Hum Dev, Aug: 87(8): 537-543.

Collett, B., et al. (2005). Neurodevelopmental implications of “deformational” plagiocephaly. J Dev Behav Pediatr: Oct: 26(5): 379-389.

Collett, B., et al. (2011). Development in toddlers with and without deformational plagiocephaly. Arch Pediatr Adoles Med: July: 165(7): 653-658.

Collett, B., et al. (2012). Brain volume and shape in infants with deformational plagiocephaly. Childs Nerv Syst: Jul: 28(7): 1083-1090.

Collett, B., et al. (2013). Development at age 36 months in children with deformational plagiocephaly. Pediatrics: Jan: 131(1): e109-e115.

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Wound Healing

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For The Record

For the Record:

I grow increasingly confused and distressed by the growing misrepresentation of my thinking appearing on Facebook pages. Granted, Facebook was created by two college-aged boys wanting a gossip rag and therefore it is designed to conjure up teenage-like angst and drama, but the sheer number of venomous and downright mistaken commentary about me and aimed at me deserves an “on the record” response.

So, for the record:

1. I absolutely think that truly tongue-tied babies need to receive surgical treatment as soon as they are accurately diagnosed with the condition. I don’t care if it is by scissors, scalpel, laser or electrocautery. What I care about is that the right tool is used for the type of tie, the age of the baby and wielded by a skilled surgeon who knows how to properly use their surgical tool and how to properly treat the baby in the process.

2. I think ALL babies should once again be screened for tongue-tie and other oral issues within a week of birth. That is one of the main reasons I created the Assessment Tool for Lingual Frenulum Function©™ (ATLFF), which, by the way, is valid, reliable, sensitive and specific. It does work, as proven by numerous studies, and it works very, very, well.

Since I was the only researcher 25 years ago who cared to jump through all the methodological hoops to create a screening tool, I have the unique privilege and the responsibility of having done it first. As a result, any new tool must be measured against the ATLFF©™ to establish validity.(1) I didn’t make up the rules, the methodologists did. So far, no one has accomplished this task. That’s just the way it is.

3. So what do I mean by truly tongue-tied? Because I developed some and formalized and codified all of the diagnostic criteria for tongue-tie (Yep, that’s right. I am the one responsible for today’s diagnostic criteria) a truly tongue-tied baby requiring surgery is one who scores <11 on the ATLFF©™ function itmes and <8 on the appearance items. These screening items were very carefully researched and crafted over a three year period back in the early 1990s.

4. The above brings us to the issue of the faux tie. Many people have butchered this concept despite its simplicity. Faux tie babies are those who score borderline on the ATLFF©™. That means they scored 10, 11 or 12 on the function items and 8 or 9 on the appearance items. Faux tie is a specific term that no one has a right to co-opt. I coined it specific to and in relationship to ATLFF©™ scores.

What might cause a baby to score borderline on the ATLFF©™? Here is a partial list:

Asynclitic presentation at birth

Intrauterine lie compromises

Operative delivery like c-section, vacuum extraction or forceps

Cord wraps around neck or body

Compound presentation

Rapid or very slow descent

Failure to complete cardinal movements

Torticollis

Plagiocephaly, brachycephaly, scaphocephaly, etc.

How do I know? We track this at our clinic.

Because the tongue organ inside the mouth box has limited ways to compensate for restrictions of any kind, it makes sense that functional deficits from acquired restrictions will be nearly identical to those caused by the congenital anomaly we call tongue-tie. That’s why differential diagnosis is so very important.

5. That brings me to the next item. Bodywork is a rubric under which all manner of manual therapies fall: occupational therapy, physical therapy, chiropractic, rolfing, craniosacral therapy, osteopathy (as practiced outside the US), etc. There are over a hundred ( and maybe more) modalities that are considered bodywork. Critics claim that there is no evidence to support the use of bodywork. Clearly, that is not factual.

When it comes to craniosacral therapy, the US government funded multiple studies to demonstrate its efficacy. The US armed forces use CST to treat veterans. As to its efficacy in treating infant sucking issues, there are three studies, one of which I designed and performed. As you read this blog, a multi-center, multi-country trial is being designed.

Should bodywork be used to resolve a true tie? The answer is a resounding NO! Can bodywork be used as an adjunct to surgical intervention? Yes, it can. Should it? That is a matter for continued discussion and research. The anecdotal evidence of its efficacy is mounting especially when the tongue-tied baby has a co-morbid acquired structural compromise.

Should bodywork be used to resolve acquired structural issues like torticollis, operative delivery injury, plagiocephaly and the like? It has been for decades. Physical therapy has long been used for torticollis; chiropractic has long been used to address subluxations and nerve impingement. I could cite many more examples but I won’t because everyone of you most likely has some positive experience with one or another bodywork modality.

Is bodywork the magic bullet? Absolutely not! Not every baby is a candidate. One must know whom and when to refer and to whom to refer.

Now let’s get to the really controversial stuff!

6. Do I believe in posterior tie? Let me answer by asking questions of my own:

What does belief have to do with it? Aren’t we supposed to be scientists?

Why does nearly everyone use the general term posterior tie when what they really mean is sub-mucosal tie?

The ATLFF©™ has always picked up on posterior ties so, for the record, I have always known they are a manifestation. The issue I have is with the sub-mucosal tie theory. (Yes, folks, it is only a theory, one that is yet unproven.) I have consistently and publicly been a skeptic. In the absence of solid evidence, I have a right to remain a skeptic until more data becomes available.

Why am I a skeptic? In my personal and extensive experience working with infant sucking compromises , the type of tongue restriction labelled a sub-mucosal tie has resolved with craniosacral therapy 100% of the time. I eschew surgery for these babies in my practice because I have an alternative to it. I would rather use a gentle hand than a beam or a blade.

7. What about the thing called a maxillary lip “tie”? Do I think it exists? Yes, I do. Do I think it’s wrong to cut on every baby who has a tongue-tie, presuming they all have lip ties as well in the absence of valid diagnostic criteria? Yes, I do. Why? Because the literature on the subject is very clear:

The tectolabial maxillary frenum is a normal morphological manifestation in infants. 93.3% of all babies have one.(2)  This normal presentation is what Kotlow refers to as a class III or class IV maxillary lip tie. His classification schema is what many, many people use as their diagnostic criteria. Two well-done studies with very large samples sizes prove that the lip frena change significantly with growth and development: they get smaller, thinner and “rise” on the gumline as the teeth erupt. This process only completes with the eruption of the permanent teeth. (3,4)

So, what most people describe as a lip tie is actually a normal manifestation in infants. No surgery required. Only people in the US have their bowels in an uproar over maxillary lip tie. I speak all over the world. No where else in the world where I have been has this become an issue. Are they all wrong?

I will go into greater detail on the literature in a future blog on maxillary and mandibular frena soon.

Simply put, we have no diagnostic criteria for maxillary lip tie and breastfeeding. In the current state of lack of knowledge on the subject, what ethical side of the issue do you want to be on?

8. And last, but not least: Do you think it is OK to steal someone else’s intellectual property? If you do then you probably ought to take a course on copyright law and professional ethics. It is plain wrong to steal intellectual property and pass it off as one’s own. It is plain wrong to criticize, publicly or otherwise, the owner of that intellectual property when they defend their rights according to the law.

If you want to know what I think about tongue, lip and buccal tie, ask me directly. If you want to say something bad about me, have the courage to say it to my face. Here’s how to contact me:

614-326-3504

www.AlisonHazelbaker.com

If you are interested in participating in a safe, professional and respectful discussion about tongue-tie and other oral issues that impact breastfeeding then join us in the Tongue-tie and Other Oral Issues and Breastfeeding group on Linked-In. No bullying, no libel, no defamation and no drama allowed!

References

1. Greenhalgh, T. (2014) 5th edition. How to read a paper. Oxford: John Wiley and Sons, Ltd.

2. Flinck, A., Paludan, A.,  Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr, 4(2):67-73

3. Boutsi, E.A. (2014). The maxillary labial frenum. J Cranio Max Dis, 3:1-2.

4. Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.

 

Modern Myths about Tongue-tie: The Unnecessary Controversy Continues

23 years ago when I was doing my research on tongue-tie’s impact on breastfeeding and developing the Assessment Tool For Lingual Frenulum Function, the most problematic attitude I ever encountered was resistance to the idea that tongue-tie could create a breastfeeding problem. (1). This resistance was purely due to lack of knowledge about the physiology of infant suck. Occasionally back then, I might have met someone whose resistance was ego-driven: the “Not Invented Here” line of thinking but that was the exception rather than the rule. Then, the challenge for those of us who understood how tongue-tie impacted infant suck was to educate, educate, and educate some more.

Today, the controversy over various aspects of the tongue-tie phenomenon are liberally laced with ego-driven resistance. It seems as if the entire world of practitioners has something to say about tongue-tie, regardless of level of expertise on the subject. And now the notions of “ lip” and “buccal” tie, and to complicate matters even more, this thing called “Tethered Oral Tissue,”  have entered the picture to further confuse parents and practitioners alike. Is this labyrinth of information, misinformation and dis-information helping us to get treatment for truly tongue-tied babies?

A dialectic between smart people who have no vested interest other than to help others remains ever useful. An out and out brawl between various factions of people spouting dogma that is liberally littered with poorly informed opinion does not. I am all for helping moms and babies, but I am definitely for helping them using solid evidence so that they get the right kind of help, at the right time, from the right practitioner.

I vote that we get back to anatomy and physiology AND to using the evidence to support what we do as practitioners and as parents faced with making the decision to have surgery performed on our infants. Let’s start with what we know about tongue-tie.

The facts:

Fact 1: Tongue-tie does exist. It even has its own gene(s) that codes for it.

Fact 2: It manifests with various syndromes, which in and of themselves are relatively rare.

Fact 3: It is hereditary.

Fact 4: It has for a very long time had a clear definition: Tongue mobility restriction due to a tight and/or short lingual frenum.

Fact 5: It is a congenital anomaly. Regardless of whether tongue-tie is genetic or epi-genetic, it occurs during development in the embryonic period.

Fact 6: Because tongue-tie, by definition, is impaired tongue mobility due to a congenital anomaly, it can cause deficits in all functions that require optimal tongue mobility, whether that be breastfeeding, bottle-feeding, chewing, protecting the airway, cleaning the teeth, or helping to form speech sounds. The degree to which this happens is somewhat known but more research needs doing before we have a firm grasp on this. Only then can we fine tune our treatment approach.

Fact 7: The incidence of tongue-tie was only hypothesized until of late. A study out of Australia has shown that the incidence hovers around 5% of all people. (2) More research needs doing before we know an exact figure. The problem with prevalence figures in the past was that no standardized assessment was being used. Dr. Todd, however, used a standardized, evidence-based screening tool for three years in a row in a large sample of infants. He was able to come up with what appears to be a very solid incidence statistic as a result. Please note here that Mother Nature does not create catastrophic increases in incidence of congenital anomalies unless some catastrophic epigenetic influence is at play. To claim that there is a rise in incidence to the tune of 20-50% is a clear misunderstanding of how epigenetic influences function epidemiologically.

Fact 8: Scissors frenotomy performed by trained practitioners has little to no risk. (No such data exists for laser, electrocautery or scalpel frenectomy.)

Fact 9: Breastfeeding improves post-frenotomy/frenectomy as long as tongue function is normalized as a result. Not all babies will show such improvement. (3) Anecdotally, many babies will need further therapy to restore proper tongue-function post-surgery.

Fact 10: Any connective tissue in the body (frena included) can be tight and impair optimal function. At what point that tightness can so severely impact function that no compensation can over-ride the restriction is an important question to put to the researchers.

Now, why do I bring up FACT 10? Because two interesting theories have emerged in the last ten years. One theory proposes that the upper lip frenum can cause breastfeeding problems. One case history was published detailing the way in which the upper lip frenum created a problem. (4) Recently, an article fleshing out the theory was published proposing a classification schema to help people determine the presence of a lip frenum that negatively impacts breastfeeding. (5) Unfortunately for the proposer, the classification system proposed did not go through the validation process so it really cannot yet be said that it accurately identifies the type of upper lip frenum that could cause a breastfeeding problem.

Let’s look at the assertion that a tight, prominent upper lip frenum causes breastfeeding problems more closely. We can use anatomy, physiology and development as our guide. First: the upper gumline changes with growth. A frenum that appears to be restricted in early infancy may substantially change as the baby grows. Second: breastfeeding does not require a lip flange, merely lip eversion. Third: the assertion that dental caries is caused by an upper lip tie begs to be proven. Breastmilk does not pool in the mouth. The position of the nipple in the mouth and the manner in which that milk is moved into the pharynx for the swallow won’t allow it. Both the peristaltic action of the tongue and the pressure differential created by tongue movements quickly push/pull the milk to its ultimate destination.

Fourth: the lips follow the tongue, if the tongue retracts, the lips move inward toward the gumline and when the tongue everts, the lips also evert. This is a developmental reflex that remains active throughout life. Anyone who has ever French-kissed can assert the truth of this. Tongue position plays such a keen role in the positioning of the lips that many types of acquired structural issues, like torticollis, can cause the tongue to retract thereby pulling in the lips. In my experience, this can be mistaken for what the theorists call an upper lip tie.

In my clinic this past year I saw such a baby. She had been misdiagnosed with both a tongue-tie and an Upper Lip Tie (ULT). She actually had low cheek tone and overactive, tight lip tone. One of my colleagues performed some very effective bodywork to bring down the lip tone and bring up the check tone. It took her 3 minutes to rectify the problem at no cost to the mother and the baby was saved from unnecessary surgery.

That leads me to my next point, without a valid definition of upper lip tie (one based on solid facts about how the labial frenum impairs lip mobility in the SPECIFIC manner that actually impairs breastfeeding) then we are hard-pressed to be able to assess it properly. The exact characteristics of a phenomenon must first be established before assessment tools can be generated to assist the clinician in proper diagnosis. No such work has yet been done.

We have put the proverbial cart before the horse when it comes to the theory of upper lip tie. How many babies have suffered the consequences as a result?

Does that mean Upper Lip Tie doesn’t actually exist? Theoretically it could because any connective tissue in the body might, out of tightness, negatively impact function. Does a tight, prominent labial frenum actually negatively impact breastfeeding? Only future research will prove or disprove this theory. Until the evidence shows us what is true, ethics dictate that practitioners remain conservative in their clinical approach.

Let’s talk about the second theory: that of the sub-mucosal posterior tie. I have been liberally accused of not believing in the posterior tie. Belief has nothing to do with it! Any clinician operating by belief is shirking his or her professional and ethical duty.

My clinical approach to the sub-mucosal tie theory is conservative. To my knowledge, no research has ever been done to verify that a restriction at the tongue-base that presents as a thick, shiny string under the mucosa is an actual tongue-tie. My experience as a structural therapist, and in the experience of many a bodyworker throughout the world, has shown that this type of tongue and/or mouth floor restriction resolves with simple bodywork; that the actual cause of this type of restriction is an acquired soft tissue strain pattern due to intrauterine or birth events.

Once again, anatomy can inform us. That tight shiny string of tissue underneath the mucosa at the tongue base may very well be the septum of the genioglossus muscle, the tough aponeurosis (a type of fascia) that connects the two halves of the genioglossus muscle together helping to stabilize the tongue in the mouth. The septum attaches to both the inside of the mandible at the mentis and to the hyoid bone in the upper throat and is confluent with the hyo-epiglottic ligament. The septum is easily visualized when two fingers press back against the tongue-base. Some practitioners claim this maneuver renders an accurate diagnosis of “sub-mucosal tongue-tie” but it may be revealing the septum of the genioglossus muscle. One has to know what one is visualizing to avoid making an erroneous diagnosis.

Ultimately, what seems to get lost in the argument over sub-mucosal tie’s existence or non-existence is that theories must be proven. We all share the burden of that proof (or disproof.) It is completely legitimate to remain skeptical until more data emerges, especially when the “cure” suggested involves cutting on a baby! I remain skeptical. The dearth of evidence for this phenomenon, which may or may not be the congenital anomaly we call tongue-tie, coupled with my own experience working with these babies as a bodyworker keeps me sitting on the fence.

Let’s now turn to the myths:

Myth 1: The incidence of tongue tie is increasing. No one, anywhere can make this assertion. No accurate incidence statistics existed prior to Todd’s 2014 study. (2) The incidence may well indeed be population-based but epidemiological studies must be done to assert this as fact.

Myth 2: All babies who have a tongue-tie have an upper lip-tie. How can this be true? We have no idea what a lip tie actually is and no valid, reliable assessment tool to even begin discerning who may have an issue and who does not.

Myth 3: Laser frenectomy is better than scissors frenotomy. No evidence demonstrates that this is the case. Any advantages of either are postulated.

Myth 4: All tongue-tied babies need a deep frenotomy. It might be true that some babies will achieve optimal range of motion of the tongue with a shallower snip. We need more evidence to make such a determination.

Myth 5: LASER frenectomy is completely safe. LASERs are, in fact, very dangerous and can do significant damage when used by an untrained practitioner. A definitive set of safety rules guide practioners to utilize LASER equipment without posing harm to themselves or their patients. There are several different types of LASERs; some more suited for soft-tissue surgery. The wrong LASER can damage collateral tissue and create excessive scar tissue that may cause re-attachment. Currently, there is no requirement for a dentist or doctor to receive training to use LASERs before performing surgery on babies.

Myth 6: The scar tissue in the wound bed must be broken down several times per day to prevent excessive scar tissue formation (re-attachment). According to new research, the frenum is a tendon, a type of fascia. (6) Breaking down the scar tissue in the fascial wound bed causes myofibroblasts to lay down a dense collagen network (excessive scar tissue formation). (7) Gentle is better, both physiologically and psychologically. It is a shame when we cause a baby trauma from too aggressive post-surgical management. Come to think of it, there is no solid evidence that post-surgical aftercare prevents re-attachment. Two studies have been performed; one was extremely flawed.

Myth 7: There is a posterior tie behind every anterior tie. Histologically this is not true. (6) This cute statement is misleading if the purpose is to encourage surgeons to remove enough tissue to adequately mobilize the tongue. It seems much clearer to say that enough tissue must be removed (without cutting into muscle) to restore optimal tongue mobility in some babies.

Myth 8: Posterior ties are more common than anterior ties. Oops! Todd’s research definitively shows this is not true. Proper assessment, proper assessment, proper assessment and differential diagnosis!

Myth 9: Classification schema serve as proper assessment. Nope, they don’t. An assessment tool must possess the following: validity, reliability, sensitivity and specificity. (8) In other words, they must be designed and be proven to accurately identify the phenomenon being assessed, be able to do so accurately from assessment to assessment and from assessor to assessor and must be able to do so nearly 100 percent of the time. A tool that falsely identifies someone as having a problem when they don’t or not having a problem when they do is not accurate enough.

Myth 10: Any lactation consultant knows how to properly assess for tongue-tie. As in any profession, members of that profession must be trained to properly assess for any given phenomenon. For that matter, not all physicians, dentists, speech-language pathologists, etc. have been trained to assess for tongue-tie. It behooves parents to ask if the practitioner has been trained to assess for tongue-tie using an evidence-based assessment tool.

For some reason, tongue-tie has become the poster child for dogma and controversy. We are at the very beginning of our understanding of this congenital anomaly. (Don’t let anyone tell you otherwise!) That means that no one knows the entire story, yet. Time and more research will tell us what is true and not true about this phenomenon. Until then, we must exercise healthy skepticism, continue to ask the hard questions, engage in respectful dialectic and err on the side of caution. Our vulnerable babies depend on us to keep them safe from harm, and that includes holding off on surgery if no evidence exists to put them through such surgery.

Our egos must learn to stand the strain of not knowing.

References:

1.       Hazelbaker, A.K. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Aidan and Éva Press.

2.       Todd, D. (2014). Personal communication.

3.       Dollberg, S. et al. (2014). Lingual frenotomy for breastfeeding difficulties: a prospective follow-up study. Breastfeeding Medicine: Vol.9: 6: 286-289.

4.       Weissinger, D. & Miller, M. (1995). Breastfeeding difficulties as the result of tight lingual and labial frena. Journal of Human Lactation: 11: 313-316.

5.       Kotlow, L. (2010). The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: prevention, diagnosis, and treatment. Journal of Human Lactation: 26: 304-308.

6.       Martinelli, R., et al. (2014). Histological characteristics of altered human lingual frenulum. International Journal of Pediatrics and Child Health: 2: 6-9.

7.       Schleip, R., et al. (2012). Fascia: the tensional network of the human body. New York: Churchill Livingston.

8.       Greenhalgh, T. (2010). How to read a paper: the basics of evidence-based medicine (4th ed.). Hoboken: Wiley-Blackwell BMJ Books.

Conventional Allopathic Vs. “Alternative” Holistic Health Care

 

by Dr. Alison Hazelbaker

It irks me to no end when conventional (allopathic) health care providers dismiss traditional therapies by attaching the moniker “alternative” to describe where they fit into the health care spectrum! Alternative to what? This implies that conventional allopathic medicine is the gold standard and traditional therapies run second, third or last; (the, OK we’ll let it slide because so many people use them but we don’t really believe they work attitude). Traditional approaches to restoring and maintaining health predate allopathic medicine by thousands of years and have worked pretty damn well all of that time.

Here’s the truth of the matter:

Over 70% of adult Americans consumed Complementary and Alternative Medicine (CAM) services spending $36 to $47 billion dollars, (12.2 to 19.6 billion out-of-pocket), in 1997 alone! In 2002, 62% of adults used complementary and alternative therapies, nearly half of them utlizing prayer as a form of health therapy. (Barnes, et al. 2004).

The average person utilizes “alternative” therapies not because doctors are non-compassionate, uneducated or poorly trained in their discipline but because allopathic medicine fails to meet their need for a holistic perspective of health.

 

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