Treating Tongue Tie: Evaluation of the Mother-Baby Dyad

[Gopi Shah]
..I would love to hear more about the mother as a patient as well in the sense of tell us just specific concrete things that you... what's part of your H & P in clinic when the baby and mom comes in?

[Felicity Lene-Voit]
..The first things that I'm looking for are signs that there might be a latch issue because that's directly related to the baby's ability to extract milk, but then there are also reasons why maybe baby is doing fine but mom may not have as good a supply. And of course, it's kind of difficult to tease that out because it could also be related to negative feedback from baby not doing a great job extracting because of a tie or a poor tone or any other reason.

But I asked mom about her thyroid status in pregnancy, which is something that all OBs test for…I ask her if she's breastfeeding if her breasts feel full before a feed and then empty afterwards. This is more on the baby side, but I ask about the suck, swallow, breathe sequencing to make sure that baby's sucking a few times then swallowing then breathing rather than just suck, suck, suck, suck, suck and not really needing to swallow because that can be an indicator that they're not extracting very much milk.

I've had a couple of moms who make so much milk and they're coming to me because of difficulty eating in it. It turns out not that the baby doesn't have a tongue-tie it's just that mom has so much milk that the baby's almost choking on it because there's either a forceful letdown or there's just so much milk the baby's kind of overwhelmed by it. And usually that's in younger babies. Usually as babies get older they can handle fast flow a little bit better or they come up with mechanisms to deal with it.

[…]

[Gopi Shah]
Right. What other things do you take into consideration?

[Felicity Lene-Voit]
So some people have different responses to birth control. There's not a lot of great evidence to support that in populations, either estrogen containing birth control or something like the Depo shot or a progesterone implant affects supply. But some moms swear that it does. And so I always ask about it just to have it in the back of my head. If they had a prolonged induction then the baby could have sort of falsely inflated birth weight, and especially in very young infants who haven't regained their birth weight yet it's useful to know that because we might be shooting for a target that's falsely inflated, and we might think there's a problem when there actually isn't.

[Felicity Lene-Voit]
And so in that case, I'll try to see if we can figure out what the 24-hour weight was because that's more likely to be a little bit closer if the induction took longer than 24 hours and mom got a fair amount of fluids in labor. If mom had a C-section, that's a risk factor for potential delay of lactogenesis too, so the transition from colostrum to a more mature milk. And particularly if there's any hemorrhage that happens. And so I ask about skin to skin mode of delivery. No one ever has any idea I'm sure. I mean, I don't know how many bags of fluids I got in labor either, but as a general rule if it took a long time, it's probably a little bit higher risk.

Scheduled C-sections are higher risk for delay in lactogenesis than our sections where mom labored for a while and then had a section for failure to progress or some form of fetal distress. But the trade-off is that when we're seeing those moms with really young babies, they're still pretty exhausted from the process of laboring and then having a section. So it can be hard to tease that out.

The other thing is there's so many demands on a new mom's time. Sometimes it's something as simple as how much water are you drinking, and they're not taking care of themselves because they're trying to take care of this baby. And then if they're not hydrating it's hard to give baby hydration if you're dehydrated.

So I don't ask everyone all of those questions, but sort of according to how the history is going those are some things that I definitely do ask. I ask primip versus multip, "Have you successfully breastfed in a child before?" And I find that the more kids that a mom has had that, and this is born out by the evidence as well, that the quicker milk usually comes in and the more sense they have as far as at least comparatively what the quality of the latches.

[Ashley Agan]
So the quality of the latch is related to if she's had multiple kids. Is that what you're saying?

[…]

[Felicity Lene-Voit]
I think she just has more of an experience-base to know what a normal latch is. And especially in the beginning, when you have a small baby with a small mouth, there can be sort of a size mismatch between nipple and mouth and even a very mobile tongue and non-retrognathic chin and a good anatomy baby with a tongue that can be very mobile to extract milk might still have a hard time with latch and there might be painful latch. But something that's a warning sign for me is pain that lasts more than the first couple minutes or so of the feed. There's a lot written by lactation consultants about lipstick shaped nipples. And then cracked fissured nipples are certainly something that I worry about.