Oral Restriction –
What is it?, Does my baby have it?
What are Oral
restrictions?
A frenulum is a small fold of tissue that secures or
restricts the motion of a mobile organ in the body. They are present in the
oral cavity (mouth), digestive tract and male and female genitalia. There are 3
common types of oral restrictions that we see, tongue ties (ankyloglossia), lip
tie and buccal ties.
Tongue tie by definition is the embryological remnant of
tissue in the midline between the under surface of the tongue and the floor of
the mouth that restricts movement of the tongue. (IATP). If there is a tongue
tie, the frenulum can be made up largely of collagen which stretches very
little max 3%, compared to normal frenulum which is normally made up from
mucous membrane. Lip tie which is less common is attachment of the upper lip to
the gum tissue. Buccal ties are the least well known and most uncommon. These are tethers extending from the cheeks
to the gums.
What should the
tongue be able to do?
When the baby’s mouth is open it should be able to elevate
the tongue and maintain this elevation, move the tongue side to side
(lateralise the tongue), cup and spread the tongue.
How does the baby
suck the milk?
Baby opens mouth wide, the lips create a seal to help create
a vacuum. The tongue then curls around and cups the breast creating a seal. The
baby then lifts and drops the tongue to create a vacuum to remove the milk from
the breast. The tongue also grooves to help control the bolus of milk. Cheeks,
jaw and facial muscles help stabilise the breast and facilitate the tongue
to drop and draw out the milk. The
palate plays an important role creating the vacuum, also closing off the
nasopharynx for swallowing. Can see that
if there are restrictions or problems with any of these areas, it can affect
how effectively the baby is able to remove the milk from the breast and effect
breastfeeding relationship.
Symptoms of the baby
The baby symptoms can be varied amongst babies but can be
irritability or colic, coughing, choking and gulping during feeds, tired and
falling asleep at the breast most feeds, difficulty latching, gassy or having
excessive wind, sliding off breast and continuing to have to relatch, gumming,
chewing and clamping down on the breast, clicking noises or poor suction noses,
poor weight gain or weight loss, and reflux. These symptoms can be masked at
times if the mother has an oversupply of breastmilk or if the baby is being
topped up with expressed breast milk or artificial milk.
Mothers symptoms
The mothers symptoms are as important as the baby symptoms
and must be assessed. These can be cracked, blister, bleeding and painful
nipples. Nipples look pinched, creased, bruised, or abrasions on the nipples
after the feed. White stripe on the end of the nipple. Discomfort or pain while
breastfeeding. Low milk supply. Plugged ducts or mastitis. Thrush. General
frustration with feeding and dreading the baby waking up and not wanting to
breastfeed. Many of these symptoms have a variety of causes which is why
important that they are thoroughly assessed by a certified lactation
consultant.
How are oral
restrictions treated?
A simple surgical procedure called a frenotomy can be done with or without anesthesia in the hospital nursery or doctor's office. The doctor examines the lingual frenulum and then uses sterile scissors or, if trained can use a laser, to snip the frenulum free. The procedure is quick and discomfort is minimal since there are few nerve endings or blood vessels in the lingual frenulum. Babies generally don’t like being held down or restrained which can cause some agitation. If any bleeding occurs, it's likely to be only a drop or two of blood. After the procedure, a baby can breast-feed immediately. Complications of frenotomy are rare — but could include bleeding or infection, or damage to the tongue or salivary glands, usually when done by untrained practitioner. It's also possible for the frenulum to reattach to the base of the tongue.
The upper lip tie is a little different, as the upper lip frenulum has extensive blood supply and many pain receptors. This procedure needs to be done under anesthesia. It is suggested that the tongue tie be addressed first, once tongue position and function is corrected, the upper lip frenulum can be reassessed and treated only if upper lip is being prevented from being everted. A wait and see approach is valid for upper lip frenulums.
While deciding on treatment
It is important that while deciding on treatment you feed the baby.
·
Work with your lactation consultant to find ways to get that baby to latch
and drink as effectively as possible using various techniques such as nipple
flipple and laid back positions.
·
Protect your milk supply. If baby is
not adequately removing the milk, discuss with your lactation consultant ways
to increase and maintain your supply through expression or other methods to
keep the milk flowing adequately.
·
Treat other issues in the meantime. If the mother has developed cracked
painful nipples, or thrush, make sure work with lactation consultant and health
care provider to treat these issues so when you have made your decision you are
starting from the best possible place.
·
Educate yourself on the short and long term consequences of treating or not
treating the oral restriction. This is the best way to make an informed,
evidence based decision. Ultimately it is the parent’s decision whether or not
to treat or wait and see.
Aftercare
If you have decided to do the frenotomy, it is important that you
·
Breastfeed immediately. After feed the practitioner will check that
bleeding has stopped.
·
Functional exercises to improve mobility and suck strength must be taught
and done. This baby may have been sucking incorrectly from birth so important
that teach baby how to suck correctly.
·
Pain relief is rarely needed but paracetamol can be given if necessary.
·
Contact your health care provider if bleeding reoccurs.
Take Home
If you are having feeding concerns and suspect that might be oral restriction. Contact a qualified lactation consultant in your area. Important that full feeding assessment done, including maternal and infant history, examination and feeding observation. Importantly Protect your Supply.
Samantha Crompton RN RM Psych & Comm. SACLC lactation consultant
