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The new breastfeeding Dyad is mom and baby, not lip and tongue. So, when providers are doing the exam, we are not just looking at lip and tongue, we are looking at the baby.

Historically, after tongues of babies were released, some still had problems. Observation of babies nursing revealed that there was no upper lip flange. So, providers started releasing lip ties with great success. It is important on the clinical exam to check suck by placing the index finger in baby’s mouth. If baby bites or gums the doctor’s nail, he is biting mom’s breast and has a poor latch. Breastfeeding should be enjoyable, not painful. The upper and lower lip must flange for a latch that encompasses the areola, not the nipple. Watch baby nurse, rub nipple over lip and baby opens mouth. Don’t torpedo nipple into baby’s mouth and closely watch pre and post procedure nursing. Additionally, providers sometimes recommend that anesthetic be avoided because we want baby to go right to the breast.

The real crisis we are facing is infants not getting the treatment they need.

The resistance providers who release oral restrictions often hear are from ill-informed pediatricians, ENT and lactation consultants who do not know how to properly evaluate the nursing baby and mother.

If a pediatrician or ENT says that we are “torturing that baby,” the real question is, “Who or what is torturing that baby?” If we allow him to have colic, reflux and pain when he could be fixed in five minutes, then we should intervene. In fact, many of these babies are inappropriately taking Nystatin for thrush when it’s actually milk on the tongue that cannot wash off by contacting the palate due to restrictions. Babies are sometimes placed on prescriptions (Prevacid, Zantac) for reflux and / or colic when the cause is a tongue and/ or lip tie that can be resolved in a few minutes. It is important to keep the infant chemical free if possible. As a doctor, we took an oath to “First, do no harm.” Somewhere on this journey we seem to have forgotten that our patients’ wellbeing is our first obligation, not someone’s ego.

Dr. Kotlow described the resistance that he faces daily from pediatricians, American College of Pediatric Dentistry, ENTs and other providers. Procedures must be justified as medically necessary. Currently, the guidelines of American College of Pediatric Dentistry’s guidelines states that “…frenotomies should be delayed until the permanent incisors and cuspids have erupted and the gap between the front teeth have been given a chance to close naturally. If the patient requires orthodontics, the release should be performed after the diastema closes as much as possible.” This does nothing to help the breastfeeding infant at the age of 9-11 and has done extensive harm rather than good.

Medically necessary care is the “reasonable and appropriate diagnostic, preventive, and treatment services and follow-up care as determined by qualified appropriate health care providers in treating any condition due to

1. Disease

2. Injury

3. Congenital or developmental malformation

Medically necessary care includes all supportive health care services that, in the judgment of the attending dentist, are necessary for the provision of optimal quality therapeutic and preventive oral care.”

Oral restrictions can lead to failure to thrive, decreased immunity, colic, reflux, maternal depression, orthodontic issues, gastrointestinal, tooth decay, airways issues and decreased bonding. This happens over the lifetime, destroys maternal confidence and sets up mothers to fail. It is obvious that oral restrictions are medically necessary. The question we must ask is, “Why do mothers give up breastfeeding?” The answer is clearly the lip and the tongue.

Common Myths:

The upper lip is not important in breastfeeding.

If you release the upper lip, it will affect the roots of the baby teeth.

The procedure requires the operating room and general anesthesia.

Lasers do not work and are not safe for children.

Revising the upper lip causes “floppy lip”.

The procedure requires sutures.

Infant will pull sutures out and will not handle healing time.

Active wound management the post-surgical exercises are too difficult: (if done properly the first 7-10 days, sites should heal up nicely).

Children will fall and fix it themselves.

From a pediatrician: “The baby’s mouth is dirty so cutting the tongue will cause infection.”

It is important to listen to mothers and their instincts. If mom presents with no pain and baby is growing, but maybe two months down the road there may be a problem. Some moms have an oversupply and babies don’t really have to suck due to high supply satiating infant’s caloric needs. Some kids may have flexible floor of the mouth. So there is compensation and there seems to be no problem initially but later there is a problem. We must ask, “Does he have a lot of colic?” Mom may respond, “Yes, feeds three times an hour and is up all night.” It is important to get good information. Just because baby is gaining weight doesn’t mean there is not a problem. Sometimes parents do not realize what is truly a problem.

When checking the baby’s suck, if it is at the nail, then baby is tied. We want it between the first and second knuckles because that means the areola is properly latched. If there are cavities on the lip side of the top front teeth, there is a good chance the baby has an upper lip tie. Observe the lips for a callous and the back of the tongue for a whitish, milk-stained appearance. It is important to observe babies nursing before and after the procedure. A good latch requires no restriction of the lips and tongue and lips must flange.

Dr. Kotlow emphasized the importance of an integrated, team approach. An email from one of his patients exemplifies his philosophy, “Thank you for all your help, it took a team effort to get this boy nursing normally.”