Tongue tie, Lip tie, and Cheek tie
Cognitive bias: “The Law of the Instrument”
In the case of frenectomy, the tool is generally a CO2 dental laser or scissors.
The “Law of the Instrument” is a cognitive bias attributed to psychologist Abraham Maslow in 1966: “When we have a hammer everything begins to look like a nail.” This concept describes the common phenomenon that occurs when there is an over-reliance on a familiar tool to solve every issue.
While it’s true that oral ties are often missed by providers who have not pursued continuing education on the topic, that many babies with feeding issues have oral ties, and that oral ties create a domino effect of dysfunction... oral ties are not the root cause of every feeding issue.
We must assess all feeding issues in infants without bias (without presuming they are always due to oral ties). It’s also important to note that if a baby does have oral ties, there can be a multitude of other reasons why they are struggling with feeding.
To name just a few:
inaccurate advice about feeding frequency, latch at breast or bottle, or positioning
low oral muscle tone
high oral muscle tone
muscle weakness
difficulty coordinating suck-swallow-breathe
gastroesophageal reflux (GER)
food allergies, sensitivities, or intolerances
thin or missing sucking pads
Torticollis (neck asymmetry)
Tortisoma (body asymmetry)
laryngomalacia (or other congenital airway anomaly)
neurological condition
To conclude, feeding issues are multifaceted and complex. Therefore, it is biased to assume that all feeding issues are caused by a tongue tie.
A Domino Effect of Dysfunction
Oral ties form during the first trimester of pregnancy and cause a domino effect of dysfunction. Some issues that occur as a direct or indirect result of this "oral anatomy domino” falling include:
uncoordinated tongue, lip, and cheek movement
suboptimal oral resting posture
compression-dominant latch and suck pattern (more up/down movement with lips and gums to generate positive pressure as opposed to negative pressure / oral suction)
“Aerophagia-induced reflux” (AIR) related to air swallowing during breastfeeding and bottle feeding
asymmetrical tension and movement patterns throughout the baby’s mouth and body which can lead to more pain and/or dysfunction when nursing on one breast vs the other breast
Nipple pain and damage
slow or no weight gain
low milk supply if the mother isn’t pumping regularly to compensate for the poor stimulation the baby is providing
shallow latch
poor breast drainage which can lead to plugged ducts and mastitis
the list of other fallen dominos goes on and on
Many families are led to believe that the frenectomy (surgical release of oral ties) will fix all of the issues they have been experiencing. Unfortunately, this is not true... although wouldn’t it be lovely if it was?
The frenectomy only addresses that first domino. All of the other fallen pieces are still down and must also be addressed in a logical order so that the issues with feeding, oral function, movement patterns, and lactation are resolved.
Neuromuscular re-education
It is helpful to have an infant feeding specialist establish a baseline of skills before the release and help facilitate neuromuscular re-education following surgery.
Many babies continue to have the same feeding difficulties after surgery, and unfortunately, some babies experience new feeding difficulties post-op. The surgery releases the tethered oral tissue (tongue, lip, and/or buccal/cheek ties), increasing the passive range of motion of the tongue, lip, and/or cheeks, however, this can lead to disorganized movement or a lack of stability if baby’s oral muscles still are not very strong and well-coordinated.
Neuromuscular re-education must take place following the surgical release for the oral motor plan for feeding to change, and therefore, for feeding to improve. To say this another way, babies must re-learn to suck and use their tongue/lips/cheeks/jaw more functionally for feeding to improve. Some babies work this out on their own post-release but others do not.
You are taking the first steps towards meeting your goals and preventing issues like the ones listed above by just reading this blog.
Wishing you a beautiful breastfeeding journey!
