Wholism, Compassion, and Realism: Is Revision Always Really Necessary? - guest post by Gabrielle Goldach, DC

Introducing Dr. Gabby Goldach, DC, a treasured colleague and a mentor. I had to reprint this blog of hers (with her permission, of course) because she so beautifully articulates what I wish I could say but find myself grasping for the right words to say it well.

Dr. Goldach gets stellar results and prevents tongue-tie surgery regularly in those babies who do not have true tongue-tie. In this lengthy blog post, she explains why she gets the results she does.

I encourage you to read through to the end. It will be worth it!

— Alison K. Hazelbaker, PhD, IBCLC, FILCA, CST-T, RCST, PPNE

In sitting down to write, I find myself dragging a string of words that want to lean upon the importance of healthy debate – an art form that may seem far and foreign in a world in which we can insulate ourselves in resonant thought bubbles with a simple click of a blue button adoringly labeled “unfollow”.

We have seemingly decided, culturally, to shy away from that which is challenging, as, for just about any topic, we can most certainly find an echo chamber in which our thoughts, ideas, beliefs, and theories can indubitably be corroborated, justifying that which may resonate as a truth, be it individual or collective.

May we start with something with which (hopefully) we can all agree?

Infants, mothers, fathers, and families as a whole are direly in need of more sound support systems.

One of the biggest inspirations for the creation of my own space of healing and practice (the inside space. a family chiropractic studio) was to cultivate, from the ground up (or rather, from the deepest corners of my social media grid to the walls of my physical space) a home for ultimate acceptance, for profound healing, generational change, sharing of wisdom and knowledge, and an abode for questions galore. Not to mention, a bad ass web of trusted providers and practitioners with whom we can all learn, collaborate, share, and care.

When building the inside space, I intentionally decided to withhold the word “chiropractic” from the first chunk of the title. Most people have a fairly strong preconceived notion of what chiropractic is and is not, can and cannot support, and can and most certainly cannot facilitate in healing. It has been my mission over these last two years to absolutely flip this definition on its head.

For my left-brain analytics who thrive on the literature, I have something for you.

A study was done on male rodents some years ago. These male rodents were exposed to the scent of cherry blossoms and then promptly delivered an electric shock. Their physiological response was measured. This created a stress response in the systems of the male rodents each and every time.

These male rodents then had offspring. These offspring were then exposed to the scent of cherry blossoms, electric shock withheld. And you know what happened? Their bodies, too, responded as if an electric shock had been delivered to their systems, just like that of their fathers. From the simple exposure to a scent that their fathers associated with a trauma, their physiological response was that of trauma, too.

But wait, there’s more.

Researchers then tested the next generation (2 generations away from the original shockees), exposing the grandchildren (rodents??) to the scent of cherry blossoms. They, too, had a physiological response resonant of the trauma that their forefathers experienced.

Trauma responses are hard-wired in our DNA passed through our ancestral and generational lines – until someone decides it is time to crack the code and make a change.

Cue the work I get to walk with people as a chiropractor.

As a chiropractor, what I care about most is the nervous system.

Not only do our nervous systems control all of the magical things that happen in our bodies, but they are also the interface that allows us to perceive our world, both our inside world and our outside world.

Within this autonomic (meaning self-driving or involuntary) nervous system exists a built in system of surveillance that is constantly scanning our environment looking to perceive, detect, and then ultimately help us to embody cues of safety from our worlds, outside and in.

When our nervous system can exist in a state of safety perception, our bodies and nervous systems can essentially be in a state of healing, growth, and restoration.

This is where we do things like regulate our emotional state, have rockin’ cycles, experience optimal digestion, get sound sleep, socially engage, play, and grow.

This is also where we do all of our healing – physically, chemically, mentally, emotionally, and spiritually.

If for some reason we are not able to perceive, detect, and embody cues of safety from our world, our nervous system shifts to a state of mobilization. Mobilization may be experienced as an energy that feels heightened or activated. We may perceive an increase in heart rate or respiration. We may notice an excess of energy that tends to live above the diaphragm, ultimately wanting to be used (mobilized) to then shift away from a perceived threat and then back to safety. Our bodies may feel stiff and rigid, as if we are in a constant state of bracing for impact.

Mobilization is not something that is bad. It is simply a state that allows us to ramp things up, ideally so we can navigate our way back to safety perception.

The problem many of us (and more and more infants and recovering, postpartum mothers) face is that we have uncoupled with our ability to navigate our way back to safety.

If we remain in a state of mobilization for long enough or if we experience extreme trauma, trauma of which is absolutely relative to each and every individual (hello increasing the conversation surrounding trauma in pregnancy, birth, and postpartum), then our nervous system shifts from a place of excess energy that wants to be used and into a state of shut down, collapse, depletion, and perhaps even dissociation.

If you are wondering when we are going to get into the part about tongue and lip tie, I promise you that we are, in fact, close. Long-windedness is the name of the game around here, so if you’ve made it this far, I thank you, and hang with me just a little bit longer. We’re going to bring this all home.

For the first 40-ish weeks of a (your!!) baby’s life, home is a place that is dark, quiet, compressed, safe, and predictable. All needs are inherently met. Baby does not have to work hard to acquire nutrients, to go to the bathroom with ease, to rest, etc. Y’all get this picture, yeah?

Fast forward to birth.

Baby transitions into a world that is entirely novel. Everything is new, except for mom.

And for mom, for the woman, she, too, has been reborn anew.

Baby is now in a world that is the opposite of where he or she just started this adventure, now finding that this new world on the outside is loud, bright, unpredictable, and entirely new.

Basic needs take some effort to meet.

I don’t know about you, but this would most certainly send my nervous system into a state of mobilization, or, bracing for impact.

May I geek out with you for just a moment? I promise to keep it brief (I’ll try).

Back to the part of our nervous system that perceives, detects, and supports us in embodying safety.

The tenth cranial nerve, the Vagus nerve, is the name of the actual tubing and wiring that is a large conveyor of sensory information back to our brain, alerting us that we are in fact, okay. However, it does also have a motor component (meaning that it sends information from the brain to a group of muscles allowing them to move and do their thing). Where may these muscles be found?

In the mouth, the throat, and the vocal cords.

In fact, the very wiring that controls and conveys our perception of safety, also controls the mechanisms that allow us to feed and latch, coordinate swallowing, intonate our voices, and ultimately utilize certain muscles of the tongue that are absolutely key players in coordinating what we call “suck, swallow, breathe”.

In synopsis, it is absolutely imperative that the newest members of this world (and their mothers) exist in the context of nervous systems that can perceive, detect, and embody safety, in order to meet the basic need of feeding and tongue coordination.

Now, with this newly acquired knowledge of the intricacies of our nervous systems, may we, together, look at the fact that so many of our babies, who now must work hard for their needs to be met, may be existing in bodies that are more in a state of mobilization and bracing for impact as opposed to one of full and utter safety perception and ease?

Here comes the tongue tie portion, FOR REAL!

As we have seen culturally, we exist in an extended season in which quick fixes seem to be what everyone is after.

Can we agree that there really are no quick fixes, particularly when we take into consideration how our nervous systems are wired, not just from our own lived experiences, but from the experiences of those who came long before us?

A quick fix that has taken our culture and society by storm is the release of supposed tongue and lip ties.

I would like to start by sharing where I obtained much of my own learning on this matter.

I have been formally trained in tongue tie assessment by Dr. Alison Hazelbaker – the creator of one of the only, if not the only, research backed tongue tie screening tools. She has obtained more letters behind her name than anyone I know. Included in this is IBCLC, PhD, and CST-T, just to name a few. This is in addition to the 40+ years she has spent in her own clinical practice, caring for over 10,000 infants, supporting them in acquiring full access to their suck-swallow-breathe mechanism. I call her a mentor, and I am also fortunate enough to call her a friend.

In my own practice over the last 5 years, I have seen infants from all over the globe, having worked in Norway, Singapore, and Belgium, before finally coming back to open the inside space in my hometown of Columbus in October 2021.

I have seen that infants in this country are coming into this world, fully braced for impact, and it is causing real difficulty in their ability to feel at ease and at home within their bodies.

The tongue exists not in isolation as a unique organism, but as a portion of a chain of connective (fascial) tissue called the deep front line. The deep front line of fascia starts at the tip of the tongue, goes through the frenum of the tongue, the floor of the mouth, through the throat, esophagus, lungs, diaphragm, hip flexors, ultimately culminating in the toes.

Tongue to toes, y’all, tongue to toes.

Do we see where we are going with this?

When our nervous systems mobilize, they cue our bodies to brace for impact, which, you guessed it, communicates to our deep front fascial line to also lock down, brace, and protect in the chance of a looming impact.

What does this do?

This gives the impression that the tongue has diminished mobility, flexibility, and peristaltic motion.

The quick fix says?!

Cut it. Laser it. Release it.

In my years of my own clinical practice, I have never seen a tongue tie release also positively impact the root cause of why the tongue appeared to have a posterior tie in the first place.

The body is still bracing for impact.

We have now just destabilized further an already unstable system instead of simply addressing the root cause – the nervous and fascial system that is holding everything that these new, little bodies have experienced thus far.

With chiropractic, craniosacral, or other trauma-informed body work applications, we can support these full humans (yes, they may be babies, but they are full PEOPLE) in landing in their bodies with ease, increasing their ability and bandwidth to perceive safety in this brand new world.

We can help them to upregulate their vagal system, while supporting them in downregulating the part of their nervous systems that tells them that their world may not hold safety.

We can support the mothers in feeling at home, at ease, and trusting in their own systems, as opposed to feeling caught in loops of hypervigilance and fear of doing the wrong thing. And ultimately, the programs of fear and vigilance may not be her own, but that of a past generation.

We get to rewrite this.

We get to show up with trust that our bodies are not wronging us, but are so intelligently doing their best to express an unmet need.

As per the current research, the current incidence of true tongue tie is 3-5%.

3-5%!!!!!

Yet, I’m sure that each and every one of us knows a handful of infants who have had releases done, with the majority being sent by an LC, IBCLC, or even a midwife directly to a pediatric dentist for a release (a surgery) prior to being sent to someone like myself or Dr. Hazelbaker for truly holistic bodywork and care that honors the wholeness of this tiny person before us, as opposed to mechanistically looking at them like they are a problem needing to be fixed.

And the truly unfortunate reality is this: even those who have been sent for releases likely end up in offices like mine because mom is still feeling in her gut that something is still not being expressed within her infant to the fullest potential (please notice I did not say that something is still wrong).

These infants who have experienced surgeries and interventions prior to receiving any bodywork at all not only have the experience of adapting to this brand new world to navigate, but now have been exposed to physical, emotional, and spiritual trauma that so many discount as negligible because it is performed on infants “when they are so young”.

This is the exact reason for which we would be wise to use extreme discernment before doing anything drastic (yes, tongue tie release is drastic relative to what we can do within the context of a vitalistic and holistic model of care).

What are we showing our children by resorting directly to a trendy “quick fix” before stepping into a state of trust in the intelligence that exists in the body in every second of every? Are we showing them that they are wise, intelligent, sentient beings who hold wisdom and answers within themselves? Or are we reinforcing the cultural narrative that health and healing are something that lie beyond the confines of our skin and beyond?

With all of this being said, how do we address the concept of tongue tie from a holistic and conservative model?

We start by honoring the wholeness that exists both amongst and between the mother-baby dyad.

So what is it that we notice in the systems of these infants who are being diagnosed with ties so frequently?

We notice that their tiny, yet whole, bodies are being guided by nervous systems who are instructing their bodies to mobilize. This cues the fascial matrix to decrease in pliability and malleability, creating less flexibility and more rigidity, particularly through the deep front line of connective tissue (tongue to toes, remember?).

This creates a tug like sensation on the entire system, with the tongue and the toes being the endpoints of this line. This results in a lingual frenum that appears tight and rigid, particularly in the posterior (back) aspect of the under portion of the tongue.

Our pediatricians and society as a whole do families a total disservice by also encouraging mothers to sleep their babies on their backs.

This creates an increased tug on the tongue, as the bones of the skull in newborns (did you know that we have 22 bones in our skull?!) are soft and pliable – again, an intelligent design on behalf of nature so baby can mold and contort to exit the vaginal canal.

Remember, nothing in the body exists in isolation.

A key player in swallowing, the superior pharyngeal constrictor muscle, is innervated by the Vagus nerve (think safety perception and ease) and attaches from the tongue to the occiput, the back of the skull.

When we sleep babies on their backs, we are creating a deep pull on that SPC muscle, which then goes on to pull the tongue even further back into the mouth and skull, exacerbating even more the perception of tightness on the frenum, a key transmitter of forces in the deep front fascial line.

So how do we support this deep front line in finding more ease, softness, and pliability within itself?

We go straight to the nervous system.

In this style of bodywork, we predominantly allow the baby to guide us. Instead of trying to run in sand that is soft and taxing on our exertion, we simply opt to follow the water line, where the sand is more firm and easier to move from.

In many of our hyper-rigid infants, the first order of business is supporting them in finding flexion, or forward folding. We do this intricately and intentionally, following the ease of their bodies, as they find what we refer to as their midline, potentially for the first time since they’ve been earthside.

We support them in wiggling and moving and releasing (this often looks like crying, but this will be a very different kind of cry than one cuing hunger or fatigue). We support their bodies in unwinding all that they experienced in making their way earthside, which is certainly easier for some than others.

We support their whole body and system in feeling seen, heard, acknowledged, and held as they process the work and effort and trauma of what it means and feels to be human on this planet.

We support their cranium in working as a unit with the rest of their bodies to pump and flow and hold with integrity and stability all that they are and all that they can be.

This process is gentle.

When we are fortunate enough to have two providers working with a single infant, the work we support these babies through almost gives the impression that they are swimming in the womb – doing the very same dance earthside that they did for several months in preparation to make an exit from safety, predictability, and comfort, into a realm of total unknown and novelty.

We are seeing a larger and larger frequency of babies being born with immense amounts of “strength”. They are holding their heads on their own from birth, they are rolling, they are holding a degree of stiffness that no baby should ever feel obligated to carry.

The gentle, yet profound, work that we do as providers seeks to remind these babies of the safety in which they are immersed. And for most of these kids, this begins with supporting them in finding their midline and moving into a state of flexion (forward folding). The infants with the most restricted tongue movement are typically ones who are not able to safely and comfortably allow themselves to drop into this forward fold.

I explain to parents who bring me their babies that showing up with a constant state of extension is the equivalent to growing a really, really, tall tree without equally as deep roots to match. The extreme state of extension and rigidity is always a compensation for lack of safety, lack of settling into oneself, and an extreme effort to fit into a tribe that moves and exists at a pace far faster than any new human should ever feel obligated with which to keep up.

It is crucial that we hold these babies in a state of support, safety, and space, so they can gently come back to themselves, so they can gently start to grow their roots, and they can gently remember that this world and this new body are okay places to be.

Almost instantly upon finding flexion, we see a drastic increase in tongue movement – which, again, does not exist in isolation. The tongue acts to mirror the very state of the rest of the body.

As we see suppleness in the tongue, so we see in the rest of the body.

Truthfully, the work with these infants that allows for them to find safety and space in their new bodies is largely difficult to articulate into written language. It is a felt sense of love, of acceptance, of listening, of care, and of reverence.

We hold the highest vision for healing for these families, never putting a ceiling on what may or may not be possible when we can find ourselves after one of the most vast transitions known to our species.

We hold them in all that with which they present, with the deep knowing that our babies are, in fact, our greatest teachers. Always showing us that which we would be wise to know, ponder, and consider.

We do not abandon them for expressing symptoms, such as reflux, colic, difficulty feeding resulting in pain for mom, constipation, torticollis, “tongue tie”, rigidity, and difficulty allowing themselves to be held.

They are actually just reflecting back to us the discomfort we experience when something is labeled as “wrong”. Our babies are here to show us that healing is always possible, from inside out, if we simply provide an opportunity to return to wholeness, as opposed to sticking with a model that believes that quick fixes are the answer, dispersing and dissipating, and deflecting any sense of ownership and responsibility as to the fact that our infants are simply mirroring all that we show up with and as.

Imagine the generational patterns that could be installed into our nervous systems and helices of immaculate code if we viewed ourselves as whole already?

Imagine how different the perception of our world could be if we did not navigate it looking for quick fixes exogenous to us, but instead looked endogenously first, inquiring as to what our whole self may be needing in order to heal, to release, to restore?

I fully believe that this would be a very different world.

If you have made it this far, I truly thank you and I commend you on your intellectual endurance, particularly with the way that our attention spans have been conditioned and molded in today’s climate.

If you are here and can find a little more fuel to keep going, I commend you, and can promise you that you will like this part –

As first points of contact for brand new families, we owe it to you to continue to learn, unlearn, and evolve what we know best practices to be.

I like to assume positive intent. I am not here to speak or suggest ill of any providers who have sent you and your infant directly to get a release – it is likely that they did not know any better.

However, this is a call to them, and to us, to do better by these families who are seeking support as they navigate brand new seasons of life.

We can do better, I know it.

We can feel more whole, I know it.

We can exist in a paradigm that urges and encourages us to lean into the trust of our bodies and all that they do and express for us.

And this starts by trusting the innate intelligence that is held within us all.

Plantillas Jornadas 2021

Plantillas Jornadas 2021

What's in a name? The Co-Option of the term Tongue-tie

Since when is it OK to change a centuries-old definition because one has observed an as yet un-comprehendible or un-parsable phenomenon? This is exactly what has happened with the co-option of the term tongue-tie.

Tongue-tie, the vernacular for partial ankyloglossia, has been written about for centuries. A passage written by Aristotle in the 3rd  century BC describes it thus: (In O’Bladen, 2010.)

The human tongue is the freest, the broadest, and the softest of all: this is to enable it to fulfill both its functions…It has, also, to articulate the various sounds and to produce speech, and for this a tongue which is soft and broad is admirably suited, because it can roll back and dart forward in all directions; and herein too its freedom and looseness assists it. This is shown by the case of those whose tongues are slightly tied: their speech is indistinct and lisping, which is due to the fact that they cannot produce all the sounds.

As the centuries unfold other prominent healers and scientists also described the phenomenon in similar terms. Celsus in the 1st century AD, Galen in the 2nd  century AD and Paul of Aegina in the 7th century AD. Paul even describes the surgical technique used to resolve the tie. (In O’Bladen, 2010.)

Complete ankyloglossia, a term originating from the Greek combined form of ankylo, meaning crooked or bent, and glossia, meaning tongue, is a complete failure of embryonic apoptosis that carves the tongue body and blade out from the block of primordial tongue tissue, thereby delineating it from the mouth floor. Complete ankyloglossia is extremely rare.

Partial ankyloglossia appears in several forms. Its appearance ranges from the swiss-cheese-like look of partial apoptosis failure to the midline defect that leaves behind a more prominent, short and/or tight lingual frenulum we refer to as tongue-tie. The midline form of partial ankyloglossia is far more common than any of the other more bizarre forms.

We do not know at what point the term partial ankyloglossia became tongue-tie or if the term tongue-tie precedes the more scientific and formal term. Perhaps its observed impact on speech and feeding led to the adoption of this common-language moniker. Tongue-tie certainly best describes the hypothesized problems that can occur when partial midline ankyloglossia is present.

The long-lived definition of tongue-tie is a functional one cum appearance characteristics. In every writing about tongue-tie, until lately, the condition is a congenital anomaly coded by one or more genes (Tbx22 is implicated.) The shortness, tightness or prominence of this midline structure likely causes tongue-motion deficits that interfere with activities of daily living like eating and talking. In Science time, we are at the very beginning of our understanding of this phenomenon. We actually know relatively little about the condition or its impact.

Here’s my most important point: the condition known as tongue-tie occurs as a result of coding errors at the gene level. Expression of one (or more) genes causes the apoptosis failure during the embryological period of development. Co-opting the term tongue-tie to refer to acquired conditions, as has been done in the last decade and a half, undermines the entire concept and definition of tongue-tie, leading professionals and parents astray.

These days, tongue-tie refers to any visible frenum making the normal phenotype pathological. Any cause of tongue motion deficits is dubbed tongue-tie leading many babies to unneeded surgery (like cattle to slaughter.) The use of the term tongue-tie to refer to torticollis, hyoid strain patterns and cranial nerve-mediated sucking dysfunction is at the very least a spectacular show of ignorance and at worst, highly unethical. We made rules about the protection of vulnerable humans for good reason.

To complicate matters, the term Tethered Oral Tissues (TOTs) entered the picture about five years ago and has spawned an industry. (What color of ribbon should we wear for this vague and confusing disease?) Does the bandying about of this term clarify or muddy the waters? I vote for the latter. These days, any sucking, feeding, eating, and talking dysfunction is attributed to TOTs. The leaders of this new industry abuse the truth to justify their opinions and so the “alternate facts” become ever-more deeply rooted.

The truth is that there is no scientific evidence that proves that prominent labial frena, “buccal ties” or any other form of (fabricated) tongue tethering causes any of the dysfunctions claimed to occur by the participants in this burgeoning industry.

The institutionalization of the TOTs rubric gives permission for anyone to park their observations under the everything-is-tied roof without data to back them up. We now find ourselves on the proverbial slippery slope.

For example, Coryllos and Watson Genna have never provided any incontrovertible data to back up their claims about “posterior tie.” At the time they proposed their hypothesis, torticollis of all types, of which there are several, was increasing and creating tongue function deficits akin to tongue-tie. The mouth floor tightness that typically accompanies torticollis can even make the lingual frenulum appear tighter than it actually is. Coryllos and Watson Genna were most likely observing the impact of torticollis when they dubbed what they were seeing “posterior tie.” If you look at Watson Genna’s website today, the pictures of “posterior ties” are pictures of babies who actually have torticollis.

Torticollis is a robust competitor diagnosis to tongue-tie because 25% of babies are afflicted, but unlike tongue-tie, torticollis is always secondary to some other cause, whether it be ischemic events during pregnancy causing scar tissue on the sternocleidomastoid (SCM) muscle or the more common soft-tissue form acquired from structural-insult events during pregnancy and/or delivery. Tongue-tie, on the other hand, is simply and ALWAYS a genetic coding event, whether it be hereditary or epigenetic in origin.

Words have meanings. Names are powerful.

Good Science shows us that only 3-5% of babies are truly tongue-tied. The co-option of the term has led us down the pathway of mis- and over-diagnosis to the tune of 50% of all babies in some corners of the world.

Its best we get back to clarity and precision in our language. Only then will we be able to continue the grounding scientific work of determining the role tongue-tie plays in feeding and development. Cleaning up the muck and mire of TOTs-informed opinion and once again relying on the science will strengthen the argument for routine tongue-tie screening and timely treatment thereof when absolutely needed.

O’Bladen, M. (2010). Much ado about nothing: two millennia of controversy on tongue-tie. Neonatology; 97:83-89.

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!

Bibliography/References

Back Sleeping

Adams, S. M., et al. (2009). Sudden infant death syndrome. Am Fam Physician, May 15: 79(10): 870-874.

Bergman, N.J. (2014). Proposal for mechanisms of protection of supine sleep against sudden infant death syndrome: an integrated mechanism review. Pediatric Research, DOI: 10.1038/pr.2014.140

Bergman, N.J. (2016). Hypothesis on supine sleep, sudden infant death syndrome reduction and association with increasing autism incidence. World Journal of Clinical Pediatrics, 5(3):1-13.

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

Cozolino, L. (2014). The neuroscience of human relationships. New York: W.W. Norton & Company.

Davis, B. E., et al. (1998). Effects of sleep position in infant motor development. Pediatrics: Nov: 102(5): 1135-1140.

Dos Santos, C., et al. (2005). Effects of sleeping and waking positions on infant motor development. European Review of Applied Psychology: March: 55(1): 1-8.

Fleming, P., Blair, P., & McKenna, J. (2006). New knowledge, new insights and new recommendations. Archives of Diseases in Childhood: Module 6: www.archdischild.com.

Fowler, E., et al. (2008). Neurologic findings in infants with deformational plagiocephaly. J Child Neurol: July: 23(7): 742-747.

Gilbert, R., et al. (2005). Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. International J of Epidemiology: 34: 874-887.

Goddard Blythe, S. (2008). What babies and children really need. Stroud: Hawthorne Press.

Hannaford, C. (2010). Playing in the unified field. Salt Lake City: Great River Books.

Hummel, P., & Fortado, D. (2005). Impacting infant head shapes. Adv Neonatal Care: Dec: 5(6): 329-340.

Kordestani, R.K., et al. (2006). Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg: Jan: 117(1): 207-218.

Lennartsson, F. (2011). Developing guidelines for child health care nurses to prevent nonsynostotic plagiocephaly: searching for the evidence. J Petriatr Nurs: Aug: 26(4): 348-358.

Levine, P. (2010.) In an unspoken voice: how the body releases trauma and restores goodness. Berkeley: North Atlantic Books.

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

Majnemer, A. & Barr, R.G. (2005). Influence of supine sleep positioning on early motor milestone acquisition. Developmental Medicine and Child Neurology, 47: 370-376.

Raine, S., Meadows, L., & Lynch-Ellerington, M. (Eds.). (2009). Bobath concept. Oxford: Wiley-Blackwell.

Salls, J. S., et al. (2002). The relationship of infant sleep and play positioning to motor milestone achievement. Am J of Occupational Therapy, 56(5): 577-580.

Solter, A., (2001). The aware baby. Goleta, California: Shining Star Press.

St. James-Roberts, I. (2012). The origins, prevention and treatment of infant crying and sleeping problems. London: Routledge.

Caries

Brohawn, N.T. (2011). 10 breastfeeding issues that every orthodontic practitioner should know. Journal of Applied Oral Science, Nov-Dec. www.orthodontics.com. Retrieved 10-1-16.

Erickson, P.R. & Mazhari, E. (1999).  Investigation of the role of human breast milk in caries development. American Academy of Pediatric Dentistry, 21(2):86-90.

Tinanoff, N. & O’Sullivan, D.M. (1997). Early childhood caries: overview and recent findings. Pediatric Dentistry, 19(1):12-16.

Tinanoff, N. & Reisine, S. (2009). Update in early childhood caries since the Surgeon General’s Report. Academic Pediatrics, 9(6):396-403.

Infant Suck and Tongue-Tie

Aarts, C., Hornell, A., Kylberg, E., Hofvander, Y., & Gebre-Medhin, M. (1999). Breastfeeding patterns in relation to thumb sucking and pacifier use. [Electronic version]. Pediatrics, 104, e50.

Agency for Healthcare Research and Quality. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. Comparative Effectiveness Review, Number 149. AHRQ Publication No. 15-EHC011-EF.

Amir, L.H. (2005). Tongue-tie: a view from down under. Pediatric Alert, July 28, 81.

Amir, L.H., James, J.P., & Beatty, J. (2005). Review of tongue-tie at a tertiary maternity hospital. Journal of Pediatric and Child Health, 41, 243-245.

Amir, L.H., James, J.P., & Donath, S.M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function [Electronic version] International Breastfeeding Journal, 1, 3.

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.

Avery, J.K., & Chiego, D.J. (2006). Essentials of oral histology and embryology. (3rd ed.). St. Louis: Mosby Elsevier.

Ballard, J.L., Auer, C.E., & Khoury, J.C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad [Electronic version]. Pediatrics, 110, e63.

Bauchner, H. (2008). Does frenulotomy improve breast-feeding? Retrieved January 27, 2009, from http://general-medicine.jwatch.org/cgi/content/full/2008/710/1.

Bell, W. H. (1989).  Surgical correction of dentofacial deformities.  Philadelphia: W. B. Saunders.

Bhaskar, S. N. (Ed.). (1991). Orban’s oral histology and embryology. (11th ed.). St. Louis: Mosby Year Book.

Bjornsson, A., Arnason, A., & Tippet, P. (1989). X-linked cleft palate and ankyloglossia in an Icelandic family. Cleft Palate Journal, 26, 3-8.

Block, J. R. (1968).  The role of the speech clinician in determining indications for frenulotomy in cases of ankyloglossia.  New York State Dental Journal, 34, 479-481.

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.

Bowen, C. (2000). Tongue-tie, ankyloglossia or short fraenum. Retrieved January 16, 2009, from http://www.speech-language-therapy.com/tonguetie.html.

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

Breward, S. (2004). Tongue tie and breastfeeding: assessing and overcoming the difficulties. Community Practitioner, 79, 298-299.

Brinkman, S., Reilly, S., & Meara, J.G. (2004). Management of tongue-tie in children: a survey of paediatric surgeons in Australia. Journal of Pediatric and Child Health, 40, 600-605.

Broad, F. E. (1972).  In the beginning was the word: suckling and speech.  Bulletin of the Federation of New Zealand Parents Centers, 53, 4-6.

Broad, F. E. (1972).  The effects of infant feeding on speech quality.  New Zealand Journal of Medicine, 76, 28-31.

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.

Buryk, M., Bloom, D. & Shope, T. (2015). Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics, DOI: 10.1542/peds.2011-0077.

Butlin, H., & Spencer, W. (1900).  Diseases of the tongue.  London:  Cassel and Company, Ltd. 1-21, 30-35, 50-51.

Chapman, D. (2008). Using ultrasound for a loser look at breastfeeding: pre and post-frenulotomy. Journal of Human Lactation, 24:460.

Cho, A., Kelsberg, G., & Safranek, S. (2010). Clinical inquiries: When should you treat a tongue-tie in a newborn? Journal of Family Practice, 59(12):712a-b.

Cinar, F. & Onat, N. (2005). Prevalence and consequences of a forgotten entity: ankyloglossia. Plastic and reconstructive Surgery, 115, 355-356.

Corbin-Lewis, K., Liss, J.M., & Sciortino, K.L. (2005). Clinical anatomy & physiology of the swallow mechanism. Clifton Park: Thomson Delmar Learning.

Coryllos, E., Watson Genna, C., & Salloum, A.C. (2004). Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby Newsletter, Summer, 1-6.

Crook, C.K., & Lipsitt, L.P. (1976). Neonatal nutritive sucking effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.

Cunha, R.F., Silva, J.Z., & Faria, M.D. (2008). Clinical approach of ankyloglossia in babies: report of two cases. The Journal of Clinical Pediatric Dentistry, 32, 277-281.

Daly, S.E.J., Kent, J.C., Owens, R.A., & Hartmann, P.E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis. Experimental Physiology, 81, 861-875.

Defabianis, P. (2000). Ankyloglossia and its influence on maxillary and mandibular development. The Functional Orthodontist, 17, 25-33.

DePorte, J. V., & Parkhurst, E. (1945).  Congenital malformations and birth injuries among the children born in New York State, outside of New York City, in 1940-1942.  New York State Journal of Medicine, 45, 1097-1100.

Dollberg, S., Botzer, E., Grunis, E., & Mimouni, F.B. (2006). Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, pospective study. Journal of Pediatric Surgery,41, 1598-1600.

Dollberg, S., Manor, Y., Makai, E., & Botzer, E. (2010). Evaluation of speech intelligibility in children with tongue-tie. Acta Pediatrica, 100:e125-7.

Dollberg, S., & Botzer, E. (2011). Neonatal tongue-tie: myths and science. Harefuah, 150(1):46-9.

Dovel, J. (2010). Teaching tongue-tied students: ankyloglossia in the instrumental classroom. Music Educators Journal, 96:49-52.

Edmunds, J., Hazelbaker, A.K., Murphy, J.G. & Phillipp, B.L. (2012). Tongue-tie. Journal of Human Lactation, 28(1);14-17.

Ekenze, S.O., Ikechukwu, R.N., & Oparaocha, D.C. (2005). Surgically correctable congenital anomalies: prospective analysis of management problems and outcome in a developing country. Journal of Tropical Pediatrics, 52, 126-131.

Evans, C. (1978).  Muscles involved in oral-motor function.  In J. M. Wilson (Ed.), Oral-motor function and dysfunction in children (pp. 79-95).  Chapel Hill: University of North Carolina.

Fanibunda, K., Adams, A. (1998). Are the features of ankyloglossia limited to the lingual fraenum. Dental Update, September, 296-297.

Fessler, D.M.T., & Abrams, E.T. (2004). Infant mouthing behavior: the immunocalibration hypothesis. Medical Hypotheses, 63, 925-932.

Fernando, C. (1998). From confusion to clarity. Concord, New South Wales: Tandem Publications.

Ferris-Amat, E., et al. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Medicina oral, patología oral y cirugía buccal, 21(1); e39-e47.

Fleiss, P. M., Burger, M., Ramkumar, H., & Carrington, P. (1990).  Ankyloglossia:  a cause of breastfeeding problems?  Journal of Human Lactation, 6 (Supplement 1), 128-129.

Forlenza, G.P., Paradise Black, N.M., McNamara, E.G., & Sullivan, S. E.  (2009). Ankyloglossia, Exclusive Breastfeeding, and Failure to Thrive Lead to Child Abuse Investigation (Unpublished). 

Fancis, D.O., Krishnaswami, S. & McPheeters, M. (2015). Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics, DOI: 10.1542/peds2015-0658.

Friend, G.W., Harris, E.F., Mincer, H.H., Fong, T.L., & Carruth, K.R. (1990). Oral anomalies in the neonate, by race and gender, in an urban setting. Pediatric Dentistry, 12, 157-161.

Furer, R. (2008). Subfunctional tongue and upper lip release in nursing babies. Israel: Self-published.

Garbin, C.P., et al. (2016). Evidence of improvedmilk intake after frenotomy: A case report. Pediatrics, 132(5): e1413-17.

Garcia Pola, J., Gonzalez Garcia, M., Garcia Martin, J.M., Gallas, M., & Leston, J.S. (2002). A study of pathology associated with short lingual frenum. Journal of dentistry for Children, 69, 59-63.

Garliner, D. (1968).  Effects of unrecognized abnormal swallowing.  Journal of the Canadian Dental Association, 34, 301-304.

Garliner, D. (1981).  Myofunctional therapy.  Philadelphia:  W. B. Saunders.

Geddes, D.T., Chadwick, L.M., Kent, J.C., GArbin, C.P. & Hartmann, P.E. (2009). Ultrasound imaging of infant swallowing during breast-feeding. Dysphagia, DOI 10.1007/s00455-009-9241-0.

Geddes, D.T., Kent, J.C., Mitoulas, L.R., & Hartmann, P.E. (2007). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.

Geddes, D.T., Kent, J.C., Mitoulas, L. R., & Hartmann, P.E. (2008). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.

Geddes, D.T., Langton, D.B., Gollow, I., Jacobs, L.A., Hartman, P.E., & Simmer, K. (2008). Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound [Electronic version]. Pediatrics, 122, e188-e194.

Gewolb, I.H., Bosma, J.F., Taciak, V. L., & Vice, F.L. (2001). Abnormal developmental patterns of suck and swallow rhythms during feeding in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43, 454-459.

Glass, R.P., & Wolf, L.S. (1994). Incoordination of sucking, swallowing, and breathing as an etiology for breastfeeding difficulty. Journal of Human Lactation, 10, 185-189.

Griffiths, D.M. (2004). Do tongue ties affect breastfeeding? Journal of Human Lactation, 20, 409-414.

Griffiths, M. (2006). Tongue ties and breastfeeding [Letter to the Editor]. Archives of Diseases in Childhood, 91, 542.

Hall, D.M. & Renfew, M.J. (2005). Tongue tie. Archives of Disease in Childhood, 90(12), 1211-1215.

Hall, D.M. & Renfew, M.J. (2006). Tongue tie: more research needed [Letter to the Editor].  Archives of Diseases in Childhood, 91, 542.

Hazelbaker, A.K. (1993). The assessment tool for lingual frenulum function: use in a lactation consultant private practice. (Master’s thesis. Pacific Oaks College, 1993). Self-published.

Hazelbaker, A.K. (1994). Tongue-tie. Columbus: A.B.R.E.A.S.T. Seminars.

Hazelbaker, A.K. (2003). The impact of craniosacral therapy on infant sucking dysfunction: a pilot study. Unpublished.

Hazelbaker, A.K. (2005). Newborn tongue-tie and breast-feeding [Letter to the Editor]. Journal of the American Board of Family Practice, 18, 326.

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

Hedberg Nyqvist, K., Farnstrand, C., Eeg-Olofsson, K., & Ewald, U. (2001). Early oral behaviour in preterm infants during breastfeeding: an electromyographic study. Acta Pediatrica, 90, 658-663.

Herbst, J.J. (1983). Development of suck and swallow. Journal of Pediatric Gastroenterology and Nutrition, 2 (Supplement 1), S131-S135.

Hillan, R. (2008). Division of tongue-tie: wicked and barbaric? The Practising Midwife, 11, 22-25.

Hogan, M., Westcott, C., & Griffiths, M. (2005). Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatric and Child Health, 41, 246-250.

Hong, P., et al. (2010). Defining ankyloglossia: a case series of anterior and posterior tongue ties. International Journal of Pediatric Otorhinolaryngology, 74(9):1003-6. 

Huang, Y., Quio, S., Berkowski, JK. A. &Guilleminault, C. (2015). Short lingual frenulum and obstructive sleep apnea in children. International Journal of Pediatric Research, 1:003.

Hyashi, Y., Hoashi, E., & Nara, T. (1997). Ultrasonograhic analysis of sucking behavior of newborn infants: the driving force of sucking pressure. Early Human Development, 49, 33-38.

Inoue, N., Sakashita, R., & Kamegai, T. (1995). Reduction of masseter muscle activity in bottle-fed babies. Early Human Development, 42, 185-193.

Jacobs, L.A., Dickenson, J.E., Hart, P.D., Doherty, D.A., & Faulkner, S.J. (2007). Normal nipple position in term infants measured on breastfeeding ultrasound. Journal of Human Lactation, 23, 52-59.

Jang, S., et al. (2011). Relationship between the lingual frenulum and craniofacial morphology in adults. American Journal of Orthodontics and Dentofacial Orthopedics, 139(4):e361-7.

Jean, A. (1984). Brainstem organization of the swallowing network. Brain, Behavior and Evolution, 25, 109-116.

Kaban, L. (1990).  Pediatric oral maxillofacial surgery.  Philadelphia:  W. B. Saunders.

Kantaputra, P.N., et al. (2011). Cleft lip with cleft palate, ankyloglossia, and hypodontia are associated with TBX22 mutations. Journal of Dental Research, 90:450-55. DOI: 10.1177/0022034510391052

Karabulut, R., Sonmez, K., Turkyilmaz, Z., Demirogullari, B., Ozen, I.O., Bagbanci, B., Kale, N., & Basaklar, A.C. (2008). Ankyloglossia and effects on breast-feeding, speech problems and mechanical/social issues in children. B-ENT, 4, 81-85.

Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A., & Hartmann, P.E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day [Electronic version]. Pediatrics, 117, e387-e395.

Khoo, A.K., et al. (2009). Nipple pain at presentation predicts success of tongue-tie division for breastfeeding problems. European Journal of Pediatric Surgery, 19(6):370-3. 

Kidd, H.R. (1976). Examination of the mouth. Canadian Family Physician, 22, 59-62.

Klockers, T. (2007). Familial ankyloglossia. International Journal of Pediatric Otorhinolaryngology, 71, 1321-1324.

Koletzko, S., Sherman, P., Corey, M., Griffiths, A., & Smith, C. (1989).  Role of infant feeding practices in development of Crohn's disease in childhood. British Medical Journal, 298, 1617-1618.

Kotlow, L.A. (1999). Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Pediatric Dentistry, 30, 259-262.

Kotlow, L.A. (2004). Using the Erbium:YAG laser to correct an abnormal lingual frenum attachment in newborns. The Journal of the Academy of Laser Dentistry, 12, 22-23.

Kummer, A. (2005). Ankyloglossia: to clip or not to clip? That’s the question. The ASHA Leader, 10, 6-7, 30.

Kupietzky, A., & Botzer, E. (2005). Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatric Dentistry, 27, 40-46.

Labbock, M.H. & hendershot, G.E. (1987). Does breast-feeding protect against malocclusion? An analysis of the 1981 child health supplement to the national health interview survey. American Journal of Preventative Medicine, 3, 227-232.

Lalakea, M.L., & Messner, A.H. (2002). Frenotomy and frenuloplasty: if, when, and how. Otolaryngology-Head and Neck Surgery, 13, 93-97.

Lalakea, M.L., & Messner, A.H (2003). Ankyloglossia: does it matter? Pediatric Clinics of North America, 50, 381-397.

Lalakea, M.L., & Messner, A.H (2003). Ankyloglossia: the adolescent and adult perspective. Otolaryngology-Head and Neck Surgery, 128, 746-752.

Lau, C., & Kusnierczyk, I. (2001). Quantitative evaluation of infant’s nonnutritive and nutritive sucking. Dysphagia, 16, 58-67.

Leith, D.E. (1985). The development of cough. The American Review of Respiratory Disease, 131, S39-S42.

Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. (2nd. ed.). Austin: Pro-Ed.

Lowe, A.A. (1984). Tongue movements ─ brainstem mechanisms and clinical postulates. Brain, Behavior and Evolution, 25, 128-137.

Lucas A., Morley, R., Cole, T. J., Lister, G., & Lesson-Payne, C. (1992). Breastmilk and subsequent intelligence quotient in children born preterm. Lancet, 339, 261-64.

Luz, C. L. F., Garib, D. G., Arouca, R. (2006). Association between breastfeeding duration and mandibular retrusion: a cross-sectional study of children in the mixed dentition. American Journal of Orthodontics and Dentofacial Orthopedics, 130, 531-534.

Mangelsdorf, M. (1986).  Effective suckling and how to encourage it. Breastfeeding Review, 8, 28-33.

Marchesan, I.Q. (2004). Lingual frenulum: classification and speech interference. International Journal of Orofacial Myology, 30, 31-38.

Marmet, C., Shell, E., & Aldana, S. (2000). Assessing infant suck dysfunction: case management. The Journal of Human Lactation, 16, 332-336.

Marmet, C., Shell, E., & Marmet, R. (1990).  Neonatal frenotomy may be necessary to correct breastfeeding problems.  Journal of Human Lactation, 6 (Suppl. 1), 117-121.

Marmet, C., & Shell, E. (1984).  Training neonates to suck correctly.  American Journal of Maternal Child Nursing, 9, 401-407.

Martinelli, R., et al. (2015). The effects of frenotomy on breastfeeding. Journal of Applied Oral Science, 23(2):153-57.

McBride, C. (2005). Tongue-tie. Journal of Pediatric and child Health, 41, 242.

McTavish, W.K., & Matthews, R.L. (1960). Airways: the key to early facial growth and malocclusions. Self-published.

Medoff-Cooper, B., McGrath, J.M., & Shults, J. (2002). Feeding patterns of full-term and preterm infants at forty weeks postconceptional age. Journal of Developmental & Behavioral Pediatrics, 23, 231-236.

Meier, P. (1988).  Bottle and breast-feeding:  effects on transcutaneous oxygen pressure in preterm infants.  Nursing Research, 37, 36-41.

Meintz-Maher, S. (1988).  An overview of solutions to breastfeeding and sucking problems.  Franklin Park:  La Leche League International.

Meyer Palmer, M., & Vandenberg, K.A. (1998). A closer look at neonatal sucking. Neonatal Network, 17, 77-79.

Messner, A.H., & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54, 123-131.

Messner, A.H., & Lalakea, M.L. (2000). Anklyloglossia: incidence and associated feeding difficulties. Archives of Otolaryngology Head and Neck Surgery, 126, 36-39.

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.

Miller, A.J. (1986). Neurophysiological basis of swallowing. Dysphagia, 1, 91-100.

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.

Mizuno, K., & Ueda, A. (2006). Changes in sucking performance from nutritive sucking to nutritive sucking during breast- and bottle-feeding. Pediatric Research, 59, 728-731.

Moore, J. R., (1985).  Surgery of the mouth and jaws.  Boston:  Blackwell Scientific Publications.

Moore, K.L., & Persaud, T.V.N. (1998). The developing human: clinically oriented embryology. (6th ed.). Philadelphia: W.B. Saunders Company.

Mueller, D. T., & Callanan, V.P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40, 141-160.

Mukai, S., Mukai, C., & Asaoka, K. (1991). Ankyloglossia with deviation of the epiglottis and larynx. Annals of Otolaryngology, Rhinology and Laryngology, 100, 3-20.

Naimer, S.A., Biton, A., Vardy, D., & Zvulunov, A. (2003). Office treatment of congenital ankyloglossia. Medical Science Monitor, 9, 432-435.

Nanci, A. (2008). Ten Cate’s oral histology: development, structure, and function. (7th ed.). St. Louis: Mosby Elsevier.

Nazif, M. M., & Ready, M. A. (1987).  Oral disorders.  In H. W. Davis, & B. J. Zitelli (Eds.), Atlas of pediatric physical diagnosis (pp. 18.1-18.13).  St. Louis:  C.V. Mosby Co.

Newman, L.A., Cleveland, R.H., Blickman, J.G., Hillman, R.E., & Jaramillo, D. (1991). Videofluoroscopic analysis of the infant swallow. Investigative Radiology, 26, 870-873.

Nicholson, W. L. (1991).  Tongue-tie (ankyloglossia) associated with breastfeeding problems.  Journal of Human Lactation, 7, 82-84.

Notestine, G. E. (1990).  The importance of the identification of ankyloglossia (short lingual frenulum) as a cause of breastfeeding problems.  Journal of Human Lactation, 6 (Suppl. 1), 113-115.

Nowak, A.J. , Smith, W.L., & Erenberg, A. (1995). Imaging evaluation of breast-feeding and bottle-feeding systems. Journal of Pediatrics, 126, S130-S134.

O’Bladen, M. (2010). Much ado about nothing: two millennia of controversy on tongue-tie. Neonatology, 97:83-9.

O’Callahan, C., Macary, S. & Clemente, S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5):827-32.

Olivi, G., Signore, A., Olivi, M. & Genovese, M.D. (2012). Lingual frenectomy: functional evaluation and new therapeutical approach. European Journal of Pediatric Dentistry, 13(2):101-6.

O’Shea, M. (2002). Licking the problem of tongue-tie. British Journal of Midwifery, 10, 90-92.

O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, Davis PG. (2014). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD011065. DOI: 10.1002/14651858.CD011065.

Ostapiuk, B. (2006). Tongue mobility in ankyloglossia with regard to articulation. Annales Academiae Medicae Stetinensis, 52 (Supplement 3), 37-47.

Page, D.C. (2001). Breastfeeding is early functional jaw orthopedics. The Functional Orthodontist, 18, 24-27.

Palmer, B. (2005). Snoring and sleep apnea: how it can be prevented in childhood. das schlafmagazin, 3, (Aug), 22-23. Retrieved May 1, 2009 from http://www.dasschlafmagazin.de

Parida, P.K. (2008). Ankyloglossia (tongue tie) [Electronic version]. Internet Journal of Otolaryngology, 8, 9-9.

Phillips, V.T. (1992). Correcting faulty suck: tongue protrusion and the breastfed infant. The Medical Journal of Australia, 156, 508.

Power, R.F., & Murphy, J.F. (2015). Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance.Archives of Diseases in Children, 100(5):489-94.

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

Prieto, C.R., Cardenas, H., Salvatierra, A.M., Boza, C., Montes, C.G., & Croxatto, H.B. (1996). Sucking pressure and its relationship to milk transfer during breastfeeding in humans. Journal of Reproduction and Fertility, 108, 69-74.

Qureshi, M.A., Vice, F. L., Taciak, V. L., Bosma, J.F., & Gewolb, I.H. (2002). Changes in rhythmic suckle feeding patterns in term infants in the first month of life. Developmental Medicine & Child Neurology, 44, 34-39.

Ramsay D.T., & Hartmann, P.E. (2005). Milk removal from the breast. Breastfeeding Review, 13, 5-7.

Ramsay, M., Gisel, E.G., McCusker, J., Bellavance, F., & Platt, R. (2002). Infant sucking ability, non-organic failure to thrive, maternal characteristics, and feeding practices: a prospective cohort study. Developmental Medicine and Child Neurology, 44, 405-414.

Rendon-Macias, M.E., Cruz-Perez, L.A., Mosco-Peralta, M.R., Saraiba-Russell, M.M., Levi-Tajfeld, S., & Morales-Lopez, M.G. (1999). Assessment of sensorial oral stimulation in infants with suck feeding disabilities. Indian Journal of Pediatrics, 66, 319-329.

Rowen-Legg, A. (2015). Ankyloglossia and breastfeeding. Canadian Pediatric Society Position Statement, 20(4):209-13. Ruffoli, R., Giambelluca, M.A., Scavuzzo, M.C., Bonfigli, D., Cristofani, R.,

Gabriele, M., Giuca,M.R., & Giannesi, F. (2005). Ankyloglossia: a morphofunctional investigation in children. Oral Diseases, 2, 170-174.

Segal, L., Stephenson, R., Dawes, M., & Feldman, P. (2007). Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review. Canadian Family Physician, 53, 1027-1033.

Shafer, W. G., Hine, M. K., & Levy, B. M. (1974).  A textbook of oral pathology. Philadelphia:  W. B. Saunders.

Shepard, J.W., Geffler, W.B., Guilleminault, C., Hoffman, E.A., Hoffstein, V.,

Hudgel, D.W., Surratt, P.M., & White, D.P. (1991). Evaluation of the upper airway in patients with OSA. Sleep; 14(4):361-71.

Smith, T.L. & Smith, J.M. (2001). Electrosurgery in otolaryngology─head and neck surgery: principles, advances, and complications. Laryngoscope, 111, 769-780.

Smith, W. L., Erenberg, A., & Nowak, A. (1988).  Imaging evaluation of the human nipple during breast-feeding.  American Journal of Diseases in Children, 142, 76-78.

Smith, W. L., Erenberg, A., Nowak, A., & Franken, E. A. (1985).  Physiology of sucking in the normal term infant using real-time ultrasound.  Radiology, 156, 379-381.

Sperber, G.H. (2001). Craniofacial development. Hamilton, Ontario: BC Decker, Inc.

Srinivasan, A., Dobrich, C., Mitnick, H., & Feldman, P. (2006). Ankyloglossia in breastfeeding infants: the effect of frenotomy on maternal nipple pain and latch. Breastfeeding Medicine, 1, 216-224.

Steehler. M.W., Steehler, M., & Harley, E.H. (2012). A retrospective review of frenotomy in neonates and infants with feeding difficulties. International Journal of Pediatric Otorhinolaryngology, 76(9):1236-40.

Stevenson, R.D., & Allaire, J.H. (1991). The development of normal feeding and swallowing. Development and Behavior: The Very Young Child, 38, 1439-1453.

Stice, E., Stewart Agras, W., & Hammer, L.D. (1999). Risk factors for the emergence of childhood eating disturbances; a five year prospective study. International Journal of Eating Disorders, 25, 375-387.

Suter, V.G., & Bornstein, M.M. (2009). Ankyloglossia: facts and myths in diagnosis and treatment. Journal of Periodontology, 80(8):1204-19.

Tait, P. (2000). Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. Journal of Midwifery & Women’s Health, 45, 212-215.

Takemoto, H. (2001). Morphological analyses of the human tongue musculature for three-dimensional modeling. Journal of Speech, Language, and Hearing Research, 44, 95-107.

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.

Velanovich, V. (1994). The transverse-vertical frenuloplasty for ankyloglossia. Military Medicine, 159, 714-715.

Voloschin, L.M., Althabe, O., Olive, H., Diena, V., & Repezza, B. (1998). A new tool for measuring the suckling stimulus during breastfeeding in humans: the orokinetogram and the Fourier series. Journal of Reproduction and Fertility, 114, 219-224.

Walker, M. (1989).  Management of selected early breastfeeding problems seen in clinical practice.  Birth, 16, 150-151.

Wallace, H., & Clarke, S. (2006). Tongue tie division in infants with breast feeding difficulties. International Journal of Pediatric Otorhinolaryngology, 70, 1257-1261.

Ward, N. (1990).  Ankyloglossia:  A case study in which clipping was not necessary.  Journal of Human Lactation, 6 (Suppl. 1), 126-127.

Warden, P. J. (1991).  Ankyloglossia:  A review of the literature.  General Dentistry, August 1991, 252-253.

Watson Genna, C. (2002). Tongue-tie and breastfeeding. Leaven, 38, 27-29.

Watson Genna, C. (2008). Supporting sucking skills in infants. Sudbury: Jones and Bartlett Publishers.

Webb, A.N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Internatioanl Journal of Pediatric Otorhinolaryngology, 77(5):635-46.

Weber, F., Woolridge, M. W., & Baum, J. D.  (1986).  An ultrasonographic study of the organization of suck and swallow.  Developmental Medicine and Child Neurology, 28, 19-24.

Wiessinger, D. & Miller, M. (1995). Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. Journal of Human Lactation, 11(4):313-16.

Wilson, S.L., Thach, B.T., Brouillette, R.T., & Abu-Osba, Y.K. (1980). Upper airway patency in the human infant: influence of airway pressure and posture. Journal of Applied Physiology: Respiration, Environmental, and Exercise Physiology, 48, 500-504.

Wilton, J. M. (1990).  Sore nipples and slow weight gain related to a short frenulum.  Journal of Human Lactation, 6 (Suppl. 1), 122-123.

Winberg, J. (2005). Mother and newborn baby: mutual regulation of physiology and behavior-a selective review. Developmental Psychobiology, 47, 217-229.

Wolf, R.P. & Glass, L.S. (1992). Feeding and swallowing disorders in infancy: assessment and management. Tucson, Arizona: Therapy Skill Builders.

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.

Wright, J.E. (1995). Tongue-tie. Journal of Pediatric and Child Health, 31, 276-278.

Zarem, H. A. (1978).  Diseases and injuries of the oral region.  In S. S. Gellis, & G.M. Kagan (Eds.), Current pediatric therapy.  Philadelphia:  W. B. Saunders.

Infant Trauma

Beebe, B & Lachman, F. M. (2014). The origins of attachment. New York: Routledge Taylor and Francis Group.

Castellino, R. (2000). The stress matrix: implications for prenatal and birth therapy. Journal of Prenatal & Perinatal Psychology & Health, 15(1):31-62.

Cozolino, L. (2014). The neuroscience of human relationships. New York: W.W. Norton & Company.

Eliot, L. (1999). What’s going on in there?: How the brain and mind develop in the first five years of life. New York: Bantam Books.

Janov, A. (2011). Life before birth: the hidden script that rules our lives. Chicago: NTI Upstream.

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.

Nathanielsz, P. W. (1999). Life in the womb: The origin of health and disease. Ithaca: Promethean Press.

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.

Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale: Lawrence Erlbaum Associates.

Siegel, D. (2012.) Pocket guide to interpersonal neurobiology. New York: W.W. Norton & Company.

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.

Vogel, A., & Venugopalan, V. (2003). Mechanisms of pulsed laser ablation of biological tissues. Chemical Review, 103(2):577-644.

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

Abraham, R., & Kamath, G. (2014). Midline diastema and its aetiology: a review. Dent Update. 41(5):457-60.

Addy, M., et al. (1987). A study of the association of frenal attachment, lip coverage and vestibular depth with plaque and gingivitis. J Periodontol. 58:752-7.

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

Ceremello, P.J. (1953). The superior labial frenum and the midline diastema and their relation to grow and development of the oral structures. Am J Orthod. 39:120-39. 

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

Chandrashekar, L., Kashinath, K.R., Suhas, S. (2014). Labial ankyloglossia associated with oligodontia: a case report. J Dent. 11(4):481-4.

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.

Dewel, B.F. (1946). The normal and the abnormal labial frenum: Clinical differentiation. J Am Dent Assoc. 33:318-29.  

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.

Dodge, J.A., & Kernohan, D.C. (1967). Oral facial digital syndrome. Arch Dis Child. 42:214–9.

dos Santos, V.I., et al.  (1985). Prevalence of different types of upper labial frenum in the deciduous dentition. Rev Fac Odontol Sao Paulo. 23:129-35.  

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

Gartner, L.P., & Schein, D. (1991). The superior labial frenum: a histological observation. Quintessence Int. 22(6):443-5.

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

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

Henry, S.W., Levin, M.P., & Tsaknis, P.J. (1976). Histologic features of the superior labial frenum. J Periodontol 47:25-8.  

Huang, W., & Creath, C. (1995). The midline diastema: a review of its etiology and treatment. Pediatric Dentistry, 17(3):171-9.

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.

Kutcsh, V. K. & Bowers, R. J. (2012). Balance: a guide for managing dental caries for patients and practitioners. Llumina Press: Tamarac, FL.

Lawande, S.A., & Lawande, G.S. (2013). Surgical management of aberrant labial frenum for controlling gingival tissue damage: a case series. International Journal of Biomedical research. 4(10):574-8

Lindsey, D. (1977). The upper midline space and its relation to the labial frenum in children and in adults. Br Dent J. 143:327-32.  

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.

Placek, M., Skach, M. & Mrklas, L. (1974). Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol. 45:891–4.

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.  

Ross, R.O., Brown, F.H., & Houston, G.D. (1990). Histologic Survey of the frena of the oral cavity. Quintessence Int. 21(3):233-7.

Senders, C.W., et al. (2003). Development of the upper lip. Arch Facial Plast Surg. 5(1):16-25.

Sewerin, I. (1971). Prevalence of variations and anomalies of upper labial frenum. Acta Odontol Scand, Oct; 29(4): 487-96.

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.

Young, C. (2015). Upper lip tie, Fall guy…Analytical Armadillo, http://www.analyticalarmadillo.co.uk/2015/01/upper-lip-tie-fall-guy.html?m=1. Retrieved 9-8-16.

Torticollis, Plagiocephaly and Brachycephaly

Aarts, C., Hornell, A., Kylberg, E., Hofvander, Y., & Gebre-Medhin, M. (1999). Breastfeeding patterns in relation to thumb sucking and pacifier use [Electronic version]. Pediatrics, 104, e50.

Adams, S. M., et al. (2009). Suden infant death syndrome. Am Fam Physician, May 15: 79(10): 870-874.

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.

Avery, J.K., & Chiego, D.J. (2006). Essentials of oral histology and embryology. (3rd ed.). St. Louis: Mosby Elsevier.

Bhaskar, S. N. (Ed.). (1991). Orban’s oral histology and embryology. (11th ed.). St. Louis: Mosby Year Book.

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.

Corbin-Lewis, K., Liss, J.M., & Sciortino, K.L. (2005). Clinical anatomy & physiology of the swallow mechanism. Clifton Park: Thomson Delmar Learning.

Crook, C.K., & Lipsitt, L.P. (1976). Neonatal nutritive sucking effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.

Dos Santos, C., et al. (2005). Effects of sleeping and waking positions on infant motor development. European Review of Applied Psychology: March: 55(1): 1-8.

Dumas, L. (2013). Influence of skin-to-skin contact and rooming-in on early mother-infant interaction: a randomized controlled trial. Clin Nurs Res: Aug:22(3): 310-316.

Evans, C. (1978).  Muscles involved in oral-motor function.  In J. M. Wilson (Ed.), Oral-motor function and dysfunction in children (pp. 79-95).  Chapel Hill: University of North Carolina.

Fessler, D.M.T., & Abrams, E.T. (2004). Infant mouthing behavior: the immunocalibration hypothesis. Medical Hypotheses, 63, 925-932.

Fleming, P., B;air, P., & McKenna, J. (2006). New knowledge, new insights and new recommendations. Archives of Diseases in Childhood: Module 6: www.archdischild.com.

Fowler, E., et al. (2008). Neurologic findings in infants with deformational plagiocephaly. J Child Neurol: July: 23(7): 742-747.

Franco, P., et al. (2005). Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics: May: 115(5): 1307-1311.

Garliner, D. (1968).  Effects of unrecognized abnormal swallowing.  Journal of the Canadian Dental Association, 34, 301-304.

Garliner, D. (1981).  Myofunctional therapy.  Philadelphia:  W. B. Saunders.

Geddes, D.T., Kent, J.C., Mitoulas, L.R., & Hartmann, P.E. (2007). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.

Geddes, D.T., Kent, J.C., Mitoulas, L. R., & Hartmann, P.E. (2008). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.

Gee, E., et al. (2013). Treatment of deformational plagiocephaly and torticollis using a weight distributon ring: a report of three cases. J of Pediatric Orthopaedics, May 22(3), 275-281.

Gewolb, I.H., Bosma, J.F., Taciak, V. L., & Vice, F.L. (2001). Abnormal developmental patterns of suck and swallow rhythms during feeding in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43, 454-459.

Glass, R.P., & Wolf, L.S. (1994). Incoordination of sucking, swallowing, and breathing as an etiology for breastfeeding difficulty. Journal of Human Lactation, 10, 185-189.

Goh, J. L., et al. (2013). Orthotic (helmet) therapy in the treatment of palgiocepahly. Neurosurg Focus: Oct: 35(4): E2.

Hazelbaker, A.K. (2003). The impact of craniosacral therapy on infant sucking dysfunction: a pilot study. Unpublished.

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

Herbst, J.J. (1983). Development of suck and swallow. Journal of Pediatric Gastroenterology and Nutrition, 2 (Supplement 1), S131-S135.

Hutchison, B. l., Stewart, A.W., & Mitchell, E.A. (2009). Characteristics, head shape measurements and developmental delay in 287 consecutive infants attending a plagiocephaly clinic. Acta Paediatr: Sep: 98(9): 1494-1499.

Hutchison, B. l., Stewart, A.W., & Mitchell, E.A. (2011). Deformational plagiocephaly: a follow up of head shape, parental concern and neurodevelopment at ages 3 and 4 years. Arch Dis Child: 96: 85-90.

Hutchison, B. l., et al. (2012). Serial developmental assessments in infants with deformational plagiocephaly. J Paediatr Child Health: Mar: 48(3): 274-278.

Hyashi, Y., Hoashi, E., & Nara, T. (1997). Ultrasonographic analysis of sucking behavior of newborn infants: the driving force of sucking pressure. Early Human Development, 49, 33-38.

Inoue, N., Sakashita, R., & Kamegai, T. (1995). Reduction of masseter muscle activity in bottle-fed babies. Early Human Development, 42, 185-193.

Jacobs, L.A., Dickenson, J.E., Hart, P.D., Doherty, D.A., & Faulkner, S.J. (2007). Normal nipple position in term infants measured on breastfeeding ultrasound. Journal of Human Lactation, 23, 52-59.

Jean, A. (1984). Brainstem organization of the swallowing network. Brain, Behavior and Evolution, 25, 109-116.

Karmel-Ross, K. (Ed.), (1997). Torticollis: differential diagnosis, assessment and treatment, surgical management an bracing. New York: Routledge.

Kidd, H.R. (1976). Examination of the mouth. Canadian Family Physician, 22, 59-62.

Kordestani, R.K., et al. (2006). Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg: Jan: 117(1): 207-218.

Korpilahti, P., et al. (2012). Deficient language acquisition in children with single suture craniosynostosis and deformational posterior plagiocephaly. Childs Nerv Syst: mar: 28(3): 419-425.

Labbock, M.H. & hendershot, G.E. (1987). Does breast-feeding protect against malocclusion? An analysis of the 1981 child health supplement to the national health interview survey. American Journal of Preventative Medicine, 3, 227-232.

Lau, C., & Kusnierczyk, I. (2001). Quantitative evaluation of infant’s nonnutritive and nutritive sucking. Dysphagia, 16, 58-67.

Lekovic, G.P., et al. (2007). New world cranial deformation practices: historical implications for pathophysiology of cognitive impairment in deformational plagiocephaly. Neurosurgery: Jun: 60(6): 1137-1146.

Leith, D.E. (1985). The development of cough. The American Review of Respiratory Disease, 131, S39-S42.

Lennartsson, F. (2011). Developing guidelines for child health care nurses to prevent nonsynostotic plagiocephaly: searching for the evidence. J Petriatr Nurs: Aug: 26(4): 348-358.

Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. (2nd ed.). Austin: Pro-Ed.

Losee, J. E., & Mason, A. C. (2005). Deformational plagiocephaly: diagnosis, prevention, and treatment. Clin Plastic Surg: 32: 53-64.

Losee, J. E., et al. (2007). Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment and outcomes. Plast Reconstr Surg: May: 119(6): 1866-1873.

Lowe, A.A. (1984). Tongue movements ─ brainstem mechanisms and clinical postulates. Brain, Behavior and Evolution, 25, 128-137.

Luz, C. L. F., Garib, D. G., Arouca, R. (2006). Association between breastfeeding duration and mandibular retrusion: a cross-sectional study of children in the mixed dentition. American Journal of Orthodontics and Dentofacial Orthopedics, 130, 531-534.

Majnemer, A. & Barr, R.G. (2005). Influence of supine sleep positioning on early motor milestone acquisition. Developmental Medicine and Child Neurology, 47: 370-376.

Margulis, A., et al. (1999). Plagiocephaly in children: etiology, differential diagnosis and helmet treatment. Harefuah: Apr: 136(7): 532-537.

Mawji, A., et al. (2013). The incidence of positional plagiocephaly: a cohort study. Pediatrics: Aug: 132(2): 298-304.

McKinney, C. M., et al. (2008). Characteristics of 2733 cases diagnosed with deformational plagiocephaly and changes in risk factors over time. Cleft Plate Craniofac J: Mar: 45(2): 208-216.

McKinney, C. M., et al. (2009). A case-control study of infant, maternal and perinatal characteristics associated with deformational plagiocephaly. Paediatr Perinat Epidemiol: Jul: 23(4): 332-345.

McTavish, W.K., & Matthews, R.L. (1960). Airways: the key to early facial growth and malocclusions. Self-published.

Medoff-Cooper, B., McGrath, J.M., & Shults, J. (2002). Feeding patterns of full-term and preterm infants at forty weeks postconceptional age. Journal of Developmental & Behavioral Pediatrics, 23, 231-236.

Meyer-Marcotty, P., et al. (2012). Head orthesis therapy in infants with unilateral positional plagiocephaly: an interdisciplinary approach to broadening the range of orthodontic treatment. J Orofac Orthod, April 73 (2): 151-65.

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.

Miller, A.J. (1986). Neurophysiological basis of swallowing. Dysphagia, 1, 91-100.

Miller, R. I., & Clarren, S. K. (2000). Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics: 105: e26.

Moore, K.L., & Persaud, T.V.N. (1998). The developing human: clinically oriented embryology. (6th ed.). Philadelphia: W.B. Saunders Company.

Mueller, D. T., & Callanan, V.P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40, 141-160.

Mukai, S., Mukai, C., & Asaoka, K. (1991). Ankyloglossia with deviation of the epiglottis and larynx. Annals of Otolaryngology, Rhinology and Laryngology, 100, 3-20.

Nanci, A. (2008). Ten Cate’s oral histology: development, structure, and function. (7th ed.). St. Louis: Mosby Elsevier.

Oden, R.P., et al. (2012). Swaddling: will it get babies on their backs for sleep? Clin Petriatr: March 2012:51(3): 254-259.

Oh, A. K., et al. (2009). Predictors of severity in deformational plagiocephaly. J Craniofac Surg: Mar: 20 Suppl 1: 685-689.

Ostfield, B. M., et al. Sleep environment, positional, lifestyle, and demographic characteristics associated with bed-sharing in sudden infant death syndrome cases: a population-based study. Pediatrics: Nov: 118(5): 2051-2059.

Palmer, B. (2005). Snoring and sleep apnea: how it can be prevented in childhood. das schlafmagazin, 3, (Aug), 22-23. Retrieved May 1, 2009 from http://www.dasschlafmagazin.de

Paoletti, S. (2006). The fasciae: anatomy, dysfunction and treatment. Seattle: Eastland Press.

Phillips, V.T. (1992). Correcting faulty suck: tongue protrusion and the breastfed infant. The Medical Journal of Australia, 156, 508.

Pogliani, L., et al. (2011). Positional plagiocephaly: what the pediatrician needs to know. A review. Childs Nerv Syst: Nov: 27(11): 1867-1876.

Pollack, I.F., et al. (1997). Diagnosis and management of posterior plagiocephaly. Pediatrics: Feb: 99(2): 180-185.

Prieto, C.R., Cardenas, H., Salvatierra, A.M., Boza, C., Montes, C.G., & Croxatto, H.B. (1996). Sucking pressure and its relationship to milk transfer during breastfeeding in humans. Journal of Reproduction and Fertility, 108, 69-74.

Qureshi, M.A., Vice, F. L., Taciak, V. L., Bosma, J.F., & Gewolb, I.H. (2002). Changes in rhythmic suckle feeding patterns in term infants in the first month of life. Developmental Medicine & Child Neurology, 44, 34-39.

Ramsay D.T., & Hartmann, P.E. (2005). Milk removal from the breast. Breastfeeding Review, 13, 5-7.

Rendon-Macias, M.E., Cruz-Perez, L.A., Mosco-Peralta, M.R., Saraiba-Russell, M.M., Levi-Tajfeld, S., & Morales-Lopez, M.G. (1999). Assessment of sensorial oral stimulation in infants with suck feeding disabilities. Indian Journal of Pediatrics, 66, 319-329.

Rogers, G. F., et al.(2008). Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly. Plast reconstr Surg: Mar: 121(3): 941-947.

Rogers, G. F., et al. (2009). The role of congenital muscular torticollis in the development of deformational plagiocephaly. Plast Reconstr Surg: Feb: 123(2): 643-652.

Salls, J. S., et al. (2002). The relationship of infant sleep and play positioning to motor milestone achievement. Am J of Occupational Therapy, 56(5): 577-580.

Scragg, R.K., et al. (1996). Infant room-sharing and prone sleep position in sudden infant death syndrome. New Zealand and cot death study group. Lancet, Jan 6: 347(8993): 7-12.

Seruya, M., et al. (2013). Correction of deformational plagiocephaly in early infancy using the plagio cradle orthotic. J Craniofac Surg: Mar: 24(2): 376-379.

Shamji, M. F., et al. (2012). Cosmetic and cognitive outcomes of positional plagiocephaly treatment. Clin Invest Med: Oct: 35(5): e266.

Shepard, J.W., Geffler, W.B., Guilleminault, C., Hoffman, E.A., Hoffstein, V., Hudgel, D.W., Surratt, P.M., & White, D.P. (1991). Evaluation of the upper airway in patients with OSA. Sleep; 14(4):361-71.

Siatkowski, R. M., et al. (2005). Visual field defects in deformational posterior plagiocephaly. JAAPOS: Jun: 9(3): 274-278.

Smartt, J. M., et al. (2011). Analysis of differences in the cranial base and facial skeleton of patients with lambdoid synostosis and deformational plagiocephaly. Plast Reconstr Surg: Jan: 127(1): 303-312.

Smith, W. L., Erenberg, A., & Nowak, A. (1988).  Imaging evaluation of the human nipple during breast-feeding.  American Journal of Diseases in Children, 142, 76-78.

Smith, W. L., Erenberg, A., Nowak, A., & Franken, E. A. (1985).  Physiology of sucking in the normal term infant using real-time ultrasound.  Radiology, 156, 379-381.

Speltz, M. L. (2010). Case-control study of neurodevelopment in deformational plagiocephaly. Pediatrics: 125: e537.

Sperber, G.H. (2001). Craniofacial development. Hamilton, Ontario: BC Decker, Inc.

Steinbok, P., et al. (2007). Long-term outcome of infants with positional occipital plagiocephaly. Childs Nerv Syst: Nov: 23(11): 1275-1283.

Stevenson, R.D., & Allaire, J.H. (1991). The development of normal feeding and swallowing. Development and Behavior: The Very Young Child, 38, 1439-1453.

Tait, P. (2000). Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. Journal of Midwifery & Women’s Health, 45, 212-215.

Takemoto, H. (2001). Morphological analyses of the human tongue musculature for three-dimensional modeling. Journal of Speech, Language, and Hearing Research, 44, 95-107.

Turk, A. E., et al. (1996). The “back to sleep” campaign and deformational plagiocephaly: is there a cause for concern? J Craniofac Surg: Jan: 7(1): 12-18.

Van Vlimmeren, L.A., et al. (2007). Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics: Feb: 119(2): e408-418.

Van Vlimmeren, L.A., et al. (2008). Effect of pediatric physical therapy on deformational plagiocephaly in children with optional preference: a randomized controlled trial. Arch Pediatr Adolesc Med: Aug: 162(8): 712-718.

Van Wijk, R. M., et al. (2014). Helmet therapy in infants with positional skull deformation: randomized controlled trial. British Medical Journal: May: 348: g2741.

Watson Genna, C. (2008). Supporting sucking skills in infants. Sudbury: Jones and Bartlett Publishers.

Weber, F., Woolridge, M. W., & Baum, J. D.  (1986).  An ultrasonographic study of the organization of suck and swallow.  Developmental Medicine and Child Neurology, 28, 19-24.

Wilson, S.L., Thach, B.T., Brouillette, R.T., & Abu-Osba, Y.K. (1980). Upper airway patency in the human infant: influence of airway pressure and posture. Journal of Applied Physiology: Respiration, Environmental, and Exercise Physiology, 48, 500-504.

Winberg, J. (2005). Mother and newborn baby: mutual regulation of physiology and behavior-a selective review. Developmental Psychobiology, 47, 217-229.

Wolf, R.P. & Glass, L.S. (1992). Feeding and swallowing disorders in infancy: assessment and management. Tucson, Arizona: Therapy Skill Builders.

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.

Wound Healing

Bernstein, A.M., et al. (2007). Urokinase receptor cleavage: a crucial step in fibroblast-to-myofibroblast differentiation. Molecular Biology of the Cell, 18:2716-27.

Darby, I. A., Laverdet, B., Bonte, F. & Desmouliere, A. (2014). Fibroblasts and myofibroblasts in wound healing. Clinical, Cosmetic and Investigational Dermatology, 7:301-11.

Desmouliere, A., Darby, I.A., & Gabbiani, G. (2003). Normal and pathological soft tissue remodeling: role of the myofibroblast with special emphasis on live ran kidney fibrosis. Lab Investigations, 83:1689-1707.

Gabbiani, G. (2003). The myofibroblast in wound healing and fibroconnective disease. Journal of Pathology, 200:500-3.

Gabbiani, G. (2004). The evolution of the myofibroblast concept: a key cell for wound healing and fibrotic disease. Giornale Di Gerontologia, 52:280-2.

Hinz, B. (2007). Formation and function of the myofibroblast during tissue repair. Journal of Investigational Dermatology, 127(3):526-37.

Li, B. & Wang, J. (2011). Fibroblasts and myofibroblasts in wound healing: force generation and measurement. Journal of Tissue Viability, 20(4);108-120.

Paoletti, S. (2006). The fasciae: anatomy, dysfunction and treatment. Seattle: Eastland Press.

Penn, J.W., Grobbelaar, A.O., & Rolfe, K.J. (2012). The role of TGF-ß family in wound healing, burns and scarring: a review. International Journal of Burn Trauma, 2(1):18-28.

Ploeger,D., et al. (2013). Cell plasticity in wound healing, paracrine factors of M1/M2 polarized macrophages influence the phenotypical state of dermal fibroblasts. Cell Communication and Signalling, 11:29. www.biosignaling.com/content/11/1/29.

Schleip, R. Ed. (2012). Fascia: the tensional network of the human body. Edinburgh: Churchill Livingstone.

Stecco, C. (2015). Functional atlas of the human fascial system. Edinburgh: Churchill Livingstone.

Tomasek, J.J., et al. (2002). Myofibroblasts and mechano-regulation of connective tissue remodeling. Nature Review Molecular Cellular Biology, 3(5):349-63.

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.

Suck, Swallow, and Breathe Podcast

Dr. Hazelbaker teamed up with Adriana Lozada from  birthful.com for a podcast on suck, swallow breathe.  

Click here to listen

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.

Tongue Tie Podcast

Dr. Alison Hazelbaker joined Barbara Robertson, IBCLC in a podcast discussing tongue tie.  

Click here to listen to the podcast and learn more about Barbara's practice in Ann Arbor, MI.  

Select publications now available for download!

Dr. Hazelbaker has made several of her publications available for download. Please click here or on the image below to browse her offerings.