Diane Michel MSPH, IBCLC, RLC | Nourish Lactation Consulting

What does a typical intake look like? What are you assessing?

The specifics vary depending on exactly what issues a family is coming to see me about. But generally, I'm assessing mom issues (asking her about her health, pregnancy, labor, birth, and how she's feeling), baby issues (asking about baby's health, weighing baby, and examining baby's body, head, face, mouth, and movement) and breastfeeding issues (how mom feels like breastfeeding is going, weighing to see how much baby took at the breast, working with positioning and latch, assessing compensations that mom or baby has to use to feed, and asking mom about breastfeeding issues such as pain and frequency of breastfeeding, pumping, and bottle feeding). There's more to the consult but those are the general ideas.

Can moms and babies see you even if they aren’t breastfeeding? If so, what would they need to see you for?

I have worked with moms and babies to help with bottle feeding difficulties and to assess and work with tongue ties when they are bottle feeding. I assess how babies feed from a bottle and also do an oral assessment, as well as take a thorough history. I also want to see a baby feed from a bottle if the babies are bottle and breastfeeding.

What do you work with specifically?

• Painful/sore nipples and/or breasts

• Uncomfortable latch/painful latch/difficult latch

• Too much or too little breast milk/low milk supply

• Low weight gain

• Concerns about possible tongue tie and/or lip tie

• Before and after the release of a tongue-tie tie and/or lip tie and/or cheek ties

• Plugged/clogged ducts

• Mastitis

• Thrush

• Pumping

• Avoiding nipple confusion

• Returning to work

• Bottle refusal/bottle feeding

What is a tongue tie?

A tongue tie is part of a bigger concept of "tethered oral tissues" which can include the tongue, lip, and cheek ties. It refers to a functional issue in which the tongue's movement is restricted due to the tightness and inelasticity of the frenulum. The frenulum is the tissue under the tongue that may feel like a guitar string. It's important to note that we all have frenula (plural of a frenulum), and so the presence of a frenulum does not indicate there is a tongue tie. What's needed is a functional examination that closely assesses your baby's movement. I do this both by examining a baby's mouth as well as observing what is happening at the breast. It's a fairly involved process that takes some time and attention. It's not just a matter of seeing if your baby can stick his tongue out, or posting a picture of your baby's mouth and frenulum on a Facebook group and asking other mothers if it's a tie.

What causes a tongue tie? Is there anything you can do to prevent it?

This is a question I'm asked all the time! During fetal development, the tissue under the tongue is supposed to go away or "resorb" as part of a preprogrammed cell death called apoptosis. When the cells under the tongue don't die off appropriately, there is a remnant of tissue that might be too short, tight, or attached incorrectly to other parts of the mouth. In a similar process, fetal fingers and toes are connected by webbing during fetal development but the cells between fingers and toes die off so that our fingers and toes are all separate. Tongue-tie does run in families. There are different theories about prevention but nothing proven, including having excellent nutrition during pregnancy. I do discuss the nutritional aspect with families in prenatal consults. It's also really important to emphasize that there is so much we don't have control over regarding whether a baby has a tongue tie and it's crucial for women not to blame themselves.

Do you refer out for diagnosis/revision if you suspect a tie? If so, what warrants a referral? 

An anatomical impairment that impairs a baby's functioning and makes it hard for a baby to feed well warrants a potential referral. When I am suspicious of a tie, I like to have a discussion with parents to let them know my concerns and why I'm having these concerns as well as to present options to them. I feel really strongly that while I have my assessment, it's up to parents to decide what to do with that information because it's their baby. Not mine! If they want to possibly consider a release I do refer out for diagnosis. (As a board-certified lactation consultant, or an IBCLC, I am permitted to assess in great detail, present my findings and make suggestions for providers to evaluate, but I am not permitted to make an official diagnosis.) The tricky thing is that parents may have several professionals weighing in, and parents may get inconsistent opinions on whether the baby has a tie. It can be a hard place for parents to be in.

Do you typically recommend exercises and how do those differ from what a dentist would give if a revision is done?

I always recommend exercises to help a baby with function so they can relearn how to use their mouths. These are different from the "exercises" a dentist gives with a release -- those "exercises" are stretches that dentists give to promote optimal healing of the wound and to prevent reattachment. These stretches are crucial but have a different purpose than functional exercises. If I see a family before a release I will start them with functional exercises right away and continue them after the release.

Why did one lactation consultant tell me there wasn’t a problem, but another one says there is? Who’s right?

First of all, I want to clarify that "lactation consultant" is a meaningless term. Anyone can -- and does -- call themselves a lactation consultant, so it's important to know the training and certification the "lactation consultant" has. There is a huge difference in training between an IBCLC (International Board Certified Lactation Consultant) and a CLC (Certified Lactation Counselor, some of whom confusingly call themselves "lactation consultants"). To become an IBCLC requires years of hands-on training and course work, versus a one-week class required to become a CLC. An "advanced" CLC requires an additional week of class. Second of all, a thorough evaluation of tethered oral tissues requires training beyond what is required of basic IBCLC training, and certainly well, well beyond the training of a CLC. Some IBCLCs, including some who work in the community setting and especially those who work in hospital settings, may not have had the additional education on this subject. Parents often tell me that no one has evaluated their baby to the extent that I have, and I think that many parents then understand why my recommendations may differ from what they have already heard.

Diane Michel MSPH, IBCLC, RLC