Is your baby’s tongue tie a tetherberg or a tether floe?

There are two kinds of ice in the ocean: icebergs and ice floes. Both can look identical on the surface, but are completely distinct below the water. Icebergs have a portion of ice seen above the surface, and huge, extensive mountains of ice below the surface, anchoring what you can see above to the masses below. Ice floes are seen from above and are basically a sheet of floating ice.

Tongue ties can also be classified into two types: tetherbergs and tether floes.

Tetherbergs are tongue ties that look tied on the surface, but the breastfeeding issues and symptoms are connected to so much more than just the tongue. Baby usually has lots of tension in the body. There may be a sensitive nervous system. A traumatic birth. Baby may live in a state of fight or flight. There may be other asymmetries or structural differences in the body. There’s so much more below the surface than meets the eye. For these babies, doing a revision of the tie is literally only the tip of the ice berg. They usually need lots of pre and post release manual therapy such as chiropractic or craniosacral therapy, occupational therapy, and suck training. It may be weeks to months before what is below the surface is fully addressed.

Tether floes are the babies I dream of in my practice. The tongue tie is the root cause of the breastfeeding problems and symptoms. A simple release is an overnight, miracle cure to nipple pain and damage, weight gain, milk supply or reflux. These babies usually need minimal additional interventions to restore the breastfeeding relationship and have all of their symptoms melt away.

Being aware of the tetherbergs vs the tether floes is the beginning to understanding your journey with a tied baby. Many families have their baby’s tie revised only to find they still have persistent symptoms. For them, the mass of ice below the surface must still be addressed before relief is gained. If you’re in the middle of your journey, keep going. Keep asking questions. Keep finding the highly trained health care providers who specialize in ties who can help.

For more information, see the original post by Michele Chatham

https://www.michalechatham.com/blog/tether-berg-or-tether-floe?fbclid=IwAR0q5o8NP_iwFkA5XijLMymDPyxcsLwvTq3cS8V4kxyRZ1jOjk3x8g5sdZE

Breastfeeding is a medical and Heath issue. It should be treated as such

Breastfeeding issues are medical problems. I wish health care providers would understand this. When a parent wants to breast/chestfeed, but is running into challenges, those challenges need to be taken seriously, just as if they were complaining about any other health or medical issue.

Feeding your baby from your body should not be painful. Our bodies are designed to feed our babies, so when there is pain there is always a reason. Pain tells us that something needs fixed. It may be as simple as the position and latch or as complex as a tongue tie. At no point should healthcare providers accept tissue damage as normal. If they are telling you it’s fine and part of the process, please get a second opinion.

When everything is going well, our bodies are designed to provide plenty of milk for our babies. If you are not making enough milk for your baby while seemingly doing all the right things, we should find the root (IGT? Wrong pump flange? Not pumping enough? Medications? Hemorrhage at birth?).

Baby unable to latch? Popping on and off? Babies are born to feed. All of their reflexes and instincts are designed to get them to latch and feed. If baby is struggling at the breast, there is always a reason. Rarely will we not find the root if we dig deep and long enough.

When there is pain, damage, low milk supply or a non-latching baby, interventions are often needed. These are medical interventions that should be overseen by an IBCLC who has lactation specific training to make sure the correct tool for the correct cause of the issue is being used. And getting the best, most accurate information for that individual family. If a family chooses not to breastfeed because of these issues, that is their choice and should be supported to the fullest. If your health care providers are not taking your concerns seriously, find another health care provider

Human milk fat


The fat in your milk accounts for 50% of the calories your baby takes in each feeding. While protein and lactose remain relatively stable throughout the day, milk fat concentration can vary by 47% in a 24 hour period!

Factors that influence milk fat in breast milk:
🤱🏽 In the lactation parent (some of these you can change and control and some of these you can’t):
Lifestyle
Diet
Body size
Health or disease/inflammation
Number of children
Type of birth
Overall milk volume produced daily

👶🏼 In the baby (the lactating parents body responds to make specific milk to accommodate the baby):
Gender
Gestational age
Birth weight

🍫 Other factors that influence fat in human milk:
⏰ Time of day (highest fat is in the afternoon/evening)
👶🏼 👧🏽 Stage of lactation (colostrum has the lowest amount of fat. Extended milk for toddlers 12+ months has the highest amount of fat!)
🗓 Time postpartum (milk fat increases with time!) mm
Ways to help increase milk fat:
🤱🏽 Feed more frequently. An emptier breast has higher fat and lower water concentrations. Pump
⭐️ Shake your breasts prior to feeding. This gets the fat at the back of the breast to be activated more quickly to flow sooner in the feeding
🐠 Add in healthy fats to your diet: salmon, herring, sardines, flax and chia seeds, and walnuts are high in healthy fats that can boost your milk fat.
🍦 Manage diabetes/blood sugars
🏋🏽‍♀️ Make sure you’re not anemic or iron deficient
♨️Reduce inflammation in the body (can often be done with diet and lifestyle changes and/or with the help of a naturopathic practitioner)

Fluid dynamics

Milk is a liquid. And it obviously flows like a liquid. Have you ever sprayed your baby in the face from milk that flows too fast during let down? Have you ever been concerned with how fast or slow your milk seems to flow in any given feeding or pump session?

Did you know the breast is like a tree inside? With lots of lobes at the back of the breast that funnel down through milk ducts to fewer nipple pores at the front? The flow of your milk is impacted by multiple things. One of the biggest things to impact how your milk flows is your unique breast anatomy.

🌳Everyone has a different number of milk making lobes, also known as alveoli. These lobes are connected to your blood steam, because milk is made from nutrients in your blood. Oxytocin triggers contractions of the lobes to release milk down your milk ducts

🌴The length and diameter of the ducts play a role in how quickly milk goes from where it is made to the baby.

🌲The viscosity, or thickness, of your milk can slow down or speed up milk flow. This viscosity can change from feeding to feeding depending on many factors. Many will take sunflower lethicin to thin their milk (keep the fat from sticking) to help speed up milk flow and reduce the risk of the milk fat sticking in the ducts and causing plugged ducts

🎄How dense or elastic your breast tissue is contributes to flow rate.

Your body and your anatomy is unique. Milk production or how milk is made in the breast is not the same for every person. If you’re struggling with making or releasing milk to your baby, schedule a consultation to figure out why and develop an individualized plan that works for your anatomy.

COLORS OF MILK

Your milk can be a variety of colors which can be caused by a variety of things.

💛Diets high in yellow-orange vegetables (yams, squash, carrots, etc) can lead to high levels of carotene in your milk, which can turn it yellow or orange.

💛Frozen milk may look more yellowish when thawed.

🧡Food dyes used in carbonated sodas, fruit drinks, and gelatin desserts have been associated with milk that is pink or pinkish orange.

💙Blueish milk is often just a higher water content in the milk. It could also be caused by food dyes.

💚Greenish milk has been linked to consuming green sports beverages, seaweed, certain herbs, or large amounts of green vegetables (such as kale or spinach). I had mine turn green from a plant based multivitamin!!

💗Pink milk, some times called “strawberry milk” be a sign of blood in your milk. This can occur with or without cracked nipples. Seeing blood in your milk may be alarming at first, but it is not harmful to babies. If you have any concerns or other symptoms associated, such as pain or mastitis, set up a lactation consultation right away.

💔Occasionally blood in breastmilk is caused by things other than nipple or breast trauma. Papillomas are small growths in the milk ducts which are not harmful but can cause blood to enter your milk. In the vast majority of cases, blood in human milk is not a concern. However, some forms of breast cancer can cause blood to leak from the nipples. Breast milk can also turn pink if a bacteria called Serratia marcescens is present, although rare this bacteria can be extremely harmful to young babies. If you’re experiencing pink milk without noticeable nipple damage, please reach out to a health care provider immediately.

🤎Brown milk may be caused by what is known as rusty pipe syndrome. During pregnancy and in the first few days after birth the ducts and milk making cells in your breasts grow and stretch. As blood flows to your breasts it can sometimes leak into your milk ducts, making your milk look brown or rust-colored. It usually clears within a few days as more milk flows through your breasts. Continue feeding your baby your milk.

FIL: How breast milk is actually made

Milk production is controlled by how often milk is being emptied from the breast. An empty breast makes milk faster than a full breast. The more you empty, the more you make. This is because milk production is being controlled in the breast by a substance called the feedback inhibitor of lactation, or FIL (a polypeptide), which is present in the milk itself. Sometimes one breast stops making milk while the other breast continues (in some cases of slacker boob), for example if a baby nurses on only one side. This is because of the local control of milk production independently within each breast. If milk is not removed, the FIL builds up in the milk and stops the cells from making any more milk. This protects the breast from things like clogged ducts and mastitis. If breast milk is emptied from the breast, the inhibitor is also removed, and making milk resumes. Milk removal can be done by the baby or a pump
.
The amount of milk that is produced is determined by the amount of FIL in the milk, which is driven by how much and how often the baby or a pump removes milk from the breast. Emptier breasts have less FIL and make milk faster. Full breasts have more FIL and make milk slower. This mechanism is especially important for continuing to make milk after 11-14 weeks when hormones shift and milk making is completely determined by how much milk is being emptied from the breast.

Immune boosting power of breast milk

🍀Doctors have long known that infants who are breast-fed get fewer infections because babies gain extra protection from antibodies and live immune cells found in human milk.
🍀Research shows every tsp of breastmilk has 3,000,000 germ killing cells in it. Even one teaspoon a day is giving baby some immune protection!
🍀Once ingested, live molecules and cells in the milk help to prevent microorganisms from penetrating the baby’s body tissues.
🍀Some of the immune molecules bind to viruses/bacteria/germs in the digestive tract, preventing them from getting into the rest of the body.
🍀Certain immune cells in human milk attack viruses and bacteria directly. Another set produces chemicals that stimulate baby’s own immune response.
🍀The most impressive amount of immune cells are found in colostrum.
🍀Several studies suggest human milk may induce an infant’s immune system to mature more quickly than with formula
🍀Some of the immune factors in breastmilk increase in concentration as baby gets older and nurses less, so older babies continue to benefit from breast milk
🍀Remember, freezing kills some of the live immune factors of breastmilk even though the nutrition (vitamins, protein, fat) is maintained. Offer fresh breast milk whenever possible.
🍀Research is showing that if you’ve had COVID or the COVID vaccine, your milk will pass antibodies to your baby to protect them from getting it!

Vasospasm: pins and needles in the nipple

Has your nipple looked waxy or dull white after feeding or pumping? That’s because the blood vessels have gone into spasm and are not letting blood through. Vasospasm occurs when there is exposure to cold, an abrupt temperature drop, vibration, or repetitive motion in the affected area. The arteries go into spasm and stop letting blood through. There is a disorder called Reynauds that make peoples experience this in their fingers and toes on a more routine basis. When it happens in the nipple it really HURTS. Some say it feels like fire or ice. Others describe it as a pinchy, slicing feeling, or pins and needles. The nipple often turns pale and become painful right after the baby unlatches. It often gets misdiagnosed as thrush but will not respond to medications. So if you’ve been on multiple rounds of medications for thrush and it’s not working, you may actually be having vasospasm.

It can simply be caused by a bad latch, but can have several other culprits. For people prone to vasospasm, the repetitive action of feeding or pumping in combination with the abrupt drop in temperature when baby unlatches or the pump stops is enough to trigger the spasm.

The two main ways to help: massage and heat.

🤲🏼Gently massaging, rubbing, or pinching the nipple helps. Immediately cover your nipples with your shirt/bra/nursing pad, then gently rub or massage them through the fabric.

🌞Heat is important because of science: evaporation is a cooling process. When liquid turns to gas, it uses heat energy from its surroundings to transition. When milk and saliva evaporate off your nipple, the skin and surface tissue cool rapidly, causing the vasospasm.

🌞To slow evaporation, place heat on your nipple as soon as baby unlatches. Use dry heat like a lavender pillow, microwaveable rice/barley/flax pack, hand warmer/Hot Hands (like you use in snowy climates for skiing), or a heating pad can help. Leave heat on for a few minutes until the pain subsides.
🌚Avoid anything wet on the nipple as this promotes evaporation.
🌝Wear wool nursing pads between feedings

Unfortunately, there isn’t a lot of good quality research about treating breastfeeding nipple vasospasm no. Much of what we know is taken from other vasospasm research, or applied from anecdotal evidence. You should always consult your primary health care provider before making any changes to your health, such as adding a supplement, taking medications, or making big lifestyle changes. At a basic level:
🌻Watch for a deep latch every time
🌻Have baby assessed for tongue tie
🌻Check your flange size. If you’re maxing our the suction on the pump, your flange is too big. When too much areola is drawn into the tunnel, the areola swells shut around the nipple and causes the spasm. Using too small a flange does the same: cuts off blood flow to the nipple tip.

Other tips to reducing vasospasm:
🌸Avoid nicotine and medications that cause vasoconstriction (such as pseudoephedrine, beta blockers).
🌸Limit or avoid caffeine
🌸Some research indicates hormonal birth control pills increase the risk of vasospasm.
🌸The main supplement that seems to help with vasospasm is vitamin B6. Dr Jack Newman suggests 100 mg of B6 twice day, as part of a B vitamin complex. If your B vitamin contains 50 mg of B6, you’d take two of them, twice a day. If it contains 25 mg of B6, you’d take four of them twice a day.
🌸Calcium plays an important role in blood vessel dilation. Magnesium helps in calcium regulation. Supplementing with cal/mag often helps with vasospasm.
🌸Being active helps prevent their vasospasm. An active lifestyle can keeps blood circulating through your body.
🌸The internet is full of conflicting opinions on if ibuprofen is a vasoconstrictor or vasodilator. Regardless, it sometimes turns up to treat/prevent vasospasm. If you have regular vasospasm, the risks of longterm ibuprofen use most likely outweigh the potential decrease in vasospasm. It may be OK for occasional vasospasm. Discuss regular ibuprofen use with a healthcare provider.
🌸For chronic, painful vasospasm that does not respond to breast-feeding help, some doctors may prescribe a short course of a blood medication called Nifedipine.

Nipple shield weaning

Did you use a nipple shield to help your baby latch? Want to transition baby off the shield? First, weaning from the shield is your choice. If you like it and it’s comfortable for you, don’t feel pressured to get rid of it before you and your baby are ready. There are risks associated with shield use, like the potential for decreased milk supply. But if that’s the only way your baby will latch right now, give yourselves time and grace to keep trying as baby gets older and more proficient at the breast. As always, if you’re really struggling to get off the shield, find a knowledgeable lactation consultant to help you with the process to make sure something else isn’t going on with baby’s latch.

💡You can always start with the shield on and take it off after your first let down once baby is not as hungry or use it on the first side and offer the second side without it

💡Start by trying without the shield once a day during daylight hours when baby is happy and not too hungry. Catching baby with early hunger cues is imperative. If they’re crying and really hungry, try a different time

💡Start in skin to skin. Taking a bath together can help. Try to be as relaxed as possible

💡Try to erect and evert your nipple. Use reverse pressure softening (RPS, see highlight reel), a pump or stimulate your nipples with your hands before attempting to latch

💡Help baby latch with laid back nursing, supporting the breast in a “C” or sandwich hold, or the flipple. Make sure baby’s chin and cheeks are physically touching the breast as much as possible. A baby that can’t feel the breast can’t latch to the breast.

💡Hand express to get your milk flowing so baby gets instant satisfaction and reduce the work

💡Relax and be patient. Babies can feel your energy. The more you can see it as fun practice, the less pressure you’ll put on yourself and your baby

💡Try a nipple shield weaning system like this one from Back to Mom (24mm) or Lacteck (small/20mm).

Lip Tie vs Normal Lip Frenulum: An SLP/IBCLC Perspective

Lip ties (and their pictures on social media) drive me clinically nuts, because is so much confusion and misinformation about who actually has one. Too often medical professionals and lactation consultants say:

“All babies have lip ties”
“All babies have a band under there, there’s no such thing as a lip tie”
“That tissue will stretch with time/migrate up as they get older”
“They’ll eventually fall and break it on their own. No need to intervene”
“It doesn’t cause any problems, so just leave it alone”

On the flip side, some providers (and other random parents on social media forums) will say:

“See how the band of tissue is really low on the gums? That’s a lip tie”
“See how thick that band is? That lip is definitely tied”
“Lip ties are causing of all your nursing issues, cut it ASAP”
“Lip ties will cause all kinds of issues in the future, even if you don’t have symptoms now, better to cut it sooner rather than later”
“Where there’s a lip tie, there’s a tongue tie, your baby must be tied if they have any symptoms if a frenulum is visible”

Lip tie

I am the first to refer to the appropriate health care provider (ENT or pediatric dentist) when a true lip tie is not allowing proper function of the lips and is impacting the success of digestion or breastfeeding. But let’s understand a few things:

✏️According to a 1994 study by Flinck, who looked at >1000 babies, 77% of them had a frenulum that inserted “low” on to the gumline. A further 17% had a frenulum that inserted into the palate. So 94% of babies have a really low gum insertion – that is NOT the definition of a lip tie. Having a low set frenulum cannot be the only criteria used for release.

✏️There is currently no published criteria defining a normal frenulum vs a lip tie. That does not mean a lip shouldn’t be addressed when function is being impacted by anatomy. But that band between lip and gums is supposed to be there to some extent to help anchor your lips to your face for proper movement and facial development.

✏️Lip tie, when it is present, can certainly get in the way of a normal latch. A lip tie may cause increased air intake (contributing to reflux and gas), breast pain from the lips gripping too tightly to the breast, contribute to lip blisters muscle compensations, or not allow the baby to be able to maintain the latch through the whole feeding. While the lips are important for feeding, I’m more concerned about the tongue for obtaining a normal latch. Many compensations baby does to overcome a tongue tie May be mimicking issues seen with lip tie. Baby needs assessed for both.

No lip tie

True diagnosis of lip tie is all about anatomy (what does it look like), physiology (what does it do), and symptoms (what is it causing). A lip tie will always impact function of the lip by restricting its expected movement. The upper lip should be soft and move to spread and pucker the lips without difficulty. The upper lip should play a passive role when breastfeeding, gently rounding to maintain the seal at the breast so milk doesn’t leak out and not gripping the breast.

An evaluation by an IBCLC should be mandatory before any baby is sent for oral surgery. Are the symptoms and behaviors at the breast being caused by poor position and latch? By tension in the body from birth trauma? Is tongue tied the actual culprit to the issues going on?

👄 The movement of the lip must be physically challenged to determine its full range of motion. If the lip is lifted up toward the nose, the center of the lip should move up toward the nose with the rest of the lip. If the center of the lip stays down against the gum line, it may be a tie. If no one physically flipped the lip up toward the nose, lip tie was not assessed.

👄 When you lift the lip, if the gums where the frenulum inserts turns white (blanches) OR the lip skin/frenulum turns white (blanches ) when you lift the lip up with reasonable amounts of pressure, the lip is tied

👄 A notch in the bone of the gums where the frenulum attaches means the lip is tied. It indicates the tissue is so tight it’s now impacting the bone. This kind of lip tie needs immediately assessed and addressed as it most likely will impact dentition and dental hygiene.

My baby has lip blisters. Does that mean they have a lip tie? Not necessarily. They may have a tongue tie and the lips are compensating for it. They may be constantly in a shallow latch at the breast or bottle and be using their lips to hang on. Lip blisters are a sign of shallow or dysfunctional latch and feeding should be observed to maximize latch.

My baby always tucks their upper lip when nursing. Does that mean they have a lip tie? If the lip is still soft and can easily be flanges out, no, it’s not tied. Some babies like to tuck the upper lip or it gets accidentally tucked when latching and it’s not a problem. Tucking the upper lip can also happen when the tongue is tied- if the tongue can’t hold the seal (which is its job), then the lips have to. If the lips hold the seal, the lips have to be tucked in or milk will leak.

The upper lip frenulum is one that can stretch and migrate up with time. As more teeth come in, they can close the gap caused by some frenulum. If that is normal, why should it be released? An upper lip frenulum can migrate up over years, but if the restriction of the lip is affecting baby and mom NOW, then it should be treated NOW.

A lot of emphasis is being put on lip ties right now, especially by well meaning parents on social media. While a lip tie can get in the way of feeding and cause some pretty intense symptoms in some babies, the main focus should be on good position and deep latch with normal tongue mobility. If you’re struggling with breastfeeding, seek out a qualified IBCLC or schedule your consultation with me ASAP to determine your next steps.