|Sleep Apnea from an Anatomical and Developmental Perspective|
Breastfeeding and Frenulums
Researcher and presenter: Brian Palmer, D.D.S., December, 2003.
All that is needed to view this presentation is Adobe Acrobat Reader. Adobe Acrobat Reader is a free download from the Internet. I would recommend you print out this 8-page commentary and read along as you view the presentation. Once the presentation has been activated, it can be downloaded free of charge to your computer and saved for viewing at your convenience without being on the Internet. You can then transfer the information to a CD or DVD to give to others, or used in presentations for educating others. You have my permission to share this presentation with anyone in the world provided there is no charge for doing so.
Breastfeeding and Frenulums Presentation Click here to download (1818kb)
Breastfeeding and Frenulums Presentation in French Click here to download (1857kb)
I have been evaluating frenulums and the importance of breastfeeding for many years. I am hoping this presentation will help those who believe tight frenulums can have a negative impact on breastfeeding but have not had the documentation needed to convince a doctor or parent to do anything about it. I am hoping this presentation will give you that needed documentation.
It is falsely assumed that tight frenulums will go away by themselves and do not have consequences. There are NO MEDICAL OR DENTAL BENEFITS of having a tight lingual (under the tongue) or labial (lip side) frenulum. There are many major medical and dental consequences that result from tight frenulums. One of the first consequences is the impact on breastfeeding.
Slide # Comments
#3 - Different spellings - Physicians usually prefer the term frenulum whereas dentists usually prefer the term frenum. The spelling or pronunciation of the word should not be made an issue. I use the words frenum and frenulum interchangeably in this presentation to try to stress there is no difference in the meaning of the various spellings.
#4 - Consequences: As described by Dr. Michael Woolridge (England), Ros Escott (Lactation Consultant-Australia) and Dr. John Neil (Australia) a normal suckle begins with a flanging of the lips to create a seal around the areolar tissue of the breast - much like a suction cup on a piece of glass. If the lip(s) cannot flange out (because of a tight labial frenulum), a good seal cannot be created and a poor latch-on could be the result. The breast (areolar tissue and nipple) gets drawn into the mouth to about the junction of the hard and soft palate. The tongue extends forward past the gum pad (mandible) to a position where the tip of the tongue can begin the suckle by compressing the areolar tissue / lactiferous sinus area. Compression of this area, aided by the mother’s let-down process, begins the flow of breast milk through the breast. The breast milk is pushed along by a peristaltic / wave like motion by the tongue until it is expressed into the throat. The gum pad does not contact the breast because it is separated by the thickness of the tongue.
Pain can be caused when the hard gum pad (mandible) can hit into the under side of the breast when it is not separated or cushioned by the thickness of the tongue.
Ineffective and long feedings can be caused when the tongue is unable to compress the WHOLE LENGTH of the breast effectively. A poor seal can be created when a tight labial frenum will not allow the lip to flange out properly.
Painful and inefficient suckling can lead to lengthy feedings, failure to thrive, with the infant often being switched to very damaging bottles and pacifiers.
#5 - Surgical Indications: - I would say about 85 to 95% of the people with any type of significantly tight frenulum have a problem in one or more of these areas. I put a ? behind SIDS because I believe there is a link, but I do not have scientific evidence to back that up.
#6 - Incidence: Ankyloglossia is the scientific word for tongue-tie. This study concluded there was an incidence of ankyloglossia of about 4.8% in newborns. I would guess this to be about the same percentage for the general population as well.
#7 - Woolridge illustration: This is what was described in #4 above. This illustration demonstrates the position and action of the tongue during breastfeeding. The tongue is fully advanced and the beginning of the suckle starts with a compression by the tip of the tongue on the areolar tissue or lactiferous sinus area. The tongue then compresses the FULL underside of the breast in a peristaltic wave motion. Note that IF the tongue was NOT advanced, the bony gum pad could hit directly into the breast and cause pain and lacerations. In other words, the tongue would not cushion the blow, and IF the tongue compressed LESS THAN the FULL LENGTH of the breast, and the compression did not start at the areolar tissue area, the feedings could be inefficient and lengthy.
#8 - The Woolridge illustration on the left was changed to show what could happen if the infant had a tight frenulum. A tight frenum limits the distance the tongue can be advanced.
*** IT IS VERY IMPORTANT TO UNDERSTAND - the tightness of the frenulum can vary, and the degree of tightness can make a major difference as to any consequences. ***
You can see in this illustration, with the tongue unable to advance over the gum pad (red arrow) because of the tightness of the frenulum, the gum pad can pound into the bottom side of the breast and cause pain and lacerations. You can also see that the tongue cannot extend out to the areolar / lactiferous sinus area to initiate the suckle (blue arrow) and can only compress 1/2 to 2/3 the length of the breast (in this illustration) - making for a very inefficient and lengthy feed.
#9 & 10 – Escott’s article basically covers the same information as the Woolridge article. I have altered the drawing in #10 to demonstrate the same thing that happened in #8.
#11 - Adult swallow: - The swallowing pattern the infant learns THEN continues on and becomes the swallowing pattern when he or she grows up. The swallowing pattern determines the action of the tongue- AND - the action of the tongue IS the key determinant on how the teeth will be arranged in the mouth. Muscle ALWAYS wins out over bone in relation to where teeth will position themselves. (Test yourself when you get to slide 77)
#12 Dr. Crelin was a professor of anatomy at Yale’s medical school for 37 years. The following few slides and ideas are based on his research.
#13 - Crelin’s illustration: Note the anterior (forward) position of the tongue, the smooth palate, and that the soft palate and epiglottis are touching. He states this relationship allows the newborn to breathe and swallow at the same time. He also states that the tongue is located entirely within the oral cavity due to the elevation of the epiglottis.
#14 - Rohen & Tokocki Atlas picture: - This is an atlas picture demonstrating a similar relationship of the epiglottis to the soft palate, the advanced position of the tongue and the smooth palate.
#15 - Chimpanzee: This demonstrates the close relationship of the soft palate and epiglottis of ALL mammals and human newborns. This allows animals to drink from a pond and still be able to smell their enemies.
#16 - Full fetus cadaver head:- this is a fetus cadaver dissection that I had the privilege of being a part of. Note the slight separation of the lips.
#17 - Lips (close up) – The color of the tongue has been enhanced to show it’s advanced position.
#18 - Mid-sagittal dissection of the head: - This is just to show the orientation of the mouth to the head.
#19 - Mouth (mid-sagittal dissection) - This demonstrates the natural anterior position of the tongue over the gum pad (Note the tooth bud inside the gum pad). IF the tongue did not cover the gum pad because a tight frenulum would not allow the tongue to advance, then you can see how the hard gum pad could cause trauma to the breast.
- By coincidence, this cadaver has a “bubble palate”. This “bubble” can sometimes cause a “clicking” sound during breastfeeding.
#20 - Clinical Symposia picture:- this picture is an illustration in the 1976 Clinical Symposia booklet. It demonstrates how a newborn can breathe and swallow at the same time. It is an excellent booklet and I would encourage you to read it.
#21 - This illustration demonstrates how the breast milk gets around the interlock created when the epiglottis elevates around the soft palate (Slide #20). The breast milk flows around the epiglottis through the Faucium channels. (Covered in more detail in another presentation).
#22 - This dissection demonstrates the unaltered anatomical position of the soft palate and epiglottis. They are touching in the resting state. These two structures form the anterior wall of an air tube that runs from the nose to the lungs. This wall helps keep the tongue out of the tube. This tube is the airway. This protected ‘tube’ allows the infant to breathe easily without having to learn immediately the complexity of and adult breathing and swallowing pattern (as illustrated in slide #28).
#24 - As stated by Dr. Crelin, there is a natural descent of the epiglottis between the 4 and 6 months of age. This happens to coincide with the peak incidence of SIDS of 3 to 5 months of age. I strongly believe there is a correlation between the descent of the epiglottis and SIDS because the descent exposes the airway to the tongue. I cover this more in a presentation on SIDS elsewhere on this website.
- By the 4th - 6th month the infant has learned how to breastfeed well enough to advance the tongue naturally while breastfeeding.
- It is with this separation of the soft palate and epiglottis by the 4th to 6th month that the infant can now start to experiment with making different sounds. This separation does NOT occur in other mammals and that is one of the reasons animals cannot speak.
#25 - This illustration tries to demonstrate how as the epiglottis descends down the throat, the tip of tongue distalizes back into the mouth as the tongue itself pivots around it’s base to assume the natural adult position.
#26 - Adult head dissection: - Note the separation of the soft palate and epiglottis that does occur. This separation makes adult humans different THAN HUMAN NEWBORNS and ALL OTHER MAMMALS. This separation allows humans to speak – but it exposes the airway to the tongue. The posterior 1/3 of the tongue is now the anterior wall of the oropharynx. This allows SLEEP APNEA and SIDS to occur.
#27 - Grant’s Atlas picture: This illustrates how the tongue and/or the soft palate can obstruct the airway - allowing snoring and/or sleep apnea to occur. (Later, please review my presentation on sleep apnea on this website - it could save your life or the life of one of your loved ones.)
#28 – This illustrates the complexity of an adult throat once the epiglottis has descended.
#30 - Bottle in mouth:- THIS IS A KEY ILLUSTRATION – this shows all the bad things that can happen during bottle-feeding but can also happen during breastfeeding when an infant has a tight frenulum:
- Imagine a breast instead of the bottle.
- The jaw or gum pad can hit the breast directly and traumatize it.
- The tongue is unable to compress the areolar tissue and lactiferous sinus areas.
- The tongue cannot compress the full length of the breast, which results in an inefficient and lengthy feed.
- The distal part of the tongue can drive the soft palate into the area of the Eustachian tubes and possibly be a contributing factor in causing otitis media.
- A distalized (pushed back) tongue can cause a premature separation of the soft palate and epiglottis, which in turn can lead to excessive swallowing and gulping of air.
#31 - Tight frenulums RARELY go away by themselves. Those who state that tight frenulums go away by themselves imply to me that they never followed up on the cases. The problem ‘goes away’ when the patient gets older and leaves the practice.
#33 & 38 - illustrations are courtesy of Dr. Greg Notestine.
#35 - Tongue lifter: - This can be used to elevate the tongue and then the frenulum can be clipped under the slit. It could have very easily been used on infants in slides 33 and 34.
#36 - Note lesion on this tight frenum. This could have made breastfeeding painful for this infant.
#42 - Clinical reason for a frenotomy: - If any of these conditions exist – painful attachment, nipple trauma or failure to thrive, please evaluate for a tight frenulum.
#44 - Tight and thick labial frenulum - This is a close up of a thick labial frenulum.
#45 - A tight labial frenum like this will cause a gap between the teeth (called a diastema). It can also prevent the lip from flanging out. The lip needs to flange out during breastfeeding to create a good seal. If a good seal is not created breastfeeding can be difficult.
#46 - There are various options for treating frenums - having various complexities and consequences.
Examples of consequences:
#49 - Cute little girl who had tight frenulum. Most people with a tight frenulum usually have some form of a tongue-thrust. She had an anterior tongue-thrust that caused and anterior open bite. See cause and effect in #53. For those who state that frenums go away and that there are no consequences to teeth, I offer you slides 54 & 55.
#57 - (Illustrations 57-59 courtesy of Catherine Watson Genna) Youngster with significant malocclusion in spite of being breastfeed.
#58 - High palate in spite of being breastfed.
#59 - Reason for malocclusion and high palate - tight frenulum. This is a great example as to why breastfed babies can have malocclusions - the negative consequences of the tight frenum were greater than the positive benefits of breastfeeding.
#61 - Severe ankyloglossia.
#62 - He could not extend his tongue out any further than this. His main concern was that his girlfriend was upset at him because he could not “French kiss” her. He ended up losing all 4 lower front teeth.
#65 - Lady in her 40s who had had significant gastric distress, bloating and gas build up since childhood. She stated she had been on medications since she was a young girl for this problem.
#66 - She had a tight frenum and could not lift it any higher than this. I told her I could not guarantee that her problems would be solved, but I thought a frenectomy might help. I referred her to an oral surgeon for a frenectomy.
#67 - She had a Z-plasty (a form of frenectomy) and could then elevate her tongue this high.
#68 - She could also extend her tongue out of her mouth much further than before. Once healed, she was off all medications she had been on for a lifetime. Only change - a frenectomy.
#70 - Down’s Syndrome case:- His physician had referred him to me to treat his unresolved sleep apnea. He was significantly tongue-tied. I referred him out for a frenectomy and then made him an appliance like this to advance his tongue out of his mouth while he slept. Getting his tongue out of his mouth greatly improved his quality of sleep and his daytime sleepiness.
#72 - A gentleman in his 60s with a tight frenulum.
#73 & 74 - Note that the tight frenulum is STILL present in this late 60 year old who suffers from severe sleep apnea. I believe the frenum and macroglossia (large tongue) are both contributing factors to his sleep apnea. He has to sleep with a CPAP the rest of his life.
#75 - I feel the main reason providers do not do frenotomies and frenectomies is the fear of litigations. Someone could do 300 procedures with excellent results, and then do one that had complications. The news media would report all negative results, but never report on the 300 cases with excellent result. The frustration of dealing with lawyers over the one case could influence others to stop doing the procedure because they would not want the stress of dealing with a lawsuit. It is a sad commentary on our legal system.
#78 – I say this in jest ….But !!!!!
I hope this presentation has been helpful to your understanding of frenulums as they relate to breastfeeding. I am hoping you will share this presentations with pediatricians, lactation consultants, and parents with infants that have a tight frenum, so all can make a more informed decision as to what is best for the patient.
For Better Health!
Brian Palmer, DDS
Kansas City, Missouri, USA