The Truth About Ties and Nipple Pain: Intervention Doesn't Have to be Invasive

The Wrong Help Can Hurt

Nipple pain is often cited as the main reason that mothers quit breastfeeding before they want to. Indeed, many of us have been there - nursing our newborn through gritted teeth and white knuckles, dreading the next feeding. Perhaps you've even had to begin pumping and feeding with a bottle, cup, finger, or spoon to give your nipples a break, only to find that the pain does not resolve when you try to nurse again. And maybe your baby now has difficulty latching after receiving a bottle for a few days, and you begin to see a dip in your supply due to pain, infant not nursing frequently, and an inefficient pump. It is not hard to see how this cascade of events can lead to early weaning. But it does not have to be this way! Breastfeeding should not hurt, no matter what you have been told.

Many moms reach out for help before they give up, intent on reaching their breastfeeding goals. The support they are given can make or break the breastfeeding journey. Research clearly shows that the most common cause of nipple pain is due to incorrect latch and positioning. Early intervention from a Lactation Consultant providing latch correction results in improvement in 90% of cases. Latch correction is well established through research as the most effective and most important method of treatment, and should be the first intervention that a mother experiencing pain receives. Often, however, mothers are told that the latch "looks" fine, and that the infant has a tongue-tie or even a lip-tie.

Your Baby's Mouth is Fine, Unless it Isn't

The truth about tongue-tie is that it is far less common than the internet forums would have you believe. An estimated 3%-10% of infants have a tongue restriction, and many of those infants are able to nurse effectively without causing nipple pain and damage. Latch correction may be the only mode of intervention that is needed. In extreme cases, where persistent nipple pain and poor milk transfer is evident, the mother should be referred to a pediatric ENT who will perform a simple procedure called a lingual frenotomy - a small scissor snip incision to release the restriction. It is relatively painless, results in very little blood, and infants are able (and indeed happy) to nurse immediately afterward. This method is well researched and documented as an effective treatment for tongue-tie. Laser frenectomy, commonly touted and done by pediatric dentists, is a method of cauterization of the lingual frenulum which results in the burning away of tissue. This method is not well researched and no data exists on the effectiveness of this procedure for the treatment of tongue-tie and the subsequent ramifications for breastfeeding. Cauterization may also lead to scarring which raises concern that it could increase tongue restriction.

The lack of quality research also applies to the claim of breastfeeding problems caused by "lip-tie", which is being increasingly spread by well-meaning lay breastfeeding supporters and Lactation Consultants alike. Lip tie is something I see mentioned frequently on support forums, and yet there is little to no reliable information on this subject, or indeed if it is even a legitimate diagnosis. The research that does exist regarding lip-tie and laser frenectomy that is most often cited is by authored by a single pediatric dentist who has investments in laser equipment and supplies used for these procedures. This presents a clear conflict of interest, as he gains to profit from the use of these devices, and his findings are therefore not unbiased.

For more information on the lack of research regarding lip-tie and laser frenectomy, see this article by Alison Hazelbaker, PHD, IBCLC, FILCA, CST, RCST. It is a must read for anyone convinced that babies should be treated for lip-tie or that a laser frenectomy is the best method for treating tongue-tie. Dr Hazelbaker developed the Hazelbaker Assessment Tool For Lingual Frenulum Function and wrote Tongue-tie: morphogenesis, impact, assessment and treatment, published in 2010.

Intervention Doesn't Have to be Invasive

Until there is concrete evidence on the subject, I can only rely on my own clinical observations and those of my colleagues to assess the efficacy of the treatment of lip-tie, as well as tongue-tie, via laser frenectomy. In my experience working with dozens of mothers per day with all types of breastfeeding obstacles, I have never met an infant with an upper lip frenulum that prevented the infant from achieving a pain-free and efficient latch. I have met infants who were tongue-tied, their lips were not flanged, they had a clamp reflex, a shallow latch, etc. The large majority of these cases have been resolved with latch and positioning correction, and the unresolved cases have had to explore alternative interventions such as allowing time for the nipples to heal while pumping and feeding the infant with an alternative method, using a nipple shield, teaching sensory exercises to improve clamp down reflex, and more. It is well established by research that tongue restrictions can effect an infant's ability to feed well, so in cases where the mother is experiencing persistent pain following these and other interventions I will refer to an ENT for evaluation and possible tongue-tie revision.

I have met mothers who have been told their infant has a lip-tie but wanted a second opinion, who were thrilled to find that they were able to achieve a pain-free latch with some coaching. I am beginning to hear moms being told that their infant has a lip-tie even though they are experiencing no problems, but their infant is fussy, won't take a bottle, clicks while nursing, etc. I have also met mothers who elected to have their infant's lip-tie revised following a diagnosis, either from a Lactation Consultant or a Pediatric Dentist. Most often, they do not see improvement in pain or milk transfer, and many state that their infant went on a "nursing strike" for several days following the procedure. This leads me to believe that this practice is not only unhelpful, but can potentially derail an already struggling breastfeeding relationship.

Due to the fact that very little, if any, reliable research exists on the efficacy of lip-tie revision or even laser tongue-tie revision, and the fact that there is a large amount of evidence that proper latch correction is the most effective mode of treatment for many breastfeeding problems including nipple pain, it is my firm belief that more quality research needs to be done in an ethical and unbiased way before any recommendations for lip or laser treatment should be made. Pediatric dentists, like any provider, are enriched financially for any procedures that are done so they have no incentive, other than a moral one, to support less invasive treatment.

Trust Your Instincts, and Get a Second Opinion

It is well documented that latch correction is both the most effective and requires the least intervention, and as such it should always be the first line of treatment when a mother complains of nipple pain. Additionally, if a mother is told the latch "looks" fine, but is still experiencing pain, she should seek out a second opinion. Just as with any professional, skill level and advice often differs between providers. Not all Lactation Consultants have enough training to resolve these issues and may not know all the ways to help. If you are experiencing pain or difficulty with breastfeeding, and you have been told the latch looks fine, that your infant has an oral abnormality, or you are still having trouble following a lip or tongue-tie revision, please contact me! I will be happy to offer my professional opinion and skills to help you get pain free and meet your breastfeeding goals.

Women and infants do not fail at breastfeeding, their support system fails to help them succeed.

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