The Developmental Effects of Ankyloglossia and Upper-Lip Ties

In recent years, the buzzword around breastfeeding difficulties is “Lip and/or Tongue-Ties.” Ask on any social media site, as Milk Meg Nagel (2015) did, about pain while breastfeeding and the responses will be instant telling people to get their baby checked for lip and tongue-ties.  An overly tight frenulum is medically referred to as Ankyloglossia, colloquially referenced as a tongue-tie. This paper will look at Attachment Theory, and how it relates to breastfeeding.  It will further look at the work of leading Doctors in the field of Ankylogossia and breastfeeding, using peer-reviewed research, to answer if uncorrected Ankyloglossia is associated with be developmental issues with attachment, infant feeding, and physical growth.

Attachment

Bonding and attachment is one of the most important parts of early parenting, and can set the tone for relationship the rest of the child’s life (Basic Theories and Principles of Child Development. n.d.). After observing being separated from their caregivers during World War 2, John Bowlby created his attachment theory (Lightfoot, Cole M., & Cole S., 2013, p. 208). Bowlby observed that primate infants have instinctual actions that are critical to humans’ attachment- clinging, suckling, cries, and resistance to separation (Lightfoot et al., p. 209). There are four phases of attachment according to Bowlby. First is the “pre-attachment phase,” during the first six weeks of life an infant needs to stay in close contact with its primary caregiver. The child will not be outwardly frustrated with being left with strangers. Second is the “attachment-in-the-making phase,” after the first six weeks until around 8 months infants show preferences for different people, and uncertainty of the unknown. Third, the “clear-cut attachment phase,” which occurs between 6 months and 24 months, is the time that the physical and emotional relationship of a child and their primary caregiver is obtained. The child makes the mother the secure base- the point of reference that they return to after exploring. Separation anxiety is greatest during this phase of attachment. Last of Bowlby’s phases is the reciprocal relationship phase, and happens between 18 and 24 months. In this phase, both parties of the mother and child dyad check on the each other when separated (Lightfoot et al., p. 209-210).

Bowlby’s attachment theory inspired Mary Ainsworth to test the mother-child relationship. She created the strange situation to test how children react to being left by their mother with an unknown lab assistant (Lightfoot et al., 2013). Ainsworth discovered three types of attachments- secure, avoidant, resistant. When the strange situation was repeated by other researchers, a fourth attachment style was discovered- disorganized. Secure attachment is defined by the infant being content when the mother is present. The infant will get upset when the mother leaves, and the stranger might be able to comfort the child, but the child will have an obvious preference for the mother. When the mother returns the child will go to the mother happily. When the mother-child relationship is an avoidant attachment, the child is indifferent when the mother is present. If the child gets upset when the mother leaves, the stranger is just as good as the mother for comforting. The child does not go to the mother when she returns.  The last of the attachment types that Ainsworth discovered was the resistant attachment. This type of attachment has children that cling to their mothers, but are distressed and try to get away at the same time. They get very upset when the mother leaves, but refuse to be comforted by her when she returns (Lightfoot et al., p. 211). The last attachment style is disorganized attachment. These children show confused reactions to the Strange Situation, and in their interactions with their mother. They will simultaneously cling and pull away. They will panic at the door when left, but refuse to look at the mother when she returns.   

The attachment needs of sucking, clinging, and resistance to separation, can all be satisfied by breastfeeding.  The World Health Organization (WHO) recommends excusive breastfeeding for the first 6 months of life, with breastfeeding to be continued for 2 years and beyond (What are the recommendations for breastfeeding?, 2013).  The 6 months of exclusive breastfeeding helping with the first 3 phases of Bowlby’s attachment, with the continued breastfeeding giving a child a secure base to return to for the third and fourth stages. Breastfeeding has a positive association for increased maternal responsiveness, greater attachment security, and less attachment disorganization, to the duration of breastfeeding (Tharner et al., 2012).  A nursing mother is forced to be close physical contact to their child while are breastfeeding. Anisfeld, Casper, Nozyce, and Cunningham, and their work with infants kept in soft structured carriers versus keeping the baby in an infant seat, found that close physical proximity helps create a strong attachment, and improved maternal awareness of the child (1990). When there is a prenatal intention to breastfeed, mothers tend to have more physical contact with their baby (Britton, Britton, & Gronwaldt, 2006), than those who do not have this intention. Their research conclusions suggest that the desire to breastfeeding is associated with a secure attachment. When 14 month olds where put into the strange situation, Tharner et al. (2012) found a subtle positive association with duration of a breastfeeding relationship and a secure attachment. They did not find any association with breastfeeding and insecure-avoidant or insecure-resistant. Breastfeeding was also found to reduce the chances of a disorganized attachment (Tharner et al.).    

Breastfeeding and Ankyloglossia

Up to 75% of women will try breastfeeding, though many stop before leaving the hospital, and less than 13% are exclusively breastfeeding by 6 months (What are the recommendations for breastfeeding?, (2013). Some of the reasons that duration of breastfeeding relationships are short include- slow weight gain, inability to latch or effectively transfer milk, infant digestive issues (Johnson, 2015) maternal-infant separation, maternal pain, and reoccurring maternal breast infections (Leff, Gagne, Jefferis, 1994). Doctor “Bobby” Ghaheri a leading ENT in Ankyloglossia, laser frenectormies- the surgery to correct Ankyloglossia, and breastfeeding, along with Melissa Cole International Board Certified Lactation Consultant (IBCLC), were interviewed for The Leaky BOOB, a leading social media breastfeeding advocate, on lip and tongue ties (Cole, M., & Ghaheri, 2012).  During that interview, they list some of the symptoms that have an association with Ankyloglossia. Symptoms in the infant- clicking while eating, difficulty flanging out the lips, increased gassiness, reflux, milk dripping from the mouth at breast or bottle, fatigue while sleeping, poor weight gain, poor milk transferring (Ghareri, & Cole, 2012). When there is Ankyloglossia it is difficult for the infant to get a deep latch resulting many of these symptoms (Mizuno, Nishida, Mizuno, Taki, Murase, & Itabashi, 2008). Maternal symptoms- extreme pain that lasts the whole feed, clogged ducts, mastitis, bleeding or damaged nipples, overfull breasted that never feel emptied, dwindling supply (Cole, M. Ghaheri). The list of reasons that women stop breastfeeding is very similar to the list of symptoms of Ankyloglossia. When the tongue is restricted due to Ankyloglossia it cannot move up to the soft pallet in the back of the mouth. This causes the tongue to compress the breast on the hard pallet, making breastfeeding painful for the mother, and more work for the infant (Palmer, 2003). It is not surprising that it is the first thing people suggest when they post about breastfeeding issues on social media.

Physical Development and Ankyloglossia

Physical development can be effected by the presence of Ankyloglossia. The shape of the skull, and the pallet, are changed by the muscles in the mouth having to work harder when there is Ankyloglossia present (Johnson, 2015). If not corrected these preventable malformations can cause issues into adulthood.

The muscles are stronger than bone and “win out” causing the position of the teeth to change by the movement of the tongue and shallowing patterns.  The shallowing patterns are different in people with ankyloglossia (Palmer, 2003). Ankyloglossia can cause a high pallet which in turn can cause malocclusions- malformations with the way that the teeth meet up with their opposing teeth on the opposite jaw (Palmer). In one case of Palmers (2003) the gap between the top and bottom teeth in the front of the mouth was great enough that the patient could not bite through food. Another case of Palmers (2003), an adult in their 30’s, lost all four front bottom teeth from the added pressure cause by the tongue being unable to move past the bottom teeth. Just like infants with excessive gas associated with swallowing air while eating because of oral ties, a 40-year-old with Ankyloglossia experience gastrointestinal distress. After her frenectomy she was gas free for the first time in her life (Palmer, 2003)  

Messner & Lalakea (2002) conducted research on 30 children, ages 1 to 12, whose speech delay was thought to be the result of Ankyloglossia. The children were given preoperative speech exams, then a frenotomy surgery, and a postoperative speech examination. There results showed that 15 of the children had improved speech. This shows a potential association between Ankyloglossia and speech issues. This also showed that surgical repair of tongue-ties can have the potential to improve the speech of those with Ankyloglossia. A survey of professionals- ENTs, Pediatricians, Lactation Consultants, and Speech Pathologists- conducted by Messner & Lalakea (2000) prior to their preoperative, and postoperative, research, showed that there was significant disagreement between professionals on the effects of Ankyloglossia. Some felt there was no developmental issues caused by restricted ties. Others felt there was some negative effects caused by Ankyloglossia, but in only one area. Last there was some that believed the ties caused speech and feeding problems that needed to repaired. These conflicting opinions from professionals likely spawned the work that brought them to the conclusions of their 2002 study.

Frenectomy

            Some people believe that Ankyloglossia will go away on its own, or that the muscle learns to stretch over time, however Palmer (2003) would disagree from his long term follow-ups on patients who did not get a frenotomy. There is also a mistaken belief that the lip tie is better left to “be fixed on its own” during a childhood fall, or wait until there is a need for braces (Johnson. 2015). No other medical problem would be ignored hoping that something traumatic happens to cut the anomaly, or expect someone to spend years and thousands of dollars to repair something that takes minutes to fix. 

            A frenotomy is a very fast procedure that can be done in office with less pain than ear piercing (Coryllos, Watson Genna, Salloum, 2004). Use of a topical numbing agent is recommended, and can be done under general anesthesia when deemed necessary (Johnson, 2015). It can be done with a laser, or a cut using blunt-ended scissors, the skill of whomever is performing the surgery is more important than their tools of choice (Ghaheri, 2014). Breastfeeding can be done immediately after the surgery is completed.   

Conclusion

Breastfeeding can help with attachment, but when there are physical anomalies like lip and tongue ties- Ankyloglossia- a mother-child dyad may need to end the breastfeeding relationship earlier than intended. It is possible that the mother will feel resentment toward the child and not want to be as close to the baby because the baby caused her pain. The infant may have experienced malnutrition because it was unable to transfer the milk properly, which caused physical and developmental milestone delays. Repairing Ankyloglossia with a routine frenotomy surgery can repair the physical, emotional, and developmental, damage caused by this malformation, creating a happy breastfeeding relationship that lasts as long as the mother and child chose.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference

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Originally submitted to Family, Consumer, and Human, Development 3500 Infant and Child Development Utah State University Fall 2015