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Pre-frenotomy therapy: necessary, or not?

Tongue tie is a hot topic in the feeding world. I see a lot of questions on social media lately about ties. One topic brought up many times recently is whether therapy before (and after) a tongue or lip tie release is necessary or not, since some providers refer families to therapy before scheduling a release. Families turn to social media for feedback and are often faced with a barrage of conflicting information. It's true that many people don't consult with a therapist before procedures….but there are a lot of reasons to consider pumping the brakes before a frenotomy. This post will focus on infant frenotomy, but therapy can be valuable to anyone preparing to undergo frenotomy, no matter the age. Here are a few reasons to consider therapy before a release: To establish a baseline It's hard to know what changed as a result of a release procedure if we don't know what function was like to begin with. An assessment of baseline oral function also gives us a good idea of what we must work to improve, and whether all of those things are related to a tie or not (for more on this, keep reading!). A good therapist is going to give you a home program that's individualized to your needs and your child's needs. To prepare the muscles and begin teaching new muscle patterns Releases "free" tight tissue, but they don't train the muscles of the mouth to do new things. Babies suck in utero, so habits are often already established at birth--i.e. "muscle memory." Oral motor therapy before a release is much like physical therapy before an orthopedic surgery; it helps to establish strength and teaches a new motor plan so the body has a better idea of what to do with the new range of motion after the procedure. Reduce tension in oral structures to achieve the best release We can't stretch a tie, but we CAN alleviate tension in the surrounding tissues and start working on good oral posture before a release happens. This can result in a better outcome afterwards and helps to build long term good habits that improve overall oral development. Get babies familiar with touch to the mouth, to reduce aversion I sometimes see families after procedures for an evaluation, and the baby is so upset by anyone approaching his/her face that it makes it difficult to work on oral motor skills. We end up having to take a step back and make touch to the mouth feel positive again. It's a difficult situation that may be greatly minimized with work BEFORE a procedure. Reduce stress for baby and family Everyone usually feels calmer and more prepared if they have had a chance to practice the work that is recommended after release (such as aftercare wound management, oral motor exercises, etc), rather than learning everything on the day of procedure when baby is likely to be upset...or waiting to get in to see a specialist after a release is performed, when families sometimes find themselves continuing to struggle with feeding.

To examine the whole picture--is the tie the main problem, or do other things need to be addressed to help achieve a good outcome? Meeting with a specialist before a procedure gives an opportunity to look at the whole picture of feeding and address OTHER underlying issues impacting function. In general, a feeding therapist or lactation consultant is the best party to pick up on these potential issues and can direct families to other appropriate professionals as necessary. What else might impact infant feeding beyond a tie? -Torticollis or posture asymmetries (does baby tilt or turn the head primarily to one side? Appear to have a curved posture?) -Plagiocephaly (flat head, abnormal skull molding) -Tension or "dysregulation" (baby seems stiff, cries a lot, seems hard to calm) -Respiratory problems (baby may have a hard time coordinating suck, swallow, breathe, gulps/choke, or makes unusual sounds when breathing while eating) -Gastrointestinal discomfort (reflux, gas, inconsistent stooling patterns) -Mom issues (if breastfeeding)--oversupply, low supply, positioning when latching, and more -Facial structures of the baby (a chin that's very "pulled back" or a high arched roof of the mouth can impact sucking, for example) ….and more In some cases, a therapist can work on these factors and help a family with a plan to make feeding much more effective, even without a frenotomy. If a tie is involved, we are likely to "plateau" with progress at some point, but we can't ignore other things that are affecting feeding and expect that a release procedure is going to completely alleviate the problems.

I meet a lot of people who feel very conflicted about whether or not a frenotomy is necessary and who are nervous about the idea of a procedure. Figuring out if problems are related to a tie is not always clear cut. I think families can feel much more confident in whatever decision they make if they receive a comprehensive evaluation to assess the whole picture. If no progress is made with conservative measures, it's good evidence that frenotomy might be helpful...likewise, if the frenulum isn't impacting function, surgery could be avoided. Parents today have a tough job. Conflicting information is everywhere. Providers involved with infant feeding want to see the best outcomes for families; collaborative care is often helpful to achieve the best possible outcome. If you have questions about pre-frenotomy therapy, please reach out to me at Flourish Pediatric Therapy and Lactation, 337-282-8703.

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