GOLD2014 (c)2014 New Thoughts on Infant Pre and Post-‐Frenotomy Care © M E L I S S A C O L E , I B C L C , R L C W W W. L U N A L A C TAT I O N . C O M Objec:ves 2 A=er this presenta:on, learners will be able to: !  Describe ways to provide an:cipatory guidance to families pre and post frenotomy !  Iden:fy unique issues and implement targeted care strategies for dyads pre-‐frenotomy !  Understand key post frenotomy issues that require assessment and care such as: wound healing, pain relief, latch support, and emo:onal support (C) Melissa Cole, IBCLC New thoughts… 3 !  Until recently, frenotomy was pretty much viewed as a ‘clip
it and forget it’ procedure, with not much thought to pre or
post care.
!  New thoughts regarding pre and post care have been
emerging amongst tongue tie professionals in recent years.
!  As awareness about more posteriorly located ties has
increased, so has our knowledge about issues such as suck
dysfunction and potential re-attachment of the incision site.
!  I recognize that pre and post-frenotomy care ‘best practice’
is still in its infancy and I propose a call to research this
subject matter further. (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 1 GOLD2014 (c)2014 Dedica:on 4 This presenta:on is dedicated to the hundreds, probably thousands, of families I have worked with pre and post frenotomy so far. They have taught me what dedica:on and perseverance mean. (C) Melissa Cole, IBCLC Pre-‐Frenotomy Points 5 !  Pre-‐frenotomy care points: !  Iden:fy issues !  Create targeted pre-‐frenotomy care plan !  An:cipatory guidance !  Emo:onal support !  Collabora:on (C) Melissa Cole, IBCLC Iden:fy Issues 6 !  Learn how to properly assess for tongue and lip :e !  Understand other issues that can masquerade as a :e or happen in conjunc:on with a :e such as: Structural Oral motor !  Neurological !  DigesIve !  Supply ! 
! 
!  Detective work and differential ‘diagnosis’
!  Avoid a myopic view of the feeding issues at hand! (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 2 GOLD2014 (c)2014 Tongue Tie (ankyloglossia) 7 !  InternaIonal AﬃliaIon of Tongue Tie Professionals (IATP) Focus !  The IATP’s current focus centers on standardizing the conceptual deﬁni:on of tongue-‐:e, classifying its types, genera:ng both ﬁrst-‐
and second encounter assessment processes, and issuing policy statements about early assessment, proper treatment and post-‐
surgical therapy and follow-‐up. IATP members remain dedicated to two main principles: the preven:on of later-‐in-‐life problems due to untreated tongue-‐:e, and the educa:on of all based on both current research and solid clinical evidence. !  What is Tongue-‐Tie !  The IATP deﬁnes tongue-‐:e as an: Embryological remnant of 1ssue in the midline between the undersurface of the tongue and the ﬂoor of the mouth that restricts normal tongue movement. (C) Melissa Cole, IBCLC Common pre-‐frenotomy complaints Infant Issues to Consider 8 •  Latch is poor, hard to maintain, slips oﬀ, chews/gums •  Prolonged feeds, sleepy at breast •  Short feeds, infant fa:gues •  Nursing marathons “uses me like a paciﬁer” •  Infant always hungry •  Weight gain concerns •  Poor seal, clicking, gag reﬂex •  Colic, reﬂux, gas, yeast •  Unable to hold paciﬁer/
boglefeed Maternal Issues to Consider •  Nipple pain, compression •  Incomplete breast drainage •  Recurrent yeast, mas::s •  Nipple blebs, plugged ducts •  Low milk supply •  Familial Hx of ankyloglossia •  Has been working on “the latch” but nothing ever improves much •  Seems like oversupply but regular management doesn’t help •  Feeling of infant gumming, ﬂicking (C) Melissa Cole, IBCLC Learn to assess properly 9 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 3 GOLD2014 (c)2014 A variety of :e presenta:ons 10 (C) Melissa Cole, IBCLC So a baby comes into an LC’s oﬃce… 11 …with gigantic
suck blisters all
over their
lips…..
What do you
expect to find?
(C) Melissa Cole, IBCLC Correct answer? Don’t expect…assess! 12 If you expect to ﬁnd a lip or tongue :e, chances are you may be right a lot of the :me but that type of thinking may close your mind oﬀ to other issues that also require pre-‐
frenotomy care! (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 4 GOLD2014 (c)2014 Pre-‐frenotomy issues to also support 13 !  If an infant presents with a tongue or lip tie, there may be other
co-factors causing issues that must be addressed
simultaneously.
!  A parent can’t be led to think a quick ‘snip’ will fix all their
issues if there are other concerns at play. Realistic,
comprehensive support is essential. The following issues may
also impact feedings and need to be dealt with along with the
tie(s):
! 
! 
! 
! 
! 
! 
Structural Oral motor Neurological/Sensory DigesIve Maternal milk supply Respiratory, etc (C) Melissa Cole, IBCLC Pre-‐frenotomy: Assess for structural issues 14 (C) Melissa Cole, IBCLC 15 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 5 GOLD2014 (c)2014 Pre-‐frenotomy: Assess for other issues 16 • Other midline issues, gene:c concerns, neurological issues, etc can complicate feeds too – watch for tell-‐tale signs • Don’t overcomplicate, don’t oversimplify • Take note and refer as appropriate (C) Melissa Cole, IBCLC Pre-‐frenotomy: Assess for other issues 17 Issues such as reﬂux, diges:ve health issues, respiratory issues (laryngomalacia, etc), can all cause clamping/tugging/fussing at the breast – there may also be a :e but never ignore other reasons a baby may be behaving they way they do at-‐breast. (C) Melissa Cole, IBCLC Mindful Assessment 18 !  Mindful assessment and
‘differential diagnosis’ are
vital - it is easy to think all
issues are related to the
tongue/lip tie and then
cease to look further.
Comprehensive support
must always be our goal.
(C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 6 GOLD2014 (c)2014 Pre-‐frenotomy: Create a Targeted Care Plan 19 !  As in the wise words of Linda Smith… !  Rule #1 – Feed the baby !  Is baby eﬀecIve? Are tools needed/appropriate? Is mom in pain? !  Rule #2 – Protect maternal milk supply !  How’s supply? Is milk being removed? !  Rule #3 – Keep working on direct breasqeeding !  Feeding a tongue/lip Ied baby is oVen a winding road, keep long term goals in sight. Provide emoIonal support. What supporIve therapies do baby/mom need? Pre-‐frenotomy care plan must be sustainable and realisIc. Help opImize intake, supply and comfort while keepign long-‐term goals in mind. (C) Melissa Cole, IBCLC Pre-‐frenotomy care: Bodywork 20 Whether or not infants have other structural concerns, bodywork pre-‐frenotomy can play a vital role. It helps: Unwind neuromuscular impingements !  Release compensatory behaviors/paXerns !  Gets baby use to safe touch/
intraoral work !  Provides healthy sensory input !  Sets oral Issues up for opImal release ! 
(C) Melissa Cole, IBCLC Pre-‐frenotomy bodywork 21 !  Who to refer to? Depends on who is available in your area! Some types of providers include: ! 
Chiropractors, Craniosacral Therapists, Bowen Therapists, Massage Therapist, Physical/OccupaIonal Therapists, Osteopaths, etc !  Points to keep in mind: !  Do they have pediatric experience? (babies are NOT liXle adults!) !  Do they do any intraoral work? !  Are they open to collaboraIng/learning more? !  Experience it yourself before referring, work as a team! !  Some online ar:cles on gentle, pediatric bodywork: hgp://kellymom.com/bf/concerns/child/cst/ (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 7 GOLD2014 (c)2014 An:cipatory Guidance 22 !  Tongue/Lip :e related feeding issues can be a physical and emo:onal roller coaster ride for families. !  Providing an:cipatory guidance on the following is vital: !  What tongue and lip Ies are !  Choices regarding treatment/no treatment !  What the procedure will be like and what to expect aVer !  Consequences of untreated Ies !  Expected Ime frame for recovery/potenIal reacIon of infant !  What post-‐care will look like !  Acknowledgement of feelings/concerns (C) Melissa Cole, IBCLC Emo:onal Support 23 !  Parents will have diﬀerent reac:ons to receiving informa:on about their baby being lip or tongue :ed. !  Feeling range from: relief, sadness, anger, disbelief, grief, worry, happiness, anxiety, etc !  Valida:ng these feelings, addressing targeted concerns and providing ample informa:on so that parents can make an informed choice is essen:al. !  Connect families with appropriate resources/providers !  Respect family’s autonomy! (C) Melissa Cole, IBCLC Collabora:on 24 !  Know who you are referring to. !  What is their level of knowledge/experience with Ies? !  What is their Tx style? !  How well do they collaborate? !  Are families ge]ng mixed messages? !  Don’t have a trea:ng provider in town? !  Network, seek out like minded providers !  Minor surgery in their scope? !  Are they willing to be trained? !  Can you spend Ime with them to opImize outcomes? (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 8 GOLD2014 (c)2014 Treatment of Ankyloglossia 25 !  Where are frenotomies performed? ! 
Doctors (MD, ND, DDS, ENTs) perform the procedure in-‐oﬃce. However, not all providers recognize all the varia:ons of ankyloglossia or do a complete release. Make sure you know who you are referring to. !  When is the procedure done? !  As soon as possible! There is no beneﬁt to delaying treatment and in fact delaying treatment creates further complica:ons. !  How is the procedure done? !  The baby is swaddled/held down brieﬂy, the head immobilized and the frenum is numbed then incised /excised with a pair of sterile scissors or laser. Baby can nurse/feed immediately before and a=erwards. !  Speakin’ the lingo…the procedure is called various things but here’s the lo-‐down: ! 
! 
! 
Frenotomy – Incision of the frenum Frenectomy/frenulectomy – Excision of frenum :ssue Frenuplasty/Z-‐Plasty – A type of surgery for severe tongue :e where more advanced techniques are employed (“Z”angle of the incision helps with func:onality/scar healing) (C) Melissa Cole, IBCLC Tongue-‐Tie Treatment 26 Laser Release Scissors Release An:cipatory guidance: Being able to tell families exactly what to expect during the treatment is useful. Become very familiar with the en:re process so that you can best support the dyads you are working with. (C) Melissa Cole, IBCLC “Will it hurt?” 27 !  “Will it hurt?” is something many parents ask when thinking about a frenotomy. !  Providing guidance around what their infant may feel and methods of coping with discomfort are essen:al (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 9 GOLD2014 (c)2014 Post-‐Frenotomy Care Points 28 !  The procedure has been done, now what? !  Discussion topics: !  Post procedure pain relief !  wound care/info !  a=er care stretches/ exercises !  Ongoing feeding and emo:onal support (C) Melissa Cole, IBCLC Post-‐frenotomy pain 29 !  Diﬀerent babies experience the procedure, and related discomfort, diﬀerently. Some variables: Personality/sensory Age of baby !  Scissors vs. laser (laser se]ngs) !  Pre-‐exiIng or developing oral aversion !  Compensatory paXerns stripped away (feeds harder?) ! 
! 
(C) Melissa Cole, IBCLC Pain Relief Op:ons 30 Conven:onal and holis:c pain relief op:ons *Please note* For op:ons you are not familiar with, please seek addi:onal support or refer as appropriate before implemen:ng into clinical prac:ce. (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 10 GOLD2014 (c)2014 Conven:onal Post-‐Frenotomy Pain Relief Op:ons 31 ConvenIonal opIons: • Acetaminophen • Check updated dosage, helps w/ pain not inﬂamma:on, hard on liver • Ibuprofen • Check with PCP if baby is under 6 mos, helps pain and inﬂamma:on • Ice • numbing/vasoconstric:ve, no major risk, infant may dislike cold • Oral Sucrose • Sucrose/water solu:on, shown to be clinically signiﬁcant in reducing discomfort, non-‐pharmacological (ex: Sweet-‐Ease) • NOTE* Benzocaine oral jels NOT recommended due to risk of methemoglobinemia (C) Melissa Cole, IBCLC Holis:c Post-‐Frenotomy Pain Relief Op:ons 32 • Homeopathics • Some commonly used for this are: aconitum, bellis perennis, bryonia alba, calendula, hypernicum, arnica, staphysagria, etc – some are in gels, pellets, liquids, etc. Hyland’s teething gel • Rescue Remedy/Flower Essences • Herbal OpIons • chamomile, st.john’s wort, skullcap, lemon balm • Misc OpIons • co-‐bathing, skin to skin, music therapy, breasqeeding/breastmilk • Please work with someone familiar with pediatric dosing and CAM modali:es (C) Melissa Cole, IBCLC Why is adequate pain relief important? 33 “ The neonate has a func:onal nocicep:ve system. However, recent research suggests that infants may be more vulnerable to the nega:ve eﬀects of pain than older children and adults. Apart from short-‐term eﬀects, untreated pain may also have long-‐term eﬀects, which may later aﬀect neurological development, including the reac:on to pain. Despite convincing evidence from recent research, the neonate is s:ll subjected to painful procedures, even surgery, without adequate treatment” (Larsson, B. A., 2001) (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 11 GOLD2014 (c)2014 Wound Info and Care 34 !  How oral mucosal/connec:ve :ssue wounds heal !  Factors that impact wound healing !  Normal oral wound healing appearance and stages !  What parents should expect !  Red ﬂags to watch for (C) Melissa Cole, IBCLC How oral mucosal/connec:ve :ssue wounds heal 35 !  When we beger understand how oral wounds heal, we can then understand the importance of a=ercare and how/why scarring or re-‐agachment happens. !  Wound healing happens in stages: Hemostasis/blood clot formaIon InﬂammaIon !  Re-‐epithelializaIon !  GranulaIon Issue formaIon !  Remodeling of the connecIve Issue (Clark and Gurtner as cited in Larjava, 2012) ! 
! 
(C) Melissa Cole, IBCLC How oral mucosal/connec:ve :ssue wounds heal 36 !  Hemostasis/blood clot formaIon !  Happens quickly in most cases, serious bleeding is rarely an issue with frenotomy procedures. Tx providers should be prepared to cope with heavy bleeding in the rare event it may occur. !  InﬂammaIon !  Reduced inﬂamma:on/scarring of oral wounds compared to dermal wounds, ‘superior healing phenotype’ in oral cavity (Wong, 2009), reduced IL-‐6, mast cells, growth factors, etc. !  When inﬂamma:on is increased more scarring and collagen deposi:on occurs (Frantz et al., 1993). !  Keloids in oral healing are rare but overproduc:on of IL-‐6 is implicated in their forma:on (Larjava, 2012). (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 12 GOLD2014 (c)2014 How oral mucosal/connec:ve :ssue wounds heal 37 !  Re-‐epithelializaIon and granulaIon Issue formaIon !  Within 24 hrs, epithelial cells at wound margins begin to migrate, by 48 hrs more cells seeded and prolifera:ng into wound site !  Cells migrate from each side of the wound un:l they contact the front leading edge of the cells coming from the other side !  Cell migra:on is s:mulated by various cytokines, growth factors, etc and proteoly:c enzymes (necessary for loosening adhesions) !  Granula:on :ssues starts forming at the same :me as re-‐
epithelializa:on, provides scaﬀold for connec:ve :ssue to regenerate. !  A=er wound contrac:on occurs, granula:on :ssue remodeling happens, due to rapid oral healing, “the end result is o=en the forma:on of connec:ve :ssue scar with reduced tensile strength, disoriented collagen ﬁbers and other molecular altera:ons” (Larjava, 2012) (C) Melissa Cole, IBCLC How oral mucosal/connec:ve :ssue wounds heal 38 !  Remodeling of the connecIve Issue !  Remodeling occurs when the contrac:ng wounds has assembled collagen ﬁbrils into thicker bundles, aligned with the perpendicular wound edges !  When scant granula:on :ssue is formed, contrac:on of wound can occur 3-‐5 days post wounding and granula:on :ssue gets replaced with more mature connec:ve :ssue. This is both a slow and fast process – contrac:on/remodeling is rapid but full strength of wound may only be 20% a=er 21 days (Larjava, 2012) (C) Melissa Cole, IBCLC How oral mucosal/connec:ve :ssue wounds heal 39 !  Other key points !  Oral mucosa is also bathed in ﬂora-‐rich saliva which may promote wound healing !  “Local pericellular microenvironment established during remodeling stage determines the phenotype and func:on of residents cells… may be key to preven:ng pathological scarring (Li et al., 2010) !  Mucosal wound healing is impacted by stress (Marucha et al., 1998) and nutri:onal factors/deﬁciencies (zinc, vit C, L-‐
Arginine, selenium, etc, etc) (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 13 GOLD2014 (c)2014 What does this mean for babies post-‐frenotomy? 40 !  Oral wounds begin healing fast, cells migrate towards each other quickly. Inﬂamma:on, stress, poor ﬂora/nutri:onal status can all impact healing. !  We are learning more about gene:c and epigene:c triggers that may be impac:ng tongue :e rates, could the same issues be impac:ng how certain babies heal or have higher rates of re-‐
agachment? !  Can reducing inﬂamma:on and doing a=er care stretches/
massage of the incision sites help prevent premature wound contrac:on, scarring or reagachment? !  Post-‐op massage for pediatric oral wound healing has not been studied but some limited data on scars treated with massage does exist: “Surgical scars treated with massage...(90%) had improved appearance” (Shin & Bordeaux, 2012) (C) Melissa Cole, IBCLC Babies prone to re-‐agaching, op:mizing healing 41 Some caregivers are having success implemen:ng targeted topical prepara:ons of certain things to prevent scarring. Some ideas to consider: !  In babies prone to keloid forma:on/scarring or re-‐agachment we may want to explore and further research the clinical usage of food grade aloe vera (Moore, 2001) and calendula (Preethi & Kugan, 2009;Tanideh et al., 2013) !  Studies show that oral supplementa:on of the omega-‐3 polyunsaturated fagy acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in ﬁsh oils have been shown to reduce inﬂamma:on and improve wound healing (McDaniel et al., 2011) (enhance through maternal diet? Directly to older babies?) (C) Melissa Cole, IBCLC What parents should expect 42 !  Immediately post-‐op babies may or may not want to feed ac:vely. Provide guidance and strategies. !  My expecta:on for feeding progress is one beger feed per day post-‐frenotomy. Helping parents iden:fy signs of progress can be empowering when they feel ‘it will never get beger’ !  Make sure their feeding care plan con:nues to evolve and meet their changing needs ! 
!  Normal oral wound healing appearance and stages !  Incision sites (healing eschar)may be diﬀerent colors (yellow, green, white, etc) at diﬀerent stages – all are normal and are NOT infec:on. (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 14 GOLD2014 (c)2014 Varied Appearances of Incision Site 43 (C) Melissa Cole, IBCLC What about oral aversion or post-‐op reac:ons? 44 !  Personality/State Regula:on !  Try to observe baby pre-‐frenotomy to assess how they may react to the procedure. Are they a happy-‐go-‐lucky kind of baby or a tense, fussy baby? How can you best prepare the family? What soothing strategies may they need. This is a personalized approach! !  Soothing strategies (co-‐bathing, skin to skin, pain relief, baby wearing, dream feeds, etc) plus back-‐up feeding plan if baby refuses to nurse short term !  Make sure any a=ercare is done playfully and respecqully. Heightened stress and inﬂamma:on will not help op:mal wound healing. (C) Melissa Cole, IBCLC Red ﬂags to watch for 45 Have parents call you and/or trea:ng provider if: !  Inﬂamma:on or redness that seems to be more extreme than normal, a post-‐procedure fever ! 
*Note – In hundreds/thousands of case, I have never seen a frenotomy site get infected! !  Prolonged bleeding/oozing !  Try compression, ice, etc ﬁrst and seek care if basics don’t stop bleeding. !  Prolonged crying, inconsolable infant !  See if basic soothing strategies, pain relief methods work ﬁrst (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 15 GOLD2014 (c)2014 Post frenotomy day 1 46 (C) Melissa Cole, IBCLC Post Frenotomy (scissors) Day 1 47 (C) Melissa Cole, IBCLC Post frenotomy (laser) – Day 1 48 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 16 GOLD2014 (c)2014 Post Frenotomy – day 3 49 (C) Melissa Cole, IBCLC Post laser frenotomy – 1 week 50 Photo credit: Bobak Ghaheri, MD (C) Melissa Cole, IBCLC Post frenotomy 2.5 wks 51 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 17 GOLD2014 (c)2014 Post frenotomy-‐ 3 weeks 52 (C) Melissa Cole, IBCLC Frenotomy vs. Frenectomy appearance 53 Labial frenectomy (laser) Labial frenotomy (scissors) Labial frenectomy (scissors) (C) Melissa Cole, IBCLC Pre and Post Frenotomy 54 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 18 GOLD2014 (c)2014 Pre and Post Frenotomy 55 (C) Melissa Cole, IBCLC Re-‐agachment 56 !  Re-‐agachment -‐ occurs when the healing :ssue adheres down on itself or begins to form a scar. Proper post-‐
frenotomy care is important to lessen the chance of re-‐
agachment. (C) Melissa Cole, IBCLC Re-‐agachment 57 See the diﬀerence? The ﬁrst picture shows clear re-‐agachment. Picture 2 shows the incision s:ll nicely open and pliable. (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 19 GOLD2014 (c)2014 Incomplete Release 58 Incomplete release – occurs when a por:on of the frenulum has been released but not fully. This infant had undergone a frenotomy at week 2. However only the most anterior por:on was released and the posterior por:on remained quite tethered. (C) Melissa Cole, IBCLC Goals for post frenotomy consult 59 !  Post frenotomy assessment !  strengths/weaknesses, incisions sites, pain !  A=er care stretches/exercises !  PosiIons for holding baby, hands-‐on work, playful, bodywork, return demo by parents !  Facilitate physical and emo:onal healing ! 
Decrease oral aversion/increase oral acceptance, foster parent/infant connecIon, enhance parental self-‐
eﬃcacy (C) Melissa Cole, IBCLC Post frenotomy assessment 60 !  strengths/weaknesses !  Extension, elevaIon, lateralizaIon, cupping, overall tone – can use same assessment tools you used pre-‐frenotomy to compare progress (Hazelbaker, Watson Genna, etc) ! 
Note *speciﬁc oral motor assessment and treatment skills won’t be covered in this presentaIon as they require more in-‐depth, in person training !  incisions sites !  InﬂammaIon, oozing/bleeding, healing eschar appearance, reaXachment – all normal or need aXenIon? !  pain/fussiness !  Is the infant sIll fussy/in pain?, oral aversion/feeding refusal? (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 20 GOLD2014 (c)2014 A=er care stretches and exercises: Posi:ons 61 !  PosiIons for holding baby !  There is no one ‘right way’. Help it feel playful/natural to baby and parent and yet be eﬀecIve. !  Can try facing parent/provider, head in lap, walking around, etc. (C) Melissa Cole, IBCLC A=er care stretches and exercises: Posi:ons 62 (C) Melissa Cole, IBCLC A=er care stretches and exercises: Posi:ons 63 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 21 GOLD2014 (c)2014 A=er care stretches and exercises: Hands-‐on work 64 !  Make it playful! While the infant may be tender ini:ally, it is possible to do the a=er care with love and respect. !  Many dyads are already trauma:zed by their pre-‐
frenotomy tongue/lip :e ordeals. Let’s help the healing process be a :me to foster connec:on. (C) Melissa Cole, IBCLC A=er care stretches and exercises: Wesley’s Video 65 (C) Melissa Cole, IBCLC A=er care stretches and exercises: Hands-‐on work 66 !  Make it a habit so parents don’t forget (every feed, when switching between breasts, every diaper change, etc). Aim for min 4-‐6+ :mes per day for 3-‐4 weeks !  Use reminders if needed (cell phone alarm, post-‐it note near changing table, etc). !  Do the ‘fun’ stuﬀ ﬁrst and then do the incision massages/
stretches at end of session. Quiet/alert state is preferred. !  It’s okay to get in and out quickly when needed and linger when baby is enjoying the work. (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 22 GOLD2014 (c)2014 A=er care stretches and exercises: Hands-‐on work 67 Babies just wanna have fun! Sing, be silly! Side: tug-‐o-‐war for extension/cupping Below: gum rub for lateraliza:on (C) Melissa Cole, IBCLC A=er care stretches and exercises: Hands-‐on work 68 To facilitate open, relaxed jaw: *Bilateral jaw massage + chin tug *‘beep bop boop bip’ (adapted from Catherine Watson Genna’s work) (C) Melissa Cole, IBCLC A=er care stretches and exercises: Ezra’s Video 69 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 23 GOLD2014 (c)2014 A=er care stretches and exercises: Hands-‐on work 70 Lip stretch/massage – !  Li= up lip (two hands works best) – give it a ﬁrm but gentle li= – visualize wound !  Use blunt side of ﬁnger to massage all across gum ridge/incision site (C) Melissa Cole, IBCLC A=er care stretches and exercises: Hands-‐on work 71 Tongue stretch/massage: • Face baby in a way you can have both hands free. • Use both hands/index ﬁngers to li= tongue up, visualize the wound. Add in some pressure upwards, sideways and towards ﬂoor of mouth • Use blunt side of index ﬁnger to massage all across/into incision site and ﬂoor of mouth • OK to be quick, just repeat frequently (C) Melissa Cole, IBCLC A=er care stretches and exercises: Sebas:an’s Video 72 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 24 GOLD2014 (c)2014 A=er care stretches and exercises: Post Wound Care 73 (C) Melissa Cole, IBCLC A=er care stretches and exercises: Hands-‐on work 74 Sample care rouIne: !  ‘Beep bop boop bip’ (chin nose, philtrum, chin tug) !  Jaw massage + chin tug !  Gum rub for lateraliza:on !  Wipers on the palate (desensi:zes heightened gag reﬂex) !  Tug-‐o-‐war and/or tongue stroke (cupping, extension) !  Li= lip/tongue up and massage over incisions site – use gentle but ﬁrm pressure – visualize the diamond shape *Note-‐Inspira1on for many of these ac1vi1es has come from: Cathy Watson Genna and various bodywork/oral motor trainings, etc (C) Melissa Cole, IBCLC A=er care stretches and exercises: Stewart’s Video 75 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 25 GOLD2014 (c)2014 Breasqeeding support post frenotomy 76 !  What issues may be lingering, more prominent, etc? !  Cheeks, sublingual strength issues o=en forgogen! !  List issues and coping strategies !  Show pump/bogle? !  Posi:oning, latch techniques (C) Melissa Cole, IBCLC Breasqeeding support post frenotomy 77 (C) Melissa Cole, IBCLC Stability and Support 78 !  Providing stability and support post frenotomy is o=en needed. Although the tongue is mobile, there are o=en aspects of oral weakness (think arm out of a cast analogy). !  Stability can come in the form of careful posi:oning, a nipple shield, gentle facial support, pacing, etc. !  Safe handling & support techniques, controversy, appropriate for baby/
situa:on (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 26 GOLD2014 (c)2014 Breasqeeding support post frenotomy: Gentle support points 79 (C) Melissa Cole, IBCLC Breasqeeding support post frenotomy: Varia:ons on Support Points 80 (C) Melissa Cole, IBCLC Slight aversion/strong gag reﬂex: Kira’s Prep Video 81 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 27 GOLD2014 (c)2014 Breasqeeding support post frenotomy: Kira – Sublingual Support 82 (C) Melissa Cole, IBCLC Breasqeeding support post frenotomy: Cheek Support Video 83 (C) Melissa Cole, IBCLC Post Frenotomy Care: Bodywork 84 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 28 GOLD2014 (c)2014 Pre-‐frenotomy bodywork 85 !  Who to refer to? Depends on who is available in your area! Some types of providers include: ! 
Chiropractors, Craniosacral Therapists, Bowen Therapists, Massage Therapist, Physical/OccupaIonal Therapists, Osteopaths, etc !  Points to keep in mind: !  Do they have pediatric experience (babies are NOT liXle adults!)? !  Do they do any intraoral work? !  Are they open to collaboraIng/learning more? !  Experience it yourself before referring, try teamwork! !  Some online ar:cles on gentle, pediatric bodywork: hgp://kellymom.com/bf/concerns/child/cst/ (C) Melissa Cole, IBCLC Case #1– A=ercare and feeding success 86 Reagachment Immediately post release 3 days post re-‐release Le=: Photos courtesy of Bobby Ghaheri, MD Right: Photos by Melissa Cole, IBCLC 9 days post re-‐release (C) Melissa Cole, IBCLC Case Study #2 – Poor weight gain to success 87 (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 29 GOLD2014 (c)2014 Ongoing feeding and emo:onal support 88 “My baby had a frenotomy and s:ll has issues…” Some useful ideas in this situa:on: !  Give parents realis:c expecta:ons for feeding progress (pre and post frenotomy). Progress is o=en measured in weeks not days just depending. !  Make sure their care plan works for them. There are many ways to love and feed a baby while we keep long term goals in sight. !  Refer out for complementary therapies as needed. !  Suggest mother-‐to-‐mother targeted support !  Provide community resources for postpartum mood professionals (C) Melissa Cole, IBCLC Resources 89 !  My web site has an extensive list of ar:cles, handouts and a bibliography of tongue and lip :e related ar:cles. Please visit us at: !  hXp://www.lunalactaIon.com/arIcles-‐hand-‐outs/ (scroll down to tongue Ie secIon) !  contact info !  Melissa Cole, IBCLC, RLC !  [email protected] !  www.lunalactaIon.com !  360-‐830-‐MILK (6455) (C) Melissa Cole, IBCLC Conclusion 90 Thank you for par:cipa:ng in the GOLD 2014 tongue-‐:e add on package. Your agendance means that you are invested in suppor:ng mothers and babies with the highest level of care! Pore/Post frenotomy care strategies are s:ll in their infancy. I look forward to learning alongside all of my colleagues in the ﬁeld as new evidence and informa:on emerges. A special thank you to Bobby Ghaheri, MD, my dear Portland, OR colleague! (C) Melissa Cole, IBCLC (C) Melissa Cole, IBCLC 30