By Noelle McCown, Psy.D.
The first time my son nursed, it was painful, but I was prepared for it. I’d never breastfed an infant before, and I knew there would be a learning curve. What I didn’t expect was to find a bruised, blistered nipple when he unlatched. I remember my midwives looking slightly perplexed, proposing I try a nipple shield. Despite their suggestion, I decided to continue to try to feed him without one. “We’ll get the hang of this,” I thought.
The pain persisted however, and in addition, I found it impossible to keep my son awake long enough to drain each breast. He’d nurse for a minute, fall asleep, and wake again within the hour for more. After three weeks, I was exhausted. Looking for guidance, I dropped into a local breastfeeding support group run by a lactation consultant named Meg. Upon hearing our story, she suggested we meet for an individual evaluation.
Meg arrived at our house the next day. I’ll never forget the punch-in-the-gut feeling that accompanied the words: “It looks like your son hasn’t gained weight since last week.” Until my son was two weeks old, he had steadily gained. By week three, my milk supply had dropped due to our breastfeeding challenges. After performing a comprehensive exam, Meg recommended he be further evaluated for tongue-tie.
Tongue-tie (ankyloglossia) or “tethered oral tissue” is a condition that restricts the tongue’s range of motion. According to the American Academy of Pediatrics (2016), it affects up to 10% of the population. When a baby is “tongue-tied,” unusually tight frenulum tissue tethers the tongue to the floor of the mouth, making it difficult to breastfeed. It can also cause long-term health concerns such as speech problems, difficulty chewing and swallowing, dental decay, and migraines (Fernando, 1998).
Meg referred us to a physician who specialized in treating tongue-tie. As I filled out the patient questionnaire, I found myself ticking all the boxes. Baby’s symptoms: falls asleep while nursing, difficulty latching, gumming or chewing the nipple, poor weight gain, and short sleep episodes. Mother’s symptoms: bruised or blistered nipples, pain when baby latches, incomplete breast drainage, plugged ducts, and mastitis.
It was determined we could benefit from a procedure called a frenotomy, in which a laser or surgical tool is used to cut and release the tethered frenulum. After a challenging few months, the combination of the frenotomy and efforts to boost my milk supply paid off—we are still breastfeeding at 22 months!
Our journey to where we are today was not without it’s emotional challenges, however. I was anxious and sleep-deprived. There were days I didn’t leave the house due to how frequently I had to nurse or pump breast milk, and the pressure mounted until I was utterly exhausted.
During this time, I was incredibly privileged to have access to a breastfeeding support group, in-home lactation consultation, medical supplies such as a hospital grade breast pump and supplemental nursing system, and a local physician who specialized in tongue-tie. Furthermore, my insurance covered a percentage of these costs. This is not the norm. The vast majority of women do not have access to the resources needed to diagnose and treat complications like tongue-tie due to a dearth of support for breastfeeding mothers.
Barriers to breastfeeding support
I recently had the opportunity to discuss these issues and their impact on maternal mental health with Joy Burkhard and Genevieve Colvin, IBCLC. Joy is the founder and director of 2020 Mom, which spearheaded the California Task Force on the Status of Maternal Mental Health Care that issued its report this May. Genevieve is an International Board Certified Lactation Consultant (IBCLC) in the San Fernando Valley and member of the California Task Force. This is what I learned from our dialogue:
The Affordable Care Act improved women’s health coverage by requiring most insurance plans to cover breastfeeding support and supplies; however, many insurance companies still don’t cover lactation services outside of hospital settings.
Most states, including California, do not license International Board Certified Lactation Consultants (IBCLCs). Therefore, IBCLCs have a difficult time contracting with insurance companies to provide reimbursable outpatient services.
Due to a significant lack of outpatient lactation services, it is unlikely a mother will receive additional lactation support outside of the hospital unless she is WIC eligible or can pay for the expense out-of-pocket.
In the United States, the vast majority of women give birth in hospitals. The 24-48 hour period spent in the hospital after delivery is generally a new mother’s only opportunity to work with a lactation consultant (if one is on staff). During these meetings, which sometimes last just minutes, complications like tongue-tie are screened for only if they are immediately apparent or if a parent insists.
If (despite the aforementioned barriers) an IBCLC performs a comprehensive evaluation and determines tethered oral tissue may be negatively impacting breastfeeding, he or she must make appropriate referrals to professionals who can diagnose and treat it. While lactation consultants are trained to recognize breastfeeding complications like tongue-tie, it is not within their defined scope of practice to diagnose them. Instead, they are expected to refer to professionals who can, e.g. physicians and pediatric dentists.
Only physicians and pediatric dentists can diagnose and treat tongue-tie, yet they frequently lack the training to provide breastfeeding support or to make appropriate referrals for necessary post-frenotomy therapies.
While multiple, empirically validated assessment tools exist, there is no universally agreed upon definition, examination method, or classification system for the diagnosis and treatment of tongue-tie. The American Academy of Breastfeeding Medicine (2004) offers a protocol for the evaluation of tongue-tie, yet many physicians do not use it.
Doctors who perform frenotomies are often in high demand, so there can be a wait to see them. While a mother waits to see a specialist, she and her baby continue to struggle.
Why is this important?
There is a positive correlation between breastfeeding difficulties and postpartum depression; meaning, mothers who report breastfeeding difficulties demonstrate higher rates of postpartum depression than their counterparts. In a study published in 2015, Brown, Rance, and Bennet examined the relationship between specific reasons for stopping breastfeeding and postpartum depression symptoms in mothers with infants, ages 0-6 months.
They found that mothers who breastfed for shorter durations, specifically due to physical difficulty and pain, scored higher on a test measuring postnatal depressive symptoms. Moreover, they found negative breastfeeding experience to be predictive of postpartum depression symptoms, specifically when challenges are due to physical difficulties or pain.
The factors influencing the development of postnatal depression in relation to breastfeeding complications are still not fully understood; therefore, further studies are needed to examine this relationship.
How to enhance breastfeeding support
Increased support should be directed toward mothers who want to breastfeed but are considering stopping due to physical difficulties or pain (Brown, Rance, & Bennet, 2015). According to Hannula, Kaunonen, and Tarkka (2008), guidance that encourages self-efficacy while empowering new mothers is especially beneficial.
Due to the Affordable Care Act, federal law now stipulates that insurance companies must reimburse out-of-network costs if they cannot provide in-network lactation services. Unfortunately however, many insurance companies still refuse to cover services outside of hospital settings (Benyo, 2015). Taking necessary steps to comply with the law and reimburse outpatient services will increase a mother’s chance of receiving breastfeeding support.
Hospitals can support new mothers by opening outpatient lactation clinics. These clinics generally offer free, low-cost, or reimbursable services to women who need additional breastfeeding support after leaving the hospital. For example, the Lactation Resource Center at Good Samaritan Hospital in Los Angeles offers consultations with IBCLCs and Certified Lactation Educators (CLEs), support groups, educational classes, and supplies. The center is grant-supported; so all services are free or donation-based and available to any mother in the Los Angeles area regardless of where she delivered.
Individual states, such as California, can begin developing rules and regulations to license lactation consultants. Once licensed by the state, IBCLCs can join insurance networks to ensure their services will be reimbursed. Additionally, physicians may be more encouraged to include lactation consultants in their practices if their services are covered by insurance and regulated by the state.
Lactation support for mothers who want to breastfeed should be included in prenatal, pediatric, and postpartum checkups. Staffing lactation consultants in outpatient obstetric and pediatric clinics would further increase the likelihood of mothers receiving outpatient breastfeeding support (Farver, 2016).
Physicians treating pregnant women and new mothers should be familiar with the complications that can contribute to breastfeeding difficulties. Additionally, if health insurance companies reimburse doctors for time spent attending to breastfeeding issues, they will be more likely to include these services in their practice (Davis, 2013).
The diagnosis and treatment of tongue-tie and other complications that impact breastfeeding should be basic competency for all physicians and pediatric dentists (O’Callahan, Macary, & Clemente, 2013). In order to achieve this, a universal definition, examination method, and classification system for tongue-tie should be established.
Finally, instead of waiting until breastfeeding challenges arise, lactation consultants and physicians could adopt a more proactive approach to assessing tongue-tie. In Brazil, national law requires all newborns to be screened for tongue-tie using a universal, empirically validated assessment tool (Martinelli, Marchesan, & Berretin-Felix, 2012).
Research demonstrates that breastfeeding practices improve rapidly when appropriate lactation support is offered (Rollins, et al., 2016). Mothers experiencing difficulty breastfeeding need greater access to these resources. When breastfeeding is not made difficult by complications, it can actually serve to protect maternal mood by lessening reactivity to stressors and inducing calm (Groer, Davis, & Hemphill, 2002). Enhancing support for mothers who want to breastfeed can ultimately play a role in improving maternal mental health.
If you are experiencing difficulty breastfeeding, you are not alone in your struggle. The following resources are available:
Women, Infants, and Children (WIC) provides breastfeeding support to pregnant and postpartum women in need of free or low cost services. You can use their online prescreening tool to determine whether you are WIC eligible.
If you are looking for an International Board Certified Lactation Consultant (IBCLC), the International Lactation Consultant Association (ILCA) offers a directory to find one in your community.
Noelle McCown, Psy.D. is a Clinical Psychologist specializing in maternal mental health in the Greater Los Angeles Area. For more information about her work, you can visit http://www.drnoellemccown.com.
The Academy of Breastfeeding Medicine (2004). Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf.
American Academy of Pediatrics and American Society of Pediatric Otolaryngology (2016). Tongue-tie in infants and young children. Retrieved from https://www.healthychildren.org/English/healthy-living/oral-health/Pages/Tongue-Tie-Infants-Young-Children.aspx.
Benyo, A. (2015, May 26). I know all about the ACA’s breastfeeding benefit, and I couldn’t get services covered. Retrieved from https://nwlc.org/blog/i-know-all-about-aca’s-breastfeeding-benefit-and-i-couldn’t-get-services-covered/.
Brown, A., Rance, J., Bennett, P. (2015). Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing, 72(2), 241–481. doi:10.1111/jan.12832
Davis, L. S. (2013, Jan 2). Is the medical community failing breastfeeding moms? Retrieved from http://healthland.time.com/2013/01/02/is-the-medical-community-failing-breastfeeding-moms/
Farver, M. (2016). A model for outpatient lactation care. MOJ Women’s Health 2(2). doi:10.15406/mojwh.2016.02.00025
Fernando, C. (1998). Tongue-tie—from confusion to clarity: A guide to the diagnosis and treatment of ankyloglossia. Sydney, Australia: Tandem Publications.
Groer, M. W., Davis, M. W., Hemphill, J. (2002). Postpartum stress: Current concepts and the possible protective role of breastfeeding. Journal of Obstetric, Gynecologic & Neonatal Nursing, 31(4), 411-417. doi:10.1111/j.1552-6909.2002.tb00063.x
Hannula, L., Kaunonen, M. and Tarkka, M.-T. (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing, 17(9), 1132–1143. doi:10.1111/j.1365-2702.2007.02239.x
Martinelli, R. L., Marchesan, I. Q., Berretin-Felix, G. (2012). Lingual frenulum protocol with scores for infants. The International Journal of Orofacial Myology, 38, 104-112.
O'Callahan C., Macary S., Clemente S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5), 827-832. doi:10.1016/j.ijporl.2013.02.022
Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., Piwoz, E. G., Richter, L. M., and Victoria, C. G. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet, 387(10017), 491-504. doi:10.1016/S0140-6736(15)01044-2