I recently spoke with Dr. Rajeev Agarwal a pediatrician who specializes in evaluating and treating babies with Tongue-tie. I hope that you enjoy listening to this podcast which I released in 2 parts. Dr. Agarwal does a fabulous job explaining in easy terms what tongue-tie is and the implications that it has not only on the baby but its effect on the entire family. The full interview can be found here. Dr Rajeev Agarwal is a local pediatrician in Arizona. He has a beautiful wife and 2 children. Dr. Agarwal moved to Arizona in 2005 and opened his first office the same year. If you are ever in the area, you must take a tour of his amazing office, It truly is a treat. He has since moved to a second office. Over the years, he has received many awards, which he proudly displays in his office. He is an expert in tongue tie procedures and has performed many over the past few years. He is also a member of the (IATP) International Affiliation of Tongue-tie Professionals. Dr Agarwal is in hot demand as a speaker and has spoken worldwide. Dr. Agarwal was born in India, and grew up in different cities because his father worked for the government as a telecommunications engineer and he would get transferred to different cities every few years. His mother stayed home with her 4 children. Dr. Agarwal describes his growing up years as being very blessed and living a very charmed life with doting parents and siblings. He was very creative with painting and drawing. His mother leaned towards treating childhood illnesses with home medicine and this is where the seeds were planted for being a physician and using natural medicine. He started engineering school and did well, but it was not very fulfilling. He did really well with it but did not feel the love. It was his sister who saw in him that he did not seem very happy with this. Since she saw that he was always the one asking people how they were doing and was so kind and caring, that perhaps he would enjoy being a Doctor. He said okay, took the exam and was accepted into medical school. As a kid growing up, it is not anything I ever thought I would be doing. We are a very close knit family She was in medical school. She said you will probably enjoy medicine more than the physics and math and I am so glad that she suggested as this was the best decision I made in my life. In medical school he wanted to be a surgeon because he thought they make the most difference, In orthopedics residency he realized after 6 months that this was not fulfilling. It was very mechanical and was missing the human interaction. In India pediatrics was not a happy branch, you saw a lot of morbidity and mortality. So, when surgical residency was not doing it for me, I decided to consider pediatrics. So now he really feels, that he actually did not choose pediatrics, he was led to it. Dr. Agarwal says that speaking with families and interacting with a family is what really gives him the joy in pediatrics. Taking care of children is the easiest part of his job. Taking care of the family is the most fulfilling. He cannot take care of children very well until he learns the families perspective on disease, how they see disease, how they see themselves not just as being cured, but as being healed. I always thought of being a pediatrician as being a part of the whole family. He grew up in a family that we did everything together. If he was sick, his sister and his parents were worried about him. That is just the way his family was. Whatever happened to one person, happened to everyone. I never thought that I would only take care of children. I realized that through a child I would be able to affect a whole time period of a family’s life. Dr. Agarwal says that when a family is born everything changes. A unit of 2 people becomes 3 or 4 or 5. With every pregnancy and every birth, a family evolves and being a part of that, is a joy of being a pediatrician for me. I absolutely love it. Dr. Agarwal next talks about his journey into learning about tongue ties. There are other ties and other issues surrounding ties, however, our focus today is going to be just on tongue tie. His definition of tongue is – A tongue tie, meaning a piece of fibrous tissue which impairs the normal function and the movement of the tongue. This is between the bottom of the tongue and the floor of the mouth. The tongue is a very mobile muscle and it has certain functions. If those functions are impaired, that is called tongue tie. Now having a piece of this fibrous tissue is a part of the human condition. All 7 billion of us have it so having this tissue does not make it a tongue tie. That makes it a frenulum which is a part of normal human anatomy. If it causes functional impairment, we call it ankyloglossia, l which means anchoring of the tongue or tongue tie. The tongue has very specific functions of movement, lateralization, extension, if the movement is impeded, so is the function If the movement is not impeded or does not affect the function,nothing needs to be done, otherwise we would be doing frenotomy on every single person and this is not what needs to be doing. Dr. Agarwal explains what the tongue does differently when bottle feeding and when breastfeeding. The mechanics of feeding on the breast and the bottle are very, very different. In bottle feeding, the baby does not have to do very much, the bottle drips the fluid right in the middle of the oral cavity and all the baby is required to do is swallow. There is not much lip or tongue activity required to make a bolus of fluid to swallow. With breastfeeding, the mechanics of the tongue and oral cavity is very different. The tongue has to extend beyond the lips, hold onto the nipple, elevate so that the nipple is held in between the babies tongue and the hard palate and also through peristaltic movement, pushes that nipple right against the soft palate so it is a much deeper latch, the nipple is almost swallowed in by the tongue movements, hence the babies lips and gums are on the areas of the areola where the milk is stored and then the baby actively sucks the milk in close to the area, of the pharynx. This is an active movement of the tongue during breastfeeding. I have seen a lot of cases in which the extension of the tongue coming out is pretty good, but other movements of the tongue the repetitive motion and the elevation of the tongue so that the nipple is held between the tongue and the hard palate and which is the most important with a baby of tongue tie, and the most limited with a child with tongue tie. If this does not happen well, if they are tongue tied and hence they are not able to do the nutritive sucking well, Extension is only needed to get the nipple into the mouth, after that it is the elevation and the peristaltic motion that is needed to to get the nipple into the mouth, after that it is the peristaltic motion and the elevation of the tongue. Dr. Agarwal explains why tongue tie babies get fatigued from breastfeeding and why time is not the best indicator of productive breastfeeding. The let down works as the bottle where the baby has little to do, they just need to swallow. Baby gets a letdown and does not have to suck as hard but after that it becomes an act of active sucking, then the tongue is trying hard to elevate itself to get those motions going. Breastfeeding is the most important biological function of a baby and the tongue is the most important determinant of breastfeeding and is a huge part of the feeding process. When babies are putting all their energy into breastfeeding and the mechanics are not in place, the efforts can be immense. Babies will get tired, they lose interest, they go to sleep, or they spend all day feeding and none of this is normal or good. The gold stand for adequacy of breastfeeding is not the time spent on the breast, it is weight gain. Dr. Agarwal states that he has lots breastfeeding moms who say their baby is doing well because he is eating so much, he eats every hour. I do a weight check and baby has lost weight and moms don’t believe this, again they are saying that their baby is eating all the time. This actually tells me that the baby is trying so hard to get what it needs, spending so much energy, not getting enough and losing weight. This tells me that something is wrong. I need to look closely in their mouth for anything that can be causing this. Other moms don’t believe their baby is feeding well because their baby feeds for 10 minutes each time and feeds about 6 times a day and is in the 90%. I don’t believe it my baby is doing well because he feeds for 10 minutes, 6 times a day. I check the baby and he is in the 90% and mom is all worried the baby is not feeding well. The mom is deciding the baby is not doing well just because his feedings are quick. Hence, I like when the lactation consultants check milk transfer. If this is not adequate that tells me for the amount of time they are breast, they did not even cover the calories they would have gotten from the milk. Dr. Agarwal tells what the common breastfeeding challenges mothers have that he relates to tongue tie babies: The diagnosis of tongue tie is basically dependent on maternal history and the child’s exam. When I hear of specific breastfeeding challenges, I look very carefully in baby’s mouth.The most common symptoms for the mother is nipple pain, which can be mild or excruciating. In some cases they say it is like a dagger and turning the dagger in a clock wise direction and really, it is that bad. I see bleeding and cracked nipples. Mothers are treated for mastitis and some several times. The moms know their baby has a shallow latch. The babies are extremely gassy and thrushy. I also see failure to thrive babies. They are 7 or 8 weeks old and maybe just back to birthweight. This is a signal to me that something is very seriously wrong and something needs to change. Some babies have been diagnosed as colic and frequently the babies are crying because they are distressed, they are hungry, they need more food. Mother’s are saying they have long feedings. and it feels like they are feeding 24/7 and they are so sleep deprived. One of the most important things I see in this breastfeeding relationship is the sense of utter failure that moms have to go through. This is a very painful thing because mothers who are trying so very hard, feel like they are not doing good enough or are not good mothers. I see sleep deprivation. I see very severe postpartum depression, all related to their feelings of inadequacy because they were not able to breastfeed and /or they feel like there is something wrong with them. Anyone who works with mothers will see that, they will think there is something wrong with them. They take it personally because they give so much. Part 2 – Let’s learn together about tongue tie Dr. Agarwal talks about aftercare and the importance of keeping the area open by extra movement and stretching exercises. He talks about stretching the “diamond” area that can be seen after the frenotomy. We have a discussion about the differences in how babies respond to the procedure, the aftercare exercises and how long it takes some babies to recover from the procedure and mothers and babies to get to the place of normal breastfeeding. Dr. Agarwal highlights the fact that the tongue does not know how to really move well as it has been restricted for so long. So all the mechanics of the tongue movement and how it is going to function – all this change needs an adjustment period. It takes a while for the tongue to figure out what it is suppose to do. There are also a lot of pieces to this recovery and normal breastfeeding. Some of these moving parts ( variables) are:

  1. Mom’s breast size,
  2. Mom’s milk production.
  3. Mom’s pain level
  4. Mom’s perception of babies pain
  5. Babies pain or soreness level
  6. Babies, palate, jaw, tongue length, just to name a few variables.

There are so many moving parts that it is impossible for us to say which baby is going to follow which path. Taking all of this into consideration, most babies follow the path of being very sore or in pain for 2-3 days of pain and80 – 90% of our babies have much better breastfeeding than what they started with. It is common for mother’s to begin to see progress, however, it may take several weeks for some babies to really figure it out. Some of the gradual changes that moms notice within several days to a week from the procedure are:

  1. babies go from no breastfeeding to some breastfeeding to all breastfeeding
  2. babies go from difficult breastfeeding to more productive breastfeeding
  3. babies go from not transferring much milk at the breast to removing more milk as the days go on.
  4. Moms changing from nipple pinching and clamping sensation, they now feel more of a comfortable tugging sensation.

Dr. Agarwal talks about one of the babies that he has saw in his practice today, which he states is something he commonly sees with tongue tie babies. First time mom whose baby just reached birth weight at 6 weeks old. ( Baby should have returned to birth weight by the time baby was 2 weeks old.) Mom started breastfeeding in the hospital, was told there is a possibility of tongue tie by a member of the hospital staff. Babies pediatrician said there is no tongue tie. Mom said great and went about her business. At one week pediatric visit, baby had shown 12% loss of body weight and the possibility of hospital admission was discussed. It was decided that mom should start supplementing, along with breastfeeding. She started pumping and offering milk from bottle , along with some formula. Baby was having a lot of reflux and dribbling and choking on breast and bottle. At next pediatric visit at 10 days, the weight had not gone up and pediatrician said baby is getting close to admission. Mom became extremely anxious, was being told by her friends that her milk is not good enough and should go to formula. About 1 week later, baby was shown to have 7% weight loss so is now starting to gain but still not as well as she should have gained. Mom spends time on the Internet and googles and learns about tongue tie. She sees a lactation consultant who feels baby is likely tongue tied and refers mom and baby to Agave Pediatrics. Until that appointment, LC suggested that mom breastfeed more, while she continued to supplement and pump. By the time baby was seen by Dr.Agarwal, baby was just about back to birthweight. Mom was breastfeeding, supplementing with her milk and supplementing with about 50% of formula. Her main concern at this point is that baby is struggling even to bottlefeed and even with supplements is struggling to gain well. Upon examination, baby was diagnosed with a recessed jaw, upper lip tie, lingual tie and high palate. The procedure was scheduled for a few days later. Dr. Agarwal explains that this is a very common scenario and upon follow up, typically the percentiles go up. The milk supply has gone up and the babies are using their tongue better and doing a better job of extracting milk from the breast. Many mothers have gone back to breast and exclusively breastfeeding. He does find that the tongue tie procedure is most effective if performed within the first couple of weeks. After that, the babies and moms will still get to exclusive breastfeeding, but as the further away from birth you get, the more difficult exclusive breastfeeding becomes. Since in the interview thee is so much more I recommend listening to the  full interview here