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Evaluation and decision making re

Using the Frenotomy Decision Tool for
the Breastfeeding Dyad.
Carole Dobrich, RN, IBCLC, ANLC
Jakarta, Indonesia
Saturday, August 4, 2018
©2018Carole Dobrich 1 ©2018Carole Dobrich 4

I would like to acknowledge and remember two

special people who were pioneers in the field of
tongue-tie and frenotomy.

©2018Carole Dobrich
Dr. Brian Palmer ©2018Carole Dobrich
Dr. Betty Coryllos 5

Disclosure A little bit of history

Co-owner - The International Institute of Human Lactation -
Health e-Learning – IIHL lactation education
Co-director - Step 2 Education International Inc. – Baby-
friendly Education

I love doing what I do! A “meeting of the minds” in 2009 –

Otherwise I have nothing else to declare. 17 attended the first meeting in person
©2018Carole Dobrich 3 ©2018Carole Dobrich 6

Photo – used with permission

©2018Carole Dobrich 1

Focus is always the mother baby dyad The recent meeting in Toronto July 26-29, 2018
Over 250 attended

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©2018Carole Dobrich

Goal – happy
breastfeeding dyad

For those of us who work in the

lactation field, breastfeeding problems
for some mother’s with tongue/lip tied
infants can be significant.

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©2018Carole Dobrich

Some of the original “minds” The types of breastfeeding

difficulties seen include:
Non-latching babies Low milk supply
Painful nipples Infant weight issues
Painful breasts Milk Blebs
Nipple wounds Noisy Feeder
Vasospasm Messy Feeder
Mastitis Slow Feeder
Recurrent blocked ducts Untimely Weaning

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©2018Carole Dobrich 2

What are we looking at when we evaluate? The Frenotomy Decision Tool for
Breastfeeding Dyads
One or more variants may be noted.
 Tongue length
 Elasticity
 Tongue mobility (elevation, lateralization, extension) Development Use
 The position where the attachment is under the tongue
 Function
 Tongue behaviour
Validation Feedback
©2018Carole Dobrich 13 ©2018Carole Dobrich 16

Now lets do some tongue exercises Now let’s help put the pieces together
Photo ©Hannah Taylor

Development Use

Validation Feedback
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©2018Carole Dobrich

Tongue-tie what’s that!

Associations between tongue-tie, lactation

problems, speech disorders and other oral motor
disorders (e.g., problems with swallowing or
licking) have been inconsistent, and are an on-
going source of controversy within the medical
community. (CPS 2015)
©2018Carole Dobrich ©2018Carole Dobrich 18
Photo ©2003Goldfarb Breastfeeding Clinic

©2018Carole Dobrich 3

This was in 2003 “One advantage of the FDRBI is that it

incorporates maternal signs and symptoms,
thereby adding functional assessment to the
anatomic one. How mother and infant fit and
perform together is the critical factor, not either
one in isolation. The authors asserted, and FDRBI
supports, that if ankyloglossia and breastfeeding
problems coexist and cannot be easily remedied by
correction of latch or other typical lactation
interventions, then frenotomy is indicated”Pediatrics 2010
Photo ©2003Goldfarb Breastfeeding Clinic (Forlenza, Paradise Black, McNamara, & Sullivan, 2010, p. 1503).
Forlenza, G. P., Paradise Black, N. M., McNamara, E. G., & Sullivan, S. E. (2010). Ankyloglossia, Exclusive Breastfeeding, and Failure

Before After
to Thrive. PEDIATRICS, 125(6), e1500-e1504. doi:10.1542/peds.2009-2101
©2018Carole Dobrich 19 ©2018Carole Dobrich 22

Original Frenotomy Decision Rule for Current 2018 version

Breastfeeding Infants (FDRBI) 2004
 Mother with nipple pain/trauma while breastfeeding
 AND/OR inability to maintain latch
 AND/OR poor weight gain in the infant (<15g/d),
 AND a visible membrane anterior to the base of the
tongue, which restricts tongue movement, leading to
 an inability to touch the roof of the mouth, OR
 an inability to cup an examining finger, OR
 an inability to protrude the tongue past the gum line
©2018Carole Dobrich 20 ©2018Carole Dobrich 23

Early Development
Follow the
• Srinivasan, A., Dobrich, C., Mitnick, H., & Feldman, P. (2006).
Ankyloglossia in breastfeeding infants: The effect of frenotomy on guide for
maternal nipple pain and latch. Breastfeeding Medicine, 1(4), 216-
224. doi:10.1089/bfm.2006.1.216 using the
• Our research showed at 3 months post frenotomy that 21 out of 27
(77.8%) were still breastfeeding; 23 out of 25 (92%) were pain free;
and 22 out of 25 (88%) felt that the frenotomy had helped.
©2018Carole Dobrich 21 diUKMJk9KCn46eaqGFFuppBHdNz6.jpg 24
©2018Carole Dobrich

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Part One Use

Part 1. # 3 Endless feeds DESCRIBED by mother

Photo ©Carole Dobrich

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Part 1. # 1 Mother with nipple pain/trauma while Part 1. # 4 Poor milk transfer observed (high
breastfeeding suck/low swallow ratio – few audible swallows)

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Photo ©Carole Dobrich 29
Photo ©Goldfarb Breastfeeding Clinic

Part 1. # 2 Infant with inability to latch or Part 1. # 5 Infant (> 5 days) with weight gain < 20g/d
maintain latch, clicking sounds, milk leakage without supplementation

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Part 2. # 2 Inability for the tongue to cup/maintain suction

Part Two Use on an examining finger or on the breast

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Photo ©Carole Dobrich

An infant with a visible or palpable membrane anterior to or Part 2. # 3 Inability to protrude tongue past gum line and/or
at the base of tongue restricting tongue movement and central dimpling of tongue on extension
leading to any of the following: (bowl or heart shape)

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Photo ©Goldfarb breastfeeding clinic Photo ©Goldfarb breastfeeding clinic

Part 2. # 1 Inability to elevate tongue at least mid-way Part 2. # 4 Diminished lateral movement
with wide open mouth of tongue

©2018Carole Dobrich Photo ©Anjana Srinivasan 33 ©2018Carole Dobrich 36

Photo ©Goldfarb breastfeeding clinic

©2018Carole Dobrich 6

Part 2. # 5 White tongue with absence of white patches An infant with a visible or palpable labial membrane at the
elsewhere (pseudoleukoplakia) center of the upper lip between the lips and the gums
leading to any of the following:

©2018Carole Dobrich Photo ©Carole Dobrich 37 ©2018Carole Dobrich Photo ©Carole Dobrich 40

Part 3. # 1 Upper lip folds in, puckering

Normal or pursed lips
This slide is to
remind me to talk
about the dyad/triad.

38 ©2018Carole Dobrich Photo ©Carole Dobrich 41

©2018Carole Dobrich Photo ©Carole Dobrich & Melody

Part 3. # 2 Perioral blanching

Part Three Use and/or naso-labial folds

Photo ©Goldfarb breastfeeding clinic

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Part 3. # 3 Two tone lips

(lighter interior of inner aspect of lips) Normal infant
This slide is to remind
us to talk about the
dyad/triad again.

©2018Carole Dobrich Photo ©Carole Dobrich 43 46

©2018Carole Dobrich Photo ©Carole Dobrich & Melody

Part 3. # 4 Persistent lip blisters Scoring

There needs to be a positive score in two parts (1 & 2 or 1 & 3). If
the total score is ≥ 2 a frenotomy may be required. Higher the
score, higher the likelihood a frenotomy maybe needed.

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Photo ©Goldfarb breastfeeding clinic ©2018Carole Dobrich

Part 3. # 5 Tension/blanching of gum/gingiva

while flanging upper lip towards nose tip Copyright
No part of this document can be changed or modified
without permission from the author. This document
may be copied and distributed without further
permission on the condition that it is not used in any
context in which the International Code of Marketing
of Breastmilk Substitutes or subsequent resolutions
are violated. For more information, please contact
Photo: ©Paul A. Bahn, III, DMD -
Carole Dobrich at
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©2018Carole Dobrich

©2018Carole Dobrich 8

Validated by 2 pediatricians Case history
in Indonesia – version 2016 • Obvious anterior tongue tie with limited lateral movement,
extension and elevation
• Special thank you to Dr Anjar Setiani and Dr Asti • Observed baby at breast
Praborini • Strong MER
• Their research indicated the FDTBD is a reliable tool • +++noisy, slurping, releasing breast and drinking very
• Currently the 2018 version is being validated in Canada • Mum stated feeds take about 20+ minutes and feeds
with Dr Louise Dumas and myself. about 16 times in 24 hours
• Content validity is complete • Mother “stated” no pain
• Working on inter-rater reliability
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Feedback from users Case history

•User friendly
•Easy checklist
•Love it because it is inclusive of dyad
•Breastfeeding is evaluated
•Can share with family and use with referral
notes explaining evaluation
©Carole Dobrich
©2018Carole Dobrich 50 ©2018Carole Dobrich

Case history
Case history
• Mother & six week old baby referred to clinic for tongue tie
• Mother explained this was a typical feed
• Referral noted no pain, excellent weight gain (60gm/day),
noisy feeder • Gave information about frenotomy
• Parents considered cancelling appointment as felt BF OK yet • Patient had discussed it already with her partner.
came because maybe it will have an impact on speech. • Wanted procedure done.
• Baby evaluated • Is it really necessary???

©2018Carole Dobrich ©2018Carole Dobrich

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What were the problems? Was this frenotomy necessary?

• Can’t maintain latch - Part 1 #2

• Mother now stated really NO pain.
• Long feeds - Part 1 #3 • Feedings went from 20+ min to 6 – 10 min.
• Limited tongue elevate – Part 2 #1 • Baby decreased feeding frequency from 18+
• Poor cupping/maintain suction – Part 2 #2 feeds/24hrs to 10 times in 24 hours
• Central dimpling of tongue - Part 2 #3 • Baby was less fussy at breast.
• Minimal lateralization - Part 2 #4 • Happy mum and baby.
• Part 1 = 2 + Part 2 = 4 FDTBD score = 6
©2018Carole Dobrich ©2018Carole Dobrich

Case history post frenotomy – Take home message

incomplete • Not always necessary to treat
• It is important to observe and evaluate a feeding
• Look at function not just anatomy
• It is still controversial
• It is an intervention
• There needs to make more training available
• Need to publich more research
• Ask the question “Is it causing a breastfeeding problem?”
• What are the risks of not doing the procedure for the
breastfeeding dyad?
©Carole Dobrich ©Carole Dobrich
©2018Carole Dobrich • Maternal pain and early weaning
©2018Carole Dobrich are risk factors

Observe a feeding

Thank you
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©2018Carole Dobrich Photo ©Carole Dobrich

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