RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 1

RobinP.Glass,MS,OTR,IBCLC

robin.glass@seattlechildrens.org

Whenfrenotomyisnotenough:Motorprogramingandit’srelationship

tobreastfeedingissues

“Toraisenewquestions...toregardoldproblemsfromanew

angle,requirescreativeimaginationandmarksreal

advanceinscience.”

(AlbertEinstein)

Tonguetiebasics§ AkaAnkyloglossia–isatetheringofthesublingualfrenulumthatimpedesfunctionaltonguemovements§ InUSA–hastypicallybeendiagnosedininfancy§ ChangingtomoreappreciationofTTeffectsacrossthelifespan

§ Commonlyclassifiedas:anteriororposterior(Coryllos,2004;Knox,2010)§ Genderdifferences–boys:girls§ Anterior1:1Posterior2:1(Knox,2010)

Anterior

Posterior

Effects/sequelaeoftonguetieMaternal

§ Pain–nippletrauma,blisters,cracks,bleeding§ Painfulbreasts§ Pluggedducts/mastitis§ Lowmilksupply§ Frustration,discouragementre:breastfeeding§ Untimelyweaning

Infant§ Suckingproblems–decreasedsuction/vacuum§ Poormilktransfer/poorweightgain§ Problemswithlatch§ Clickingsoundduringnursing§ Fussinessorbreastrefusal§ Fallingasleepatthebreast§ Lengthybreastfeedingsessions

(Griffiths,2004;McBride,2005;Hall,2005;Forlenza,2010;Rowan-Leff,2011)

Tonguetiecausingnippletrauma

BaseCompression Tipcompression

(Geddes,2008)

Tonguetieeffects/sequelaeacrosslifespan

Child

§ Difficultytransitioningtosolids–foodselectivity§ Notabletolick(eg:icecreamcone)§ Speechdisorders§ Orthodonticproblems§ Difficultywithoralhygiene§ Skull,palatedeformities§ Disorderedsleepbreathing

Adult

§ Becomestiredwhilespeaking§ Skull,palatedeformities§ Sleepapnea–sleepdisorderedbreathing§ Possibleroleinheartdisease,stroke,dementia

§ Orthodonticproblems§ Difficultywithoralhygiene

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 2

Lifespaneffectsoftonguetie Identifyingatonguetie§ Signsandsymptoms§ Visualinspection:§ Shapeoftongueasitmoves§ Pointofcontactwithtongue–withfloorofmouth

§ Observespontaneousmovementoftongue–crying§ Elicitedmovementsoftongue§ Tipelevation,lateralization§ Tongueprotraction+downward=TT§ Palpationoffrenulum§ Consistency–fibrous,ropey,coveredwithmembrane

“Spinnaker”shape

Assessingtonguetie§ Shouldyouuseagradingscale?–dependsontypeofpractice§ Mostgradingscalesaredescriptionsoflocationoflandmarks§ Tongueattachmentontongue§ Tongueattachmentonfloorofmouth

§ Physicalfeaturesareconsideredalongwithfeedingdysfunction§ Indecisiontoreleaseornot§ Howitlooksdoesnotalwaysdeterminehowtongueworks(Amir,2006;Genna,2009)

Anteriororposteriordebate§ Isreallyamisnomer–referringtohowfarforwardtheattachmentis–whatyoucansee§ Allanteriorshaveaposteriorcomponent§ Anterior–bindstip-obvious,thinmembrane,heart-shapedtongue§ Posterior–bindsmiddle-submucosal,hidden,invisible

Tonguetieassessmenttools§ Ratingofphysicalclassification(Type1-4)§ Coryllos§ Kotlow

§ Physicaldescription+somefunction§ **Martinelli2015–Lingualfrenulumprotocolforinfants§ Hazelbaker-theassessmenttoolforlingualfrenulumfunction(ATLFF)(Amiretal,2006)§ Bristoltonguetieassessmenttool(BTAT)(Ingrametal,2015)

§ Mustassesstheaffectofthephysicalcharacteristicsofthefrenulum§ Onthedevelopmentallyappropriateoralfunction

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 3

Aftercarefollowingrelease:scissorsorlaser§ Releaseonlyonepartofprogram§ Aftercareexercisestomaintainrelease§ Noconsensuson:§ Whethertodostretchingornot§ Painmanagementafterrelease§ Frequencyofstretchingperday§ Duration(days/weeks)ofstretching§ SCH–yesaftercarestretches–alsogentlyencouragefunctionaltonguemovements§ Mayneedoralmotortxprogramtoimprovefeedingskills

Stretchingthewoundsite

Appropriatestretching§  Pushback§  Liftup§  Pushsidestowardmiddle

Inappropriatestretching§  Tonguesideswingup§  Tonguenotlifted§  Woundnotstretched

(Ghahari,B2019)

Tonguetieandprematurity§ Frenotomy-safelyintheNICU§ Incidenceinpreemiesissameasterminfants(Knox,I.2015,personalcommunication)§ Correctedageattimeofconsult–38wks

§ Factorstoconsiderregardingtiming§ Previousclinicalfeedingevaluation§ Ageattimeofconsult§ Previousfeedingexperience§ Physiologicresponse(decompensation)topain§ Airwaystability

Tongue-tievideos&otherresources

§ https://www.youtube.com/watch?v=XZae0tz8RPE

§ Dr.EvelynJain§ SpeaksfromMDpointofview§ Describesprocedureforfrenotomy§ http://www.drjaintonguetie.com

§ Dr.BobakGhahari(ENT-drghahari.com)§ IATP(InternationalAffiliationofTonguetieprofessionals–(tonguetieprofessionals.org)§ BrianPalmer,DDS(brianpalmerdds.com)§ LawrenceKotlow,DDS(kiddsteeth.com)

Whenfrenotomyisnotenough:Motorprogramingandit’srelationship

tobreastfeedingissues

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 4

Whenmotorprogramsarefaulty§ Canbecomederanged–problemswithexecutionofprogram§ Lackofcentralnervoussystemsignalingtomuscle

§ Muscle(s)becomeslessresponsive-possiblybecomesweak§ Motorprogram“drops”muscle(s)outoftheprogram

§ Substitutionbeginstooccur§ Useswrongmusclegroupsinwrongsequence§ Over-recruitsmusclesthatdowork–eg:tightenlipsatcornersofmouthsecondarytodecreasedstrengthofintra-oralvacuum(suction)

Motorprogramsinaction

§ Efficiencyofmovement-bodyhas“scripts”,motorprogramsthatrunautomatically§ Eg:posturalsupportforarmreach§ Lowbackextensorsoncontralateralsidefiremillisecondsbeforethearmlifts§ Providetheposturalsupportforthedistalarmmovement

§ Sometimesprogramrunsincorrectly§ Pickingupalightsuitcasewhenyouareexpectingaheavyone

Normalmovementpatterns:oralormotor

§ Infant’sspontaneousmovementsprovidewindowintotheintegrityofCNS§ Hallmarkofnormalmovementpatterns:§ Complexity,variety,fluidity

§ Exquisitedifferentiationoftonguemovement§ Observelackofvarietyofmovementsintonguetie§ Beforeandoftenafterfrenotomy§ Spinackershapedtongueduringcrying§ Howmuchofearlymotordevelopmentisinborn–howmuchisonthejobtraining

FetalDevelopmentalPatterns§ Fetalfeedingbehaviorsemergein2ndtrimester§ Selforal-facialstimulationprecedessuckling&swallowing10wks–swipestowardsface§ By2ndtrimester–handmovtsdirectedtopartsofface

§ Progressfrommorebasicàmorecomplexmovements§ Anteriorthrust–15wks§ Midlinedepression“cupping”–16wks

fetusabcnews.comMiller,2003.Scarboroughetal.,2008,Delaneyetal,2008

Motorprogramming&learningin-utero§ Earlyinuteroexperiencescanalterbrainfunction&structures§ Synapticdevelopmentbeginsat6wks§ Before32wks–occursindependentofexperience§ After32weeks–influencedbyexperience

§ Fetalmovementpatternsthatarerepeatedarelearned§ Incorporatedintomotorprogram§ Usedafterbirth&onwards

§ Preemieshavelesstimeforpractice

•  Alsetal.2004

“Whatfirestogether–wirestogether”

Brainorganization&learningafterbirth§ Afterbirthneuralmapsdevelopedfrompast&presentexperiences§ Furthereffectsmotor&sensorysynapticdevelopment

§ Abnormalitiesinanatomy,tone-reinforcehabitualpattern§ Fornewmotorpatternsneed“feel”appropriatemotorpatterninordertoreproduceit

Barlow,2009,Graven,2008

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 5

Howdowedevelopmotorprograms&motorlearning?

Howisthisrelatedtotongue

tie&breastfeeding?

Definitions§ Motorcontrol–understandingtheneural,physical,behavioralaspectsofmovement§ Motorlearning–focusontheacquisitionofskilledmovementasafunctionofpractice/repetition§ Motorprogram–setofinstructionsfromacentralpatterngeneratorcontainingallinformationneededtocarryoutmovement

TheoriesofMotorControl§ Havemanytheoriesabouthowwecontrol&learncoordinatedmovement§ Theoriesvaryin:roleofcentralvs.environmental&/orfeedbackcontrolofmovement§ Describehowchangesaremadetoourmovementpatterns§ Involvessolvingthedegreesoffreedomproblem§ Howdothemuscles,joints,structuresmoveindependentlyinoneormultipleplanestocreatethedesiredmovement?

Tonguetiecanalteranatomy§ Mayalterthealignmentofthegenioglossusmusclefibers§ Intrinsic&extrinsictonguemusclefibersareinterwoven§ Internalpathologicalremodelingcanoccur§ Similarlyorientedfiberbundlesmayreactenmasse

§ Retainedinternaltetheringdespiteadequatefrenotomy§ Mayhaveshorteningorchangestointernalfacialplanes

•  Kubin,2015,Takemoto,2001,Gilbert2005

Degreesoffreedom&tonguetie§ Restrictionsintonguemovementservetolimitthedegreesoffreedom§ Tonguetiechangesinherentanatomy§ Maychangethealignmentofmusclefibers

§ Altersthemovementsavailabletothetongue§ Furtherimpairsmuscleaction&motorpatterns§ Isareinforcingloopofinadequateandinappropriatemusclefunction§ Leadstolearningofthismotorpatternasthepreferentialone

**Formfollowsfunctionàfunctionfollowsform

Dynamicsystemsapproach§ Multi-causality–componentsaffect&changeeachotherwithinacomplexenvironment§ Infantperformanceisfragile&contextdependent

§ Tendencytowardsself-organization–nosingleelementhascausalprioritybecausecomponentsinteract§ Changeisnon-linearandcreatesdifferentoutcomesfromthesamestartingpoint§ Changeemergesovertime-occursoverdifferenttimeframes–eg:reactiontime(millisecs)àhrsàdaysàmos.

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 6

Dynamicsystemsapproach§ Smallchangesin1ormorecomponentsleadstoreorganization&largedifferenceinbehavior§ Eachchangesetsstageforfuturechanges

§ Developmenthappensforindividualinfantssolvingindividualproblemsinownuniqueways§ Balancebetweenstability&instabilityofsolutions§ WithaTT–see“stable”,unchangingmotorpattern§ Whatisneededisflexibility

§ Ifthecontextchanges–motorbehaviorcanchange§ Sameroff(1968,1973)–babies“learned”tousecompressionorsuctiontoobtainliquidasconditionschanged

Dynamicsystems&breastfeeding§ Qualitiesofthebaby§ Interplayoforalmovements&facialstructures§ Superimposedonhead/neckcontrolandposturalcontrol§ Sensoryabilities–registration,respondsivity§ Intertwinedwithbreathingandswallowingmechanisms

§ Environment–birthexperiences&beyond§ Inthecontextofthemother§ Maternalanatomy§ Milkavailability-atthisfeeding;overtime§ Maternalskills&knowledgetoassistbaby

Dynamicsystems&breastfeeding§ Infantinteractswiththeenvironmentàenvironmentchangesinfantbehavior§ Infantalsocreatesadynamicsystemthatshapesbehavior§ Action/behaviorinthismoment–setsthestageforbehaviorinthenextmoment&intothefuture

Infant+Interactionwithenvironment=Behavior

Howcanweusetheseconceptstoimprovebreastfeeding

Timelinessoffrenotomy§ Fasterthereferralthebetter§ Lesstimeformotorpatternstobecomemoreingrained§ Soonertherehabilitativeprocessbegins§ Lessensdevelopmentofsecondaryeffects§ Decreasingmaternalmilksupply§ Developmentofinfantfeedingbehaviors§ Learnedhelplessnessand/orrefusal

§ Affectsoninfantnutrition/growth

§ Knowyourreferralsources

Coachinginlactationsupport§ Mayneedtoprovideconcrete,explicitfeedbacktomotheraboutcorrectoralpatterns§ Usevisual&auditoryinformationtoassessperformance§ Watchfordrinkingsucks§ Listenforswallows§ Lookatbreastshapewhenbabyisremoved

§ Mayneedtoprovidehands-onassistancetomotherandbaby

Thebirthcenter.com

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 7

Conceptofpractice–infantsided§ 10,000repetitionstobecomeproficientinanewskill§ Needtopracticefeedingatthebreasttolearnnewwaystobreastfeed§ Practiceneedstobeofappropriatenotinappropriatemovementpatterns§ Howmanytimesperdayshouldbabybebreastfeeding?§ Forhowlong?

§ Useexternalsignsofdrinking-nottimetomakedecision

Conceptofpractice–mothersided

§ Mothershavea“motorprogram”forlatchorpositioning§ Fromtimewiththisbabyorsiblings

§ Repeatssamenon-functionalwaystolatch§ Needstolearnnewmotorpatterns–newwaystoassistthisbaby§ Timemanagementforallfeedingtasks§ Breastfeeding,pumping,otherchildcare

§ Treatmentplanneedstoberealistic

Oralbasedmotortreatment§ Rangeoftreatmentmodelstodevelopspecificoralmovements§ Understandthespecificoralcomponentsneeded§ Notageneralizedapproach§ Oralmotortreatmenttechniques§ Neurodevelopmentaltreatmentforhead/neckandposturalcontrol§ Oralfacilitationforstability

•  Beckman,D,2012

Flowaltersmotorpatterns§ Suckingpatternschangeinresponsetochangesinflowrate–sensorystimulusofflow§ Varywith-stageoflactogenesis–duringabreastfeeding§ Betweencontainers–breast/bottle/cup

§ First4dayspostbirthintermbaby§ Morerapidsuckingrate,longersuckingpauses,strongersuckingpressures

§ Asmilkonsetoccursandestablished-suckingpatternchanges§ Slowerrate,longerburstduration

Flowasalearningstimulus§ Manybabiesreliantonspecificsensoryconditionstoproduceappropriatemovements§ Observecompressivepatternpre-MERorbetweenMER’s§ Developsmoresuctionduringactivemilkflow

§ Ifbabyisatbreastinmostlylow-flowconditions§ Perpetuatestheuseofdysfunctionaloralpatterns§ Maternalsequelaecontinue–pain,nippletrauma,dec.milksupply§ Developdysfunctionalinfantbehaviors–resistancevs.learnedhelplessness

§ Motherinternalizesbaby’spatternasappropriate

Flowforremediation:maternalflowpatterns§ Understandhowmother’sinherentMERpatternmesheswithinfant’ssuckingabilities§ Withinonemother–patternofmilkejectionissimilarfeedtofeed§ Betweenmothers-variabilityoftypeofpatternofmilkejection§ DurationofasingleMERandintervalbetweenoneMERandthenext§ Canalterqualityofinfantsuckingpattern§ Beyond1stMER–caninfant’ssucktriggersubsequentMER’s

•  Primeetal,2011,2012

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 8

Milkejectionpatterns

ADiscrete,few(24%)BDiscrete,many(44%)CNon-discrete(24%)DPulsatile(8%)

•  Primeetal.2011

Usingmaternalflowpatternstherapeutically

§ Havingbabyatthebreastonlyduringmaternalletdown§ Ifactiveflowimprovessuckingpattern

§ Helpingmother’sidentifyingdrinkingfromnon-drinkingpatterns§ Drinking=longslowsucks,1-3sucks:swallow§ Notdrinking=shortfastsucks,4+sucks:swallow

§ Assistwithmilkflow§ Breastcompression/massage§ Switchnursing

Addingflowatthebreast

§ Externalflowdevice–manytypesofdevices§ Wantasystemthatcandeliverhigh&consistentflow§ Timingofuseofaddedflow§ Rightfrombeginning–allthetime§ Nursethroughfirstlet-downthenadd

§ Wantbabytospendmajorityoftimeatbreastusingappropriatesuckingpattern§ Usetimeatbreastwisely–timemanagementformother

Otherfactors:TTisaredherring§ #1-DifferencesinCNSfunction–“true”motordelaysorabnormalities§ #2–Swallowingdysfunction§ Releasemayimproveswallowbutnotalways§ Primaryswallowingdysfunction§ Notsecondaryandrelatedtoanatomy§ Signsofswallowingdysfunction:§ **feedingrefusal–mixedfeedingsignals§ Incoordinationofs/s/b§ Congestionduring/afterfeeding§ Shortfeedingsessions–suddenlystoppingfeeding§ Dreamfeedings–feedingbetteroronlywhenasleep

Howtonguetieeffectsswallowingfunction

§ Idea#1–Shortened/tetheredextrinsicmusclesimpedehyoidmovement§ Hyoidpulledupwards&doesn’tdropforairwayprotectionduringtheswallow

§ Idea#2–tongueplaysimportantroleinboluspropulsion§ Speedofbolusassistswithswalloworganization&airwayprotection§ Havedecreasedanterior/posteriormovementofthebolus§ Posterioraspectoftonguedoesnotgiveadequate“push”&momentumtobolusenteringpharynx

Afterfrenotomy–whydon’tthingsimprove

§ Presenceoftonguetieduringfetaldevelopmentaltersanatomyinwaysthatareunchangedafterclip§ Dysfunctionalmotorpatternsarepracticed§ Synapticdevelopmentoccursaccordingtothesedysfunctionallines§ Amotorprogramislearnedthatincorporatesthesedysfunctionalpatterns§ Thecontext–theenvironmentthatincludeduniquequalitiesofbothmother&baby–reinforcesthedysfunctionalmotorpatterns

RobinP.Glass,MS,OTR/L,IBCLCPFAMarch2019 9

“Developmentisaboutcreatingsomethingmoreoutofsomethingless.Inhumandevelopment,everyneuralevent,everymovement,everysmileandeverysocialencountersetsthestageforthenextandthereal-timecausalforcebehindchange.”

Smith&Thelen,2003