Associate Professor Donna Geddes - All tied up
An interview from the Medela Breastfeeding and Lactation Symposium with Associate Professor Donna Geddes about what the evidence says about tongue tie. Donna discusses the intense focus of tongue tie as a contributor to breastfeeding problems is reflected in the drastic increase in diagnoses and treatment.
Associate Professor Donna Geddes
Donna Geddes, DMU, is Associate Professor in the School of Chemistry and Biochemistry at the University of Western Australia. She is Senior Research Fellow, directing one of the most prestigious human lactation research groups in the world, founded by Emeritus Professor Peter Hartmann.
A Prof Geddes is internationally renowned for her novel work with ultrasound imaging, which has revolutionized our understanding of: the anatomy of the lactating breast; milk ejection and blood flow in the breast; infant sucking technique; infant suck-swallow-breathe co-ordination; infant gastric emptying; and the body composition of both the term and preterm infant. Her current research also delves into the composition of human milk and its impact on the growth and body composition of breastfed infants, the investigation of HM metabolites, and the effect of storage conditions on milk. She has published 98 peer-reviewed papers and 11 book chapters. She has received over 7 million dollars in research grants as principal investigator, and is currently supervising four Post-Doctoral Fellows, five PhD students and two Masters Students.
Donna has received several awards, including the Healthy Children Faculty Award (2007), the Early Career Research award from the International Society for Research in Human Milk and Lactation (2008) and the Certificate of Distinction for Innovative Research from the Raine Medical Research Foundation, Perth (2008) in recognition of her contribution to scientific research. She is a member of the Editorial Board for Breastfeeding Review and Secretary for the International Society for Research in Human Milk and Lactation.
Abstract #1: All Tied Up: what does the evidence say about tongue tie
“The treatment of tongue tie is controversial” is probably the understatement of the year! The intense focus of tongue-tie as a contributor to breastfeeding problems is reflected in the drastic increase in diagnoses and treatment. This trend is mirrored by the exponential rise in the number of published articles on tongue-tie in the past 5 years. Unfortunately, two thirds of these publications are considered low impact, in that they are reviews, editorials and opinions (1). This somewhat reflects the conundrum of the clinician where few strong research studies have been carried out that can be translated into practice. Whilst some randomized controlled trials (RCT) have been carried out they suffer numerous issues such as ethical considerations resulting control groups being offered or requesting frenotomy, making them less robust according to scientific requirements (2). It is also widely acknowledged that it is difficult to accurately and reliably measure, grade or assess the functional impact of tongue-tie in breastfeeding infants making the interpretation of the RCTs difficult. Indeed, our initial study of the effectiveness of frenotomy in tongue-tied babies, nearly all babies would be classified as having an anterior or classical tongue-tie (3). Both prospective and retrospective audits have great value in monitoring practice however we must recognize they are biased to the clinician’s skill and expertise in diagnosis and treatment, so unfortunately do not represent clinical practice in the whole population.
Breastfeeding is a complex relationship that is influenced by both maternal and infant physiology and behaviour. At UWA, in our research programme, we endeavour to measure as many aspects of these areas as possible (3). For example, we measure breastfeeding behaviour and milk production with 24-hour test weighing (4) in the mother’s home. This allows us to determine if the mother already suffers low production and whether the infant is effective or efficient at removing milk from the breast. We also incorporate validated pain scores (5), breastfeeding self-efficacy and extensive demographic questionnaires into the assessment to objectively measure outcomes. During monitoring at the lab we measure sucking pressure and use real time ultrasound simultaneously (6) to image movement of the tongue. Most recently we have embarked upon a study that also measures the tongue-tied infant’s suck-swallow-breathe patterns pre- and post-frenotomy, which is then compared, to a prospective control group.
Using a multifaceted research approach, we are endeavouring to unravel the complexity of the of tongue-tie and determine the impact on breastfeeding.
(1). Bin-Nun A, Kasirer YM, Mimouni FB. A Dramatic Increase in Tongue Tie-Related Articles: A 67 Years Systematic Review. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 2017;12(7):410-414.
(2). O'Shea JE, Foster JP, O'Donnell CP, et al. Frenotomy for tongue-tie in newborn infants. The Cochrane database of systematic reviews. 2017;3:CD011065.
(3). Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-194.
(4). Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006;117(3):e387-395.
(5). McClellan HL, Hepworth AR, Garbin CP, et al. Nipple pain during breastfeeding with or without visible trauma. Journal of human lactation : official journal of International Lactation Consultant Association. 2012;28(4):511-521.
(6). Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. Tongue movement and intra-oral vacuum in breastfeeding infants. Early human development. 2008;84(7):471-477.
Associate Professor Donna Geddes - All tied up
Abstract #2: The wide range of normal breastfeeding patterns and milk production
The most common reason cited by mothers for ceasing exclusive breastfeeding is a perception of insufficient milk supply. This perception is based on the mother feeling that her infant is not satisfied after breastfeeds, her concern that her infant is not attached and sucking well during breastfeeding, and/or that her infant is feeding too often or too quickly. Perceptions can be confirmed or refuted by objective measurements. Objective measurement of 24-h milk profiles involves the mother using accurate digital scales at home to weigh the fully-clothed infant before and after every breastfeed for a 24-26-hour period (1). This allows calculation of the number, duration and amount of milk consumed by the infant at breastfeeds, and total milk production. Comparison of individual data with a reference range can establish whether or not the breastfeeding parameters are within normal limits.
We have used the 24-h milk profile technique to gather data from 71 mothers who were exclusively breastfeeding at the breast healthy term infants 1 to 6 months old (2). This has demonstrated that there is a wide range in breastfeeding parameters, with infants taking milk from the breast 6 to 18 times per day, as 4 to 13 breastfeeding sessions (1, 2 or 3 breasts per session). On average they took 30 to 135 mL of milk from each breast during each breastfeed, or 54 to 234 mL per breastfeeding session; and on average a breastfeed lasted 5 to 37 minutes, and a breastfeeding session lasted 12 to 67 minutes. The daily milk intake of these infants, who were growing normally, was 478 to 1356 mL (2). An awareness of this wide variation in these breastfeeding parameters may allay some of the concerns expressed by mothers and give them more confidence in their breastfeeding. It is recommended that a reference range be based on data from at least 120 healthy reference subjects (3). As such, the existing data need to be extended to provide a reliable objective tool that will complement clinical assessment of the breastfeeding dyad. We have recently used the same technique to gather data from a further 62 exclusively breastfeeding dyads and confirmed the wide range in all these parameters. We aim to continue recruitment until we have data for 400 dyads.
The critical time for establishing breastfeeding is the first 2 weeks after birth (4, 5). Infants should have regained their birth weight by the second week of lactation (6), and if this has not occurred an objective measurement should be made of the mother’s milk production and the infant’s milk transfer at the breast. It is agreed that full milk production is reached by 4 weeks after birth, but it is of clinical importance to know the expected milk production in early lactation. We have shown that within 2 weeks of birth 55% of 116 mothers who measured their 24-h milk profile between 6 days and 4 weeks after birth had a milk production within the normal range for established lactation, even though the majority (103) perceived that they had breastfeeding problems. Those whose breastfeeding milk production was within the normal range gave 7 to 24 breastfeeds per day. On average the infants took 22 to 133 mL of milk from each breast during each breastfeed, and on average a breastfeed lasted 7 to 35 minutes. Among mothers whose breastfeeding milk production was below the normal range there was no significant difference in the frequency or duration of breastfeeds, but the amount of each breastfeed was significantly lower (2 to 51 mL).
Objective measurement of 24-h milk profile, both in early and established lactation, can be compared with a substantiated reference range to either reassure mothers, or provide evidence to guide clinicians in the management of the lactation.
(1). Arthur, P. G.; Hartmann, P. E.; Smith, M. Measurement of the milk intake of breast-fed infants. J Pediatr Gastroenterol Nutr 1987, 6, 758-763.
(2). Kent, J. C.; Mitoulas, L. R.; Cregan, M. D.; Ramsay, D. T.; Doherty, D. A.; Hartmann, P. E. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics 2006, 117, e387-395.
(3). Katayev, A.; Balciza, C.; Seccombe, D. W. Establishing reference intervals for clinical laboratory test results: is there a better way? Am J Clin Pathol 2010, 133, 180-186.
(4). Hill, P. D.; Aldag, J. C. Milk volume on day 4 and income predictive of lactation adequacy at 6 weeks of mothers of nonnursing preterm infants. J Perinat Neonatal Nurs 2005, 19, 273-282.
(5). Hill, P. D.; Aldag, J. C.; Chatterton, R. T.; Zinaman, M. Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth. J Hum Lact 2005, 21, 22-30.
(6). Tawia, S.; McGuire, L. Early weight loss and weight gain in healthy, full-term, exclusively-breastfed infants. Breastfeed Rev 2014, 22, 31-42.