What is Infant Tongue Tie?

Infant tongue tie is something that has come to light in the past few years as more and more of us mommies are breastfeeding our babies. I have been getting questions at an increasing rate on this topic. Does my baby have tongue tie? Is it a problem? Do I need to do something about it?


What is tongue tie?
Tongue tie is when the tip of the tongue is attached to the floor of the mouth. There are varying degrees of tongue tie from minimal attachment to the full length of the tongue being attached to the floor of the mouth.

What problems can it cause?
In infants, it can cause difficulty feeding/latching and for momma, it can cause nipple pain upon feeding.

Do I need to do something about my infant’s tongue tie?
This is the process I use to decide if my patients are candidates for the surgical procedure to relieve the tongue: I ask parents if it is causing a problem?” If the parents say no, it is usually something they have noticed visually and not noticed problems. These children are not a candidate. If the parents say “yes,” then I ask what problems they are experiencing. If the parents say the child has colic or gastric reflux and is fussy, they are not typically a candidate. These issues are best brought up to the child’s pediatrician and once GI issues have been ruled out, they may be a candidate. If the parents say the child is having difficulty eating, is in a low weight class, or the mom is having pain on feeding, then the surgery may be helpful. Notice, I said MAY be helpful. This is the controversial part! Scientific research has found a correlation between the surgical removal of the attachment and better feeding/less nipple pain. Is it a relatively harmless procedure? Yes. Is the recovery difficult? Not typically. Is it helpful in some cases? Yes. Is it 100% effective? No. Am I going to recommend it to all of my patients with tongue tie? No. A serious discussion needs to occur between the provider and the parents where the pros and cons of the procedure are weighed to determine if it is the right course of action. A good clinical evaluation is important. Sometimes the tongue is not the main source of the problem. Occasionally, the top lip can be attached firmly and is not allowing the baby to latch effectively.

Who performs this type of procedure?
Due to its controversial nature, only a select few doctors perform it. The best place to start in most cases is a lactation specialist. Although they do not perform the procedure, usually they know who in your area does. Among the list may be Ear, Nose and Throat physicians, Neonatologists, Periodontists (dentists who specialize in gums), Pedodontists (children’s dentist), and Oral Surgeons.

What does the surgery entail?
There is a section of gum tissue under the tongue that attaches to the floor of the mouth. This tissue is called a “frenum” or “frenulum.” The frenum is cut with either scissors, a scalpel, or a soft tissue laser to allow the tongue to move freely. Sometimes it is necessary to place stitches to allow the tissue to heal, but it is not always required.

Will my baby have to be put to sleep?
This depends on the surgeon you are using. Typically these babies are less than 6 months of age and general anesthesia is not required. Some ENT physicians may combine this procedure in with another surgery, for example, if your child also needs ear tubes. Most of the time, these procedures can be completed with your baby awake.

Will my child feel pain?
Babies are like adults. They do feel pain just like anyone else. But, there are risks to giving infants numbing medication because they are so small, and it is easy to give them too much. Some practitioners are of the school of thought that the child will not remember the procedure, so they do not give the baby numbing medicine. This is a topic to discuss with your surgeon and decide how you would like to proceed.

What is the recovery like?
Typically, following the procedure, the provider will give the baby to the mom to begin breastfeeding and help soothe the child. Yes, unless your child was put to sleep, your baby will scream throughout the procedure. This is normal and is not necessarily indicative of pain. Most babies do not like to have their mouth messed with, and their only known way of responding is to cry. Before you leave with your baby, you may be given instructions to do tongue and lip exercises at home. Typically the surgeon will schedule a follow up exam a week to a month following the surgery. This will allow them to monitor the healing and make sure the procedure was successful. In the meantime, Tylenol/Motrin can be used for any post-operative pain unless the pediatrician recommends otherwise.

I hope this is helpful and not overwhelming. I am attaching links to this post with more information on the topic.

http://www.aapd.org/assets/1/25/kupietzky-27-1.pdf

https://www.ncbi.nlm.nih.gov/books/NBK299106/

Can My Baby Use Orajel for Teething Pain?

Orajel is a topical numbing agent that’s uses range from relieving pain from canker sores, tooth and gum pain, as well as for cold sores.  The active ingredient in Orajel is 20% Benzocaine which is a topical local anesthetic (pain reliever).  Some formulations also contain Menthol which is obtained from mint oils.  Menthol increases blood flow to the area and provides at cooling sensation. 

Benzocaine has been used for decades to relieve oral pain temporarily.  Dentists most commonly use it to place on their patient’s oral tissue prior to an injection of numbing medicine.  How does it work?  Pain is caused by stimulation of specific types of nerve endings.  Benzocaine stops the nerve from being stimulated temporarily by blocking the uptake of the molecule that stimulates the nerve.

Like any drug, we must be aware of its potential side effects, especially when we are talking about young children.  It is generally safe and non-toxic when applied topically.  So, what’s the problem?

Benzocaine has been associated with an uncommon, but serious condition called Methemoglobinemia (pronounced Met–hemo– globe-in-emia).  I found out it was one of my husband’s pet peeves when it is called METH-hemoglobinemia.  To avoid a lengthy and yawn-inducing discussion over its chemical formula, and why it is called METhemoglobinemia, I am stressing its pronunciation.  Please!  Not again!

I will try to keep my “sciency stuff” to a minimum.  Bear with me.  Let me start with explaining what hemoglobin is.  Hemoglobin is the oxygen carrying molecule in red blood cells.  It delivers oxygen to the tissues in the body.  The oxygen bond with hemoglobin is not strong.  Some may say, it’s down-right weak!  It sounds terrible, but it is actually a great thing.  The weak bond of hemoglobin is what allows oxygen to be released to the oxygen-depleted tissues.  Methemoglobin is a different chemical formula of a hemoglobin molecule that binds strongly to oxygen, thus not allowing for its release to the body.  When this occurs, the body is unable to function well due to the decreased oxygen availability.

What is methemoglobinemia?  When benzocaine is applied to the tissue and is absorbed into the blood stream, it can convert normal hemoglobin to methemoglobin and cause an oxygen depletion.  It has been found to be severe, especially in children ages 2 and younger.  Unfortunately, this age group most often suffers from teething discomfort.

What are the symptoms of methemoglobinemia?  Pale, gray, or blue skin color, shortness of breath, fatigue, headache or lightheadedness, and rapid heart rate.  These symptoms can occur in minutes to hours after Benzocaine’s application.

What is the treatment to reverse methemoglobinemia? The child would be placed on oxygen and given a substance called methylene blue through an IV.  The improvement is typically rapid.

Methemoglobinemia is well known by the Orajel company, so they have come out with a children’s version without Benzocaine.  In fact, they have two kinds: daytime and nighttime teething gel.  It is called Orajel Non-medicated Cooling gels for Teething.  The active ingredient in the daytime gel is Simethicone.  It is commonly used to relieve colic in babies.  Simethicone drops allows for smaller gas bubbles to come together in the stomach and become one big bubble to aid in the baby burping.  I have been unable to find how it aids in relieving teething pain.  The nighttime active ingredient is chamomile in addition to the simethicone.

I love a good cup of tea and chamomile is one of my favorites, but I also have the unfortunate quality of being a skeptic when it comes to homeopathic remedies.  Some research out of the University of Michigan supports the use of crushed chamomile tablets mixed with water and given in a dropper to your child can relieve diarrhea associated with teething.  Many herbalists suggest that chamomile has anti-inflammatory and calming properties to alleviate teething pain, but currently there is not enough research I have found to prove or disprove this theory.  The bottom line is, chamomile has not been found to be harmful for children.  One way that it can be used is by making a cup of chamomile tea, dipping a corner of a washcloth in the tea then freezing it for your child to chew on.  The rule of thumb with anything is “Everything in Moderation.”

References:

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-reports-rare-serious-and-potentially-fatal-adverse-effect-use-over

http://www.med.umich.edu/yourchild/topics/paininf.htm

When Will My Baby’s Teeth Come In?

Jane at 6 months

Those sweet, gummy smiles!  I, personally, cannot get enough of them, but at some point, we hope the teeth start to come in.  Teeth serve many purposes: they can aid in chewing food, developing the child’s speech, give soft tissue support for an aesthetic profile, direct the permanent teeth in their eruption, and aid in the growth and development of the jaws. 

On average, the first tooth comes in around 6 months of age.  Conveniently enough, this is the time that babies begin eating solid foods.  The typical pattern is the front four teeth on top and bottom come in first, followed by the first molar.  Next is the canines (the pointy teeth made popular by Dracula) and lastly, the second molars in the very back.  The teeth continue to erupt until the child is 2-3 years old.  There is a total of 20 primary (baby) teeth.

I have found that teeth do not always follow the textbooks.  Many parents are concerned when teeth are not in by 6 months.  Neither one of my babies have gotten teeth before 8 months of age.  Some children get their teeth in early, but it is far more likely for teeth to erupt later.  Genetics does play a role on eruption timing, so if the teeth are being slow, blame it on your spouse!  Children that were born prematurely often have their teeth come in later than children that were born full-term. In many cases, the teeth will come in six months following the mother’s original due date.

Teeth can be termed “delayed” if the child is fifteen months of age and no teeth are visible.  At this point, the dentist can attempt to take radiographs (x-rays) to see if teeth are present in the jaws.  Blood work can also be completed by the child’s pediatrician to rule out any systemic issues.  Most cases are simply delayed, and no treatment is needed to help the teeth erupt.  It can be important to involve the child’s pediatrician if there is a suspected hormonal imbalance or an underlying issue affecting the child’s growth and development.  But until then, enjoy those sweet, gummy smiles for as long as you can!

Julia at 8 month
Julia at 9 months
Julia at 10 months
Julia at 18 months
Julia at 24 months. She is so old, she has had to resort to reading glasses!

Amber Teething Necklaces

I had the wonderful opportunity to write an article on teething for our local Parents and Kids magazine.  Nowadays, when I discuss teething, I am frequently asked about amber teething jewelry.  Until writing the article, I had not dug deep into the research to understand all the ins and outs of this topic.  I feel like I understand it so much better now!  It is easy to spout my opinion on topics, but it’s just that… an opinion.  Let’s get to the cold, hard facts!

Amber was made popular by the cult-classic film, Jurassic Park.  What a glorious plot line: cloning a dinosaur from a mosquito preserved in amber.  That is Hollywood gold right there!  For thousands of years, amber has been touted for its healing properties.  Some believe that it cleanses the body and mind, absorbs pain and negative energy, clears depression, promotes self-confidence and self-expression.

What are amber teething beads?  They are a piece of jewelry (necklace or bracelet) that a child wears to aid in teething discomfort. 

What is amber?  Amber is fossilized tree resin.

Do they chew on the beads?  The beads are not meant to be chewed on but simply worn by the child. 

How would beads help relieve teething pain?  Amber contains a substance called succinic acid.  Succinic acid is an anti-inflammatory agent.  It has been approved by the FDA and is used to treat arthritis in creams and can be used in tablet forms as a blood pressure medication and to treat migraines.  The theory behind the amber beads is that the child’s body temperature warms the beads and as the amber is warmed, succinic acid is released and taken up by the body.  Once it is absorbed into the blood stream, the succinic acid relieves pain by reducing inflammation.

Does it work?  This is where things get debatable.  There is not enough research at this point to prove or disprove if it works consistently.  Some mamas swear by these beads and some see no difference.

What is the downside to wearing the jewelry?  The American Academy of Pediatrics and FDA have issued statements discouraging children from wearing jewelry.  Necklaces can be a strangulation hazard and the beads, if broken off, can be a choking hazard.

What do the studies show?  Thanks to the invention of Google, it is easy to find a study to support just about any side of an argument.  My background is heavily research based.  In college, I conducted research with the University of Mississippi Dental School in the Biomaterials department and in dental school, I conducted separate research studies for the Periodontic department.  Once I was in my pediatric dental residency, I had to complete a research study and it was in community health.  I do not say this to brag, only to say that I have a bit of experience in this arena.  All research is not created equally, valid research takes time, is well thought out, must have the Institutional Review Board Approval (IRB), has a specific hypothesis/null-hypothesis, and typically uses other valid studies to support the findings.  All of this to say, because the FDA has found the necklaces to be a choking/strangulation hazard, the IRB has trouble approving studies where children are involved.  Some studies have been conducted using the beads in a saline solution that at different temperatures for a certain amount of time to measure how much succinic acid has been released from the beads to see if it reaches a therapeutic dose (dose high enough to relieve pain).  These studies have shown that the succinic acid is not released from the amber until it reaches a temperature of 392°F.  This is higher than body temperature at 98.6°F.

What are my options to relieve teething pain?

  1. Objects for the child to chew on: Sophie the Giraffe, banana toothbrush, frozen teethers, frozen or warm wash cloths
  2. Tylenol or Motrin

**Please do not use Orajel or Hyland’s Teething Tablets.  They can reach toxic levels quickly in infants.  I will write a full blog post on this topic in the future.

Can I Protect My Child’s Teeth Before They Are Born?

Congratulations!! You are having a baby!  I have been blessed to go through the process twice, and it is the best of times; it is the worst of times.  I do not consider myself an anxious person, but both times I was pregnant, my anxiety level increased significantly.  There was an overwhelming feeling of responsibility to take care of the precious bundle growing inside of me.  Suddenly, I was questioning things like, are the chemicals in my face wash safe for my baby and do I need to sleep on my left side or my right side?  No one tells you about these small decisions that seemed insignificant when you were simply taking care of yourself.  They begin to add stress to your day-to-day life.

Did you know that children’s baby teeth and some of our permanent teeth begin to form while he or she is in your tummy?  The teeth begin forming when the baby is only six weeks in utero!  Children’s dental health starts with the mom’s (and dad’s) dental health.  Research studies have shown when the primary caregiver has cavities, the child is more likely to get cavities.  Dental cavities are a transmissible disease.  A species of bacteria is directly linked to the formation of cavities… Streptococcus mutans if you are curious.  How would one pass cavities from one person to the other?  Blowing on your child’s hot food (guilty), drinking after one another (guilty), or sweet kisses (100% guilty).  Give those kiddos kisses and don’t stop!  But one way you can protect your child from getting cavities is to have any cavities you may have filled before your child is born.

Dental cleanings are safe and recommended during pregnancy.  Dental x-rays are safe for the pregnant woman if a lead apron is used to shield her thyroid and abdomen (although dentists may forgo taking x-rays while you are pregnant if you have a history of not having cavities or they do not see anything emergent).  Pregnancy does take quite a toll on your body.  As many women have found out, it can be tough on your oral cavity with morning sickness and the hormonal changes can affect your gums.  In my opinion, the best time to have your teeth cleaned and evaluated while pregnant would be during the second trimester.  In the first trimester, I was so nauseated, I was afraid the toothpaste flavor would make me sick, and in the third trimester, the weight of my baby bump made it difficult to lie on my back for any extended period. 

Another way to protect your child’s teeth is to eat a balanced diet with green vegetables and foods high in calcium. Taking your prenatal vitamins will cover your bases with any minerals you may be lacking. If you are suffering from morning sickness, swishing with a mixture of baking soda and water can bring the acidic level back to normal and prevent the enamel from wearing. It is important to stay hydrated, and drinking water with fluoride will aid in remineralizing any enamel that has been damaged.

Being pregnant is not for the faint of heart.  Just remember that this too shall pass and soon enough, you will have that snuggly little guy or girl in your arms and everything will be well worth it.  You may even do it a second or third time!

When Should I Start Brushing My Child’s Teeth?

Once upon a time, in a land that was so magical, it could only have been dreamt up by fairy princesses, there lived a kind, peaceful woman and her newborn daughter. This baby girl was the light of her mother’s eyes and the very center, warmest part of her mother’s heart. Together, they would sit and read stories while they snuggled and giggled for hours at a time. As the darling girl grew, the mother began to notice the child’s smile changing to a toothy grin. Of course, the mother knew exactly what to do, since it is after all in her nature. She began brushing the child’s teeth with a soft bristled toothbrush and a smear of toothpaste. The little girl laughed and laughed at how the bristles tickled her gums. This was the child’s favorite time of day, since she knew her mother would snuggle her to sleep after a long day of precious memories.
And that’s all there is to it! Lies. Lies. LIES!!!!! I am so glad to be writing this post after having had a beautiful, sweet, yet headstrong child. My answer to this question, altogether has not changed since becoming a mother, but the delivery of my answer is quite different than it was prior.
As a pediatric dentist, I strive to always follow the guidelines set forth by the American Academy of Pediatric Dentistry. When parents would ask me this question, I would tell them, “You should start brushing your child’s teeth when the first tooth erupts with an appropriately sized soft bristled toothbrush and a smear of fluoridated toothpaste twice a day, before bedtime and after the morning meal.”
As I think back to the families that I told this to, I remember the bewildered and dejected faces that read, “I have not been doing what is best for my child.” Now when I am asked the question, I ask, “What have you been doing so far?” If the answer is “Nothing,” then I tell them the guidelines and offer tips on how to start the process. Firstly, I encourage parents to use a warm washcloth to wipe the teeth and gums. I also encourage them to get a yellow banana rubber brush so the child gets used to the feel. These banana toothbrushes are great teethers and trainers, but they are not the best for really cleaning teeth. As the child gets more used the this, you can attempt a baby toothbrush with no toothpaste or with just a little dab. This can help your child get adjusted to the sensation.
Another option that has been successful with my daughter is the flavored xylitol tooth wipes. Xylitol is a sugar that has anti-cavity effects. Hallelujah! Where have you been all our lives? With that said, the wipes are just a tool I am using to get my daughter comfortable with me being in her mouth. My ultimate goal is to make toothbrushing time enjoyable.
I have found it helpful to have my daughter watch us brush our teeth. After several days of watching us, she began begging to use our toothbrushes. The thought occurred to me that she may not like her toothbrush because it is manual and not electric. I purchased her a children’s electric toothbrush that is like ours, and it has been a game changer! She loves using it, but she still does not like me brushing her teeth. I have also purchased a few toothbrushes and put them places where my daughter will be sitting for a while (car seat, in front of tv, etc…) so when she gets bored, she will play with it. With all of this said, I am still navigating the toothbrushing journey. I have goals that I want to achieve, but I will not get there overnight. Be patient with yourself. Be patient with your child. And happy brushing!

Infant Oral Healthcare

I am sorry! I have not had a chance to write specifically about Infant Oral Healthcare. I have attached a few links of the American Academy of Pediatric Dentistry on the topic. These guidelines can also be found with a Google search.

Infant Oral Healthcare:

http://www.aapd.org/media/policies_guidelines/g_infantoralhealthcare.pdf

Perinatal (while in the womb) Oral Healthcare:

http://www.aapd.org/media/Policies_Guidelines/G_PerinatalOralHealthCare3.pdf