A Perfectly Imperfect Breastfeeding Journey

Kristen Nemoto Jay


Dr. Juliana Hsu outside of the First Smiles Pediatric Dentistry office, located in Mānoa Marketplace.
Dr. Juliana Hsu outside of the First Smiles Pediatric Dentistry office, located in Mānoa Marketplace. (Photo by Brandon Miyagi)

I remember the day my daughter’s tongue and lip ties were “released,” a procedure that happens to a lot of babies who have a hard time breastfeeding. It was the morning of Wednesday, Dec. 9, 2020. I was sitting outside of First Smiles Pediatric Dentistry in Mānoa Marketplace. My husband ‘Iwi was inside the office, checking us in for our daughter’s appointment with pediatric dentist Dr. Juliana Hsu. My daughter, Winter, born just two and a half weeks prior at Adventist Health Castle, was sound asleep in my arms from the car ride. As I sat and waited, tears streamed down my face, anxious and scared for my tiny baby’s fate, which would soon be in the hands of a complete stranger.

A week and a half prior to this appointment, my lactation consultant and Winter’s pediatrician advised my husband and me that there may be something that needs “fixing” in our breastfeeding journey. It was a week into Winter’s birth and she wasn’t gaining enough weight. To top off the concern was the immense pain I felt each time I tried to breastfeed. Shards of paper-thin glass is the only clear description I can think of to explain the immense pain I felt each time my little human fed at my breast. I thought it was “normal” yet desperately prayed for some kind of cure to make it less so. I wanted to breastfeed, that was in my birth plan at least, but not if it meant my life would equate to holding up ice cubes to my nipples every couple of hours and constantly washing blood-stained nursing pads and bras.

The lack of sleep due to a crying and hungry baby while still trying to exist as a human and take care of the wounds from my natural childbirth — which required stitching — created this horribly bundled package of misery that made me feel so very bad about being a first-time mother. Being a mom was a role I’d been waiting for since forever yet I couldn’t enjoy any of it due to my physical state and constant obsession of whether my baby was getting enough milk; a process I thought would come naturally soon after I gave birth. It was when my lactation consultant pointed out that breastfeeding is not supposed to hurt, does not come naturally for many, and that there were options we could do to fix the problem is when I started to ask the questions on how to make it better.

“What’s most important is that you understand it’s not and should not be all on you,” said Julee Portner, my former lactation consultant from Kahala Pediatrics, during Winter’s one-week check up and when I first expressed concerns about my difficulty in breastfeeding. “You are doing the best that you can and that is more than enough.” Portner’s words of encouragement soothed me and opened my lens to accepting more help. When various other methods on how to make breastfeeding more comfortable were not working — such as paying close attention to Winter’s “hunger cues” and positioning her to get a better “latch” — Portner then suggested Winter’s tongue and lip ties could be “released” to allow better movement of the tongue and its ability to suckle.

“What and what?” is all I remember repeating back, assuming my lack of understanding what a lip and tongue tie was due to my current state of sleep deprivation. She further explained that some babies’ tongues have a tight band of tissue known as the frenulum or frenum, that tethers the tongue to the floor of the mouth. The condition is called ankyloglossia, which can affect how a child speaks, sleeps, eats and may interfere with breastfeeding. A lip tie is a similar condition in which a band of tissue connects the upper lip to the upper gum. A tongue and lip tie can cause ongoing health problems due to the restricted movement of the tongue or lip. When a tongue or lip tie is “released,” it most usually refers to a surgical procedure called a frenectomy, where the frenum is cut with scissors or “lasered” away by a pediatric dentist or Ear Nose and Throat (ENT) doctor. According to Dr. Hsu, laser is the optimal method for infant frenectomy because it allows better visualization for a complete release of the frenum. By utilizing a specialized laser, the band of tissue that connects the tongue to the floor of the mouth (lingual frenum) and the upper lip to the upper gum (labial frenum) is lasered away, which releases the fascia fibers and corrects problems that arise due to the tongue or lip tie conditions. 

In my case, the recommendation from Portner for Winter to get checked by a pediatric dentist whether a tongue and lip tie release would help was due to my difficulty and pain in breastfeeding. Desperate and tired, I agreed to the consultation with Dr. Hsu, one of Portner’s known pediatric dentist contacts, despite the fact that I hadn’t known anything about the procedure prior and what it would entail.

“I remembered you both,” said Dr. Hsu in a recent Zoom call from her home in Kaka‘ako. “Yeah, you both looked very concerned but were open to learning which is so important for this procedure.”

Dr. Hsu, a Washington state native, has been performing frenectomies soon after she became a pediatric dentist when a friend of hers was having a hard time breastfeeding and asked her opinion if her baby should get a frenectomy done.

Dr. Hsu with her parents, father Tsu-Liang Hsu (left) and mother Lein-Chun Shaw Hsu (right) on graduation day from Tufts University.
Dr. Hsu with her parents, father Tsu-Liang Hsu (left) and mother Lein-Chun Shaw Hsu (right) on graduation day from Tufts University. (Photo courtesy of Dr. Hsu)

“I initially said no because I thought it was unnecessary,” said Dr. Hsu. “Thinking in line with ‘less is more’ motto because although it was uncomfortable, she was still able to breastfeed.” When her friend decided to opt for the surgery and felt a tremendous difference in the baby’s ability to suck and fully empty out the breast, Dr. Hsu was intrigued to learn more about the procedure.

Dubbed a “forever student” by her mother, Dr. Hsu is a graduate of Tufts University School of Dental Medicine. After she completed a general dentistry residency in Fresno, California she moved to New York to work with children and adults with developmental disabilities at the Rose F. Kennedy Center. Dr. Hsu also worked with patients affected by cancer at Memorial Sloan-Kettering Cancer Center, where she completed a fellowship in dental oncology. She then attended the University of Michigan where she received her masters in pediatric dentistry. Prior to joining First Smiles, Dr. Hsu worked in a private practice in New York and then the San Francisco Bay Area. She is a board-certified pediatric dentist, a member of the American Academy of Pediatric Dentistry, and a certified lactation education counselor. A classmate of hers got her in touch with a friend in Hawai‘i who was looking for someone to cover his shifts when he went spearfishing. Dr. Hsu then came to O‘ahu frequently until she packed up her life and moved permanently since 2018. She then joined First Smiles Pediatric Dentistry after getting introduced to Dr. Emily Bordner through a friend. She’s been performing frenectomies for several years and lost count of how many procedures she’s done after the first couple of hundred. However with so many frenectomies that she’s performed, it’s a wonder why so many mothers don’t know about it. Myself included.

“I think the more mothers, lactation consultants, pediatricians, and pediatric dentists learn about the benefits of this procedure the more awareness there will be,” said Dr. Hsu who noted that the guidelines for tongue and lip tie and frenectomy procedures were only recently implemented within The Reference Manual of Pediatric Dentistry in the last few years. “They teach you about [tongue and lip ties] but not in depth while in school. But the more I learned about tongue and lip ties, and its effect on so many aspects of a child’s development, the more I wanted to learn.”

Soon after Dr. Hsu’s friend showed much improvement in her breastfeeding journey after the baby’s frenectomy procedure, Dr. Hsu immersed herself to learn more about tongue and lip ties. She started working with and learning from other clinicians who performed tongue and lip ties, sought out mothers whose babies had the procedure done, and researched through materials and articles to learn more. What she discovered in her findings was an array of benefits that the baby and child showed after their tongue and lip tie were released. A child or baby’s quality of sleep got better, speech issues were nearly resolved, former troubles in swallowing milk and food quickly improved, which opened up many other avenues of a baby and child’s overall development.

“Some older children that I see who have a tongue tie and then go through this procedure are able to have more confidence in themselves,” continued Dr. Hsu. “For many it’s embarrassing because of speech problems they have or they can’t sleep well so sleepovers are almost nonexistent. This gives them an option to correct those problems if the family chooses.”

The procedure is especially helpful when a baby has trouble breastfeeding. More often than not, when Dr. Hsu asks mothers of older children — who come in to have a frenectomy performed — if they had trouble breastfeeding when their child was a baby, majority will say that they “didn’t produce enough milk.” While that is partially true, Dr. Hsu says, it may be because the baby didn’t have the right latch, or there’s a restriction in the tongue’s ability to move freely. So if a baby is not able to feed successfully and empty out the breast, the mother’s body then believes it doesn’t have to produce as much milk, therefore causing the milk production to slow and eventually wean off completely. She also notes that because we live within a world where formula is easily available and that some mothers do not know about utilizing a lactation consultant or learning about breastfeeding in general until it’s too late, Dr. Hsu is not surprised by the current lack of knowledge of tongue and lip tie awareness. Current stressors of societal pressure for mothers to heal their postpartum bodies and go back to work quickly is also another factor why many become discouraged and stop breastfeeding altogether. Though Dr. Hsu encourages all mothers to pick what’s best for their family situation as she understands breastfeeding is not for everyone, she stresses that having breastfeeding struggles does not mean there’s a “deficiency in their ability to be a mom.” That there’s a “learning curve” in everything, especially breastfeeding.

“Nobody is born knowing how to breastfeed,” said Dr. Hsu adamantly. “It really just depends on the anatomy of the baby and the mother. All babies have frenums and some are able to breastfeed successfully and some are not … It depends on the flexibility of their tissue and whether their frenum is long enough to allow the tongue to move freely. So it’s really important to work with a lactation consultant if breastfeeding is the journey for you and your family.”

An avid hiker, Dr. Hsu is happy to call O‘ahu home.
An avid hiker, Dr. Hsu is happy to call O‘ahu home. (Photo courtesy of Dr. Hsu)

Once the decision is made for a baby to get their tongue, lip, or both ties removed, an appointment to have a consultation with Dr. Hsu at First Smiles Pediatric Dentistryis recommended. Dr. Hsu will then examine the baby’s mouth and then give her recommendation on whether the tongue or lip tie release would help. If a parent or guardian agrees to the frenectomy right then, Dr. Hsu will have the parents wait outside while she performs the procedure. A numbing cream is first placed on the baby’s area that will be lasered. While Dr. Hsu’s dental assistants help make the baby comfortable and adjust what’s needed to perform the procedure, Dr. Hsu quickly lasers the frenum connecting either the tongue, lip or both. The laser doubles up to release the fibers but also cauterizes the wound so that bleeding is minimal to non-existent. The procedure is fast — quicker than it takes for the numbing cream to set in — and the benefit can be nearly instant when a baby breastfeeds, which Dr. Hsu reserves more than enough time for a mother to do so after the surgery. That’s what I felt soon after Winter’s procedure. 

And though it didn’t seem like it at the time of our daughter’s appointment, a frenectomy is actually “easy” compared to the aftercare. The aftercare is the most crucial part to the success of the procedure. Before and after the frenectomy, Dr. Hsu will reiterate the importance of the exercise “stretches” that must take place in order for the tissues to remain separated. For tongue tie stretches, while the baby is lying down and facing the opposite direction of the person doing the stretching hovering above, one will place two fingers inside the baby’s mouth and press down and pull back the tongue so that it folds almost entirely back and helps stretch the wound out. Lip tie stretches are similar in that the top lip is lifted back so that the lip and top of the gum shows complete separation. This is done six times a day for a month and possibly longer, depending on the pediatric dentist’s recommendation. It’s the hardest and most heartbreaking part, as your baby will scream in discomfort (the wound is equivalent to a cold sore), but the result may create a complete turnaround in the baby’s mouth and tongue’s ability to breastfeed. If the stretches are not done, the tissue will grow back sometimes stronger and tighter than what it was before. With Dr. Hsu and her team’s help and guidance through our before and after care of Winter’s frenectomy, I was able to continue breastfeeding and pumping for my daughter until she was 17 months old. I even had an oversupply of milk, which allowed me to pump and save a back stock of breastmilk in our freezer; our soon-to-be toddler’s current morning and night time drink of choice.    

What also makes a tremendous difference in a mother’s breastfeeding journey is having a great partner to help them through it. Whether it be a spouse or a family member or a friend, having support will help mothers get through the hard moments. Flashback to the day we took our daughter to get her tongue and lip tie released, my husband, my steady rock and righthand man, was my then (and still to this day) appointment maker, dishwasher, chef, grocery shopper, bottle scrubber, pump assembler/desembler, Hydroflask refiller, house cleaner, driver, night nurse, and so much more. For partners of mothers who are currently expecting, Dr. Hsu says their collaboration is critical to the overall success of a mother’s breastfeeding journey. Whether it be taking on the reins of making all the doctor appointments or washing all the bottles and pump parts and having them ready every time a mother needs them, Dr. Hsu says it’s important for the partner to empathize and realize that they’re needed more than ever during a mother’s postpartum. And if anything, she said, fathers make the best “stretchers.”

Baby Winter Jay (12 months) with her parents 'Iwi Jay and Kristen Nemoto Jay.
Baby Winter Jay (12 months) with her parents ‘Iwi Jay and Kristen Nemoto Jay. (Photo by Illuminate Photography)

“I’ve had some dads come in and say ‘I can’t do this, my fingers are too fat!’” exclaimed Dr. Hsu with a hearty laugh. “But I tell them ‘Oh no, don’t worry, you will be fine’ and also remind them that ‘they’re not getting out of this one.’”

If given the choice to do it all over again, the breastfeeding and lip and tongue tie release, I would. I would have also accepted help a lot sooner. For me, breastfeeding was the hardest part about being a mother. It was actually harder than my labor experience. Being in labor — though was a grueling 19-hour long marathon with no epidural — was a piece of pie compared to breastfeeding. Because after I gave birth, my labor was over. The contractions (though reemerged in the beginning months of breastfeeding) stopped and resulted in a beautiful baby. Breastfeeding, if a mother chooses that route, is constant. It’s every two to three hours, sometimes one hour or every five minutes, with sleep that lasts not much more than the baby’s next demand for milk. And if a mother continues to breastfeed until the American Academy of Pediatrics’ recommended time of six months to a year, you’re talking about a near full-time job that’s dedicated to nursing. It’s no wonder why many women stop or have to stop due to their other lists of demands. For myself, because my husband and I were “lucky” to be able to work from home during the pandemic, I was fortunate to be able to pump or breastfeed in the comfort of my home. Overall, with the help from my husband and our entire support system, which consisted of Dr. Hsu, Portner, both our parents and extended family members, our daughter’s pediatrician Dr. Joseph Ward, my obstetrician Dr. Heather Awaya, and my former editor Jodie Chiemi Ching, my breastfeeding journey had become the most rewarding experience of my life. I owe our daughter’s ability to have my breastmilk for this long to them, which I cannot fully express how grateful I feel. 

To all the mother’s reading this story who may be experiencing their own breastfeeding journey, know that you are not alone and that there are many people willing to help you should you need it. There’s also a reason why you’ve been tasked with this role. You are one tough mother and don’t you forget it.

For more information about First Smiles Pediatric Dentistry, call 808-988-2636 or go to firstsmileshi.com. 


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