It’s not always obvious, the tongue can look ENTIRELY normal to the untrained eye… Sometimes it’s pulled into a heart shape or the attachment may be visible on the tip of the tongue? But this is just one type, others may be missed by many health professionals, yet a hidden cause of serious breastfeeding problems. Have you guessed what it is yet? Tongue tie! (Ankyloglossia)
If you look under your tongue, you might see it is attached to the floor of your mouth with what is called a lingual frenum or frenulum. This “string” is left over tissue from facial development and typically works its way back down the tongue during pregnancy, reducing to insignificance before birth. Sometimes this doesn’t happen and ties can also occur on upper or lower lips, gums and cheeks.
If the string is too short, or tight and so restricts movement of the tongue, this is termed “tongue tie” (Ankyloglossia).
Milk Matters offer certified, insured, registered healthcare professionals to perform frenulotomy.
How Common Is It?
It seems to be a hot topic at the moment, but there are very good reasons for this. Tongue tie in early infancy is more likely to be obvious in a breastfed baby; bottle teats do not complain of compression, blister if an incorrect tongue action is used, nor does bottle supply dip as a result of poor feeding action. Even if mum finds her baby refuses the bottle or struggles with a slow flow teat, is colicky, refluxy or showing other common signs – it may never be linked to the tongue.
For decades bottle feeding was more popular than breastfeeding, and as a result many medical professionals lost their skills of diagnosing and treating tongue-tie. This means that not only are the statistics we have likely to be misleading because they only include those diagnosed, but also that mums may have trouble finding someone who can effectively recognise and treat the problem. A more recent study at Southampton suggested 10% of all babies born had tongue tie (Note as Ankyloglossia is genetic, this rate may vary area to area and country to country).
“Tongue tie often runs in families. Some relatives may only have mild effects or no apparent symptoms while others show a severe impact on structure and function. As this strong familial tendency exists, parents may also notice a similarity to other relatives with tongue tie, especially in the older child. The similarities observed may include postures of lips and tongue, habits of speech, and shapes of the nose and face.” (tonguetie.net)
In order to breastfeed effectively, a baby needs to have full movement of the tongue – they need to be able to create a seal will their lips and tongue to form a vacuum. The tongue needs to cup the breast and also be able to elevate, not only to perform a correct suck/swallow pattern (without excessive air intake), but also to undulate during feeding and create the negative pressure that = milk transfer. They need to be able to maintain this throughout the feed to trigger subsequent milk ejections.
To bottle feed well the baby needs to make and maintain a seal and move the bolus in an organised way to the pharynx for swallowing too. If not feeds can be extremely slow or very rapid and gulpy. Gaps may be visible at the corners of baby’s mouth and he may leak milk (sometimes profusely), or simply intake air with each suck resulting in excessive flatulence or trapped wind.
Not all babies with tongue tie struggle with feeding, even if easily visible it may be stretchy enough to allow the baby to feed. In this instance as the infant grows, it may not cause any further significant problems; in other cases further problems can be linked to the tie or the often resulting high palate into adulthood (as discussed later in this entry). Similarly not all problems are tongue tie, there are other factors that can hinder a baby’s ability to suck and swallow in an organised fashion (which is why it’s important to see someone thoroughly trained in oral assessment).
Ultrasound evidence shows tongue tied infants use two different distinct sucking actions. The nipple ends up in a different place in the baby’s mouth, the suck is stronger, yet transfers less milk. (most resolved completely after frenulotomy) You can read more here
- Persistent very sore or damaged/blistered nipples – however it’s important to note that there may be no nipple pain/trauma
- Compressed nipples (change in shape) and/or blanching after feeding
- Excessive weight loss or slow weight gain (may not occur if topping up)
- Difficulty establishing breastfeeding or baby refuses to latch.
- Excessive hunger/weight gain in baby
- Excessive sucking need – baby wants to feed or suck very frequently/constantly.
- Baby only swallows infrequently or swallows well for initial “milk ejection” (letdown), but then swallows become less frequent/sporadic. In young babies this may result in falling asleep quickly at the breast.
- Cannot maintain a seal at the breast/bottle, often has gaps at corners of mouth which milk may spill out from.
- Mammoth feeds – or falls asleep quickly and then wakes hungry as soon as breast/bottle is removed.
- Baby doesn’t seem satisfied after a breastfeed
- Very frequent feeds
- Fussing at the breast shortly into a feed or takes very short, fast feeds, baby may pull away and cry, arch back – bobbing on and off.
- Parents may comment they can hear air being gulped, milk hitting the tummy, or baby is a very “noisy feeder” with loud swallow sounds.
- Low milk supply
- Mastitis/blocked ducts
- Frequent hiccups
- Food intolerances due to digestive disruption
- Baby rarely/never settles to a deep restful sleep – some “catnap” and are described as very poor sleepers
- Windy/squirmy and unsettled when sleeping.
- Excessive flatulence
- Green stools
- Sucking blister on upper lip
- Latch trouble or slipping down the nipple when feeding ie as though struggling to remain attached at times- resulting in “nipple hanging”
- Clicking sound when feeding. May pop on and off.
- Disorganised suck/swallow pattern – may result in coughing/spluttering/gagging and give an appearance of oversupply. Bottlefeeding mums may note this happens even with the slowest flow teat
- Weak suck/poor sucking reflex
- Oral aversion/ increased sensitivity – frequently refuses breast and/or bottles and/or spoons. May gag frequently
- If baby led weaning, may be very slow to start solids compared to peers, may appear keen but spit rather than swallowing food (see diary of 9 month old here)
- If breastfeeding may refuse bottles/cups
- Tongue tremor whilst feeding
- Noisy breathing/snoring sounds when sleeping
- Opens mouth to attach but doesn’t, shakes head or bobs on and off before becoming frustrated
- Small mouth gape
- Gape is wider horizontally than it is vertically when crying.
- Unable to protrude tongue (some with tongue tie can, protrusion does not rule out tongue tie as the image at the top of the page highlights)
- Excessive drooling/bubbles at the mouth
- Displays stressed body language when feeding – hands up near face, fingers splayed.
- Breastfeeding requires “advanced” techniques such as nipple flipping or pin point accurate positioning which mum struggles to replicate at each feed when not assisted. Mum may feel a need to support the breast from the side to keep in baby’s mouth or he/she slips off (due to ineffective seal)
- Restricted tongue elevation when crying.
*may not always be the case if mum has an abundant or over supply. Sometimes these babies will have a much larger than average weight gain, perhaps due to obtaining larger quantities of lactose (sugar) rich first milk due to being unable to effectively release fat higher up, or maybe due to frequent feeding. These babies are more likely to slip through the system and even receive medication for the reflux/colic. Tongue tied infants present in a wide variety of ways, often not related to severity of tie.
Is Tongue Tie Painful For Baby?
Many sources state a restricted tongue is not painful for baby. However several tied adults have commented they experience a burning sensation when certain tongue movements are performed (depending upon where the tie is). Certainly many babies express discomfort when their tongue is lifted if it is tied so is it therefore safe to assume baby feels no discomfort from this restriction?
Place and hold the tip of your tongue into the gum tissue below the lower front teeth – try to swallow, eat or talk with the tongue held in this position. For those who cannot feel a difference or who adamantly oppose recommending frenotomies or frenectomies, I will send someone over to your office and suture your tongue to the floor of your mouth. After one week you will understand the significance of a tight frenum! (Brian Palmer DDS)
The Difficulty With Diagnosis.
Ties are often split into categories “anterior” (at the front of the tongue) or “posterior” (at the back), in reality there are a whole host of shades of grey as the tie can be anywhere down the tongue. Those at the front are often easily seen and treated (although not always!) whilst the ones further back may prove far more problematic when trying to obtain diagnosis.
“All tongue ties do not look alike – adding to the difficulty of spotting them. They can be thin and membranous, thick and white, short, long or wide, extending from the margin of the tongue all the way to the lower front teeth, or so short and tight that they make a web connecting the tongue to the floor of the mouth” (tonguetie.net)
They often can’t be easily seen, therefore it takes someone skilled in lactation to piece things together. To consider breastfeeding history, observe a feed, evaluate babies tongue function and oral presentation alongside mum’s comments. Simply peering into a baby’s mouth or just feeling under the tongue at the front, is not a reliable method of evaluation (eg you may not be able to feel a submucosal tie and tongue may appear typical)
If they find anything unusual they will discuss their observations, and if they do not treat tongue tie themselves or perform the full oral assessment to confirm, should advise seeing someone who specialises in this field.
This can be easier said than done.
Unfortunately the number of people holding the above skills are very limited and posterior ties are regularly missed by Paediatricians, Midwives, ENT (ear, nose and throat) Consultants, Breastfeeding Counsellors, Health Visitors and sadly even some Lactation Consultants (IBCLC) and/or Infant Feeding Advisors (read one mum’s experience here). Some only recognise a tie at the front of the tongue and state baby is not tied if they can’t easily see the frenulum, some might even tell parents posterior tongue ties don’t exist! Despite the fact that evidence highlights posterior tongue tie is a problem poorly recognised in the community.
Discussing ties with several pediatricians and ENT specialists – it seems many do not receive specific tongue tie education during training (I’m not sure whether any do?)
Therefore if any of the above state they suspect a tongue tie, or you have problems nobody else can seem to help resolve – it is worth seeking out someone who states clearly they specialise in this field. Regardless of how you feed your baby, you can still contact many IBCLC tongue tie specialists for help.
What makes diagnosis even more difficult is that other things can impact on oral function beyond tongue tie. As the nerves that control the tongue and jaw run through the head and neck, compression can inhibit the jaw and tongue movement. This may be from positioning in the womb, a long first stage or a difficult or traumatic delivery – resulting in the infant displaying similar symptoms to those described above.
What other problems can an undiagnosed or untreated tongue tie cause.
As discussed above not all ties need intervention to breastfeed, however parents should be aware that a tongue tie can impact in other areas at a later stage – when treating is a much bigger procedure.
- Ongoing colic/wind/reflux or unsettled sleep patterns
- Eating difficulties – as the tongue requires a full action to process food, infants with tongue restriction may refuse spoons, gag/choke easily, or refuse to move on from runny foods. Some may be classified anywhere from “picky eaters” to “food phobic” depending upon severity.
- Dribbling/drooling – which may be prolonged and into childhood.
- Dental problems which may be severe and wide ranging due to the palate.
- Speech may be unclear due to several aspects, especially coordination
- Ongoing acid reflux/indigestion
- Sleep Apnoea
- Tongue tie can also prevent the tongue from contacting the front of the palate. This can then promote an infantile swallow and hamper the progression to an adult-like swallow which can result in an open bite deformity.
- It can also result in mandibular prognathism; this happens when the tongue contacts the anterior portion of the jaw with exaggerated thrusts.
The specific challenges an adult with a tongue tie may face include:
- Clicky jaws
- Pain in the jaws
- Protrusion of the lower jaws
- Burning sensation when elevating tongue
- Effects on social situations, eating out, kissing, relationships, appearance
- Dental health: a tendency to have inflamed gums, and increased need for fillings and extractions . The high or bubble palate also changes the shape of the oral cavity, which can result in hindered dental development, ill fitting teeth or too many to fit the space (ie if palate is high it will naturally make it narrower), overbite/underbite, or tongue thrust (the tongue protrudes forwards when at rest impacting on teeth)
- Acid reflux/indigestion/bloating/gas from incorrect chew/swallow mechanism and sucking in of air.
- Sleep Apoena
For further information and details of other potential implications, please visit BrianPalmer DDS.
It’s important to remember that not all ties need treating to facilitate goodfeeding; some babies have a tie that is stretchy and doesn’t impede the function of the tongue. Tongue tie practitioners should assess whether the tongue, mouth and lips move as expected – and whether the baby is feeding using a good technique, or is compensating on the breast or bottle because of the restriction.
“Up to the year 1940, tongue ties were routinely cut to help feeding. When this changed – because of a fear of excessive/unnecessary surgery and a reduction in the practice of breastfeeding – the belief that tongue tie was not a “real” medical problem but an idea held by over-zealous parents became widespread.”
“Early intervention is ideal since it avoids habit formation and the negative effects of failure: whether it is due to messy or slow eating, funny looking teeth or speech problems. When there are no strong habits to eradicate there is a better chance of success in correcting the difficulties that poor tongue mobility has caused.”
“Once a tongue tie has been diagnosed, the primary need is to correct the structural anomaly causing the problem. After the structural problem has been successfully corrected, it is reasonable to expect to improve function, and to treat secondary problems successfully. The type of treatment that is most appropriate depends on the problems that have been experienced.” (tonguetie.net)
Treatment is often called: snipping, dividing or clipping which describe a “frenulotomy”. A pair of blunt ended sterilised scissors are used to simply snip into the frenulum (which has few nerve endings and blood vessels) before the mum puts baby immediately to the breast. Some studies have noted a sleeping baby may not even wake during the procedure; in one study 3 out of 36 babies continued sleeping, and in another the figure was 39 out of 215 (NICE Division of ankyloglossia (tongue-tie) for breastfeeding). Some parents note their child cried at being held for a moment to allow access, but that this crying did not increase in intensity when the frenulum was clipped. NHS guidance suggests an average crying time of 15 seconds (Bath and North East Somerse, Tongue tie information for parents).
Feeding immediately after the procedure is not only soothing, swooshing the area with the antibacterial and anti inflammatory properties of breastmilk, but also allows baby to try out their new tongue action which would be hindered if the area was numb from anaesthetic.
“Although division in the outpatient clinic can still be done in many older children, general anesthesia may be required in some patients. Division of tongue-tie is a simple, easy and safe procedure. Early and aggressive treatment is recommended. It is best managed without anesthesia during infancy before teething at the outpatient clinic. Delayed treatment may put some children under the risk of general anesthesia.” (Outpatient division of tongue-tie without anesthesia in infants and children, Ming-Lun Yeh, World Journal of Pediatrics)
Other oral specialists agree:
“Based on 30 years of clinical observation I have sufficient documentation to state that:
• Frenulums do not go away by themselves.
• Frenulums can have significant consequences on oral cavity development and total health.
• Side effects are minimal, benefits are significant.
• #1 reason surgery is not performed – fear of litigation.
• Procedures not taught in medical or dental schools.
• Myths / misinformation abound on the topic. Breastfeeding and Frenulums Brian Palmer, DDS.
Are there risks to Frenulotomy?
It is estimated the risk of infection is 1 in 10,000 infants. Saliva contains some antibacterial properties, and breastmilk also has many antibacterial and healing characteristics. As a small amount of localised bleeding may occur, babies with any blood clotting disorders may be at increased risk.
Baby may become fussy, or mum may not note an improvement for 24-48 hours post frenulotomy.
NICE guidelines state:
“You may have been offered the tongue-tie procedure for your baby. NICE has decided that the procedure is safe enough and appears to work well enough for use in the NHS.” Division of ankyloglossia (tongue-tie) for breastfeeding
Hogan et al 2005 found:
“Overall, division of the frenulum in the babies resulted in improved feeding in 54 out of 57 babies (95%). There were no problems with infection or bleeding, either primary or secondary. Most babies cried for only a few seconds until they were given a feed. The author concluded that division was safe and significantly improved feeding for mother and baby and division was significantly better than the intensive, skilled, professional support of the lactation consultant.”
Dollberg et al (2006):
“The authors reported a significant decrease in pain score after frenotomy than after sham and significant improvement in latch score after frenotomy. No significant side effects of the frenotomy were observed in any of the patients and bleeding (a few drops) was controlled within seconds in all cases. The authors conclude that frenotomy appears to alleviate nipple pain immediately after frenotomy and that it is effective in treating breastfeeding difficulties.
The authors reported that 80% were feeding better by maternal assessment at 24 hours, 57% noticed a difference immediately, 95% could poke out their tongues at 3 months. No anaesthetic or analgesic was used and there were no reports of significant complications.”
Amir et al (2005)
“After the tongue-tie release, 83% of mothers reported improvement in breastfeeding. Parents reported high levels of satisfaction with the frenotomy procedure and no complications were reported.”
“Latch improved in all cases, and maternal nipple pain levels fell significantly after the procedure: There were no complications related to the procedure.”
Based on the research, a critical review entitled, ” The effectiveness of frenotomy in the treatment of breastfeeding difficulties in infants with ankyloglossia” concluded:
“The studies collectively provide significant evidence for the effectiveness of frenotomy in the treatment of breastfeeding difficulties in infants with ankyloglossia. Therefore, it is recommended that frenotomy be considered an effective approach to treatment of breastfeeding difficulties in infants with ankyloglossia.”
One mum’s experience of tongue tie and frenulotomy.
“From day one I’d experienced pain on feeding with increasing nipple trauma. Holly also suffered poor weight gain with signs of wind and reflux including really bad hiccups. Other signs were her breathing, snoring and ineffective feeding.
We experienced an 8 week long battle to get Holly’s tongue tie recognised and addressed. Charlotte from Milk Matters identified the problem when Holly was 2 weeks old, but we were told repeatedly by numerous health professionals that there was no tongue tie; these included our GP, Health Visitors, Hospital based Lactation Consultants, Midwives and even the Tongue Tie clinic at Oldham who turned us away. Charlotte continued to act as our advocate and support over the telephone, finally getting us access to a private Lactation Consultant in London who was visiting Leeds.”
Snipping the tie…
“Ann came to assess Holly at home and stayed with us 2 1/2 hours. She undertook a really thorough assessment taking an extensive history of our feeding experiences and an intensive physical assessment of Holly’s mouth and sucking pattern. She confirmed a diagnosis of posterior tongue tie and recommended the procedure to have it snipped. We were really nervous as the thought of doing anything to hurt Holly was awful. Ann took us through the procedure in great detail though and we quickly felt reassured. By the time we were ready to start Holly was pretty hungry so she was crying before the snip was done. I didn’t actually watch the snip but stayed near to Holly but as I wanted her to be able to hear my voice for reassurance. She was wrapped in a blanket to swaddle her and keep her still and it seemed to be over in a couple of seconds. Ann placed a piece of gauze on the site to stem some bleeding – it wasn’t bad at all though and quickly stopped. After the gauze was removed we quickly put Holly to the breast and she started feeding straight away with a really good latch. We got to keep the scissors used for the procedure – a pair of sterilized blunt scissors that didn’t look too horrendous. Ann stayed with us for a while after the snip to assess feeding and gave us great advice on positioning and feeding technique to suit Holly’s newly released tongue! Holly was fine after the procedure and the immediate difference in her tongue movements was amazing to see.
Ann did a follow up visit a week later to check that the procedure had worked effectively – with a posterior tie there is a risk that the site can heal down again. We had been given exercises to do with Holly to develop tongue movement and these were great to incorporate into her daily routine. Ann checked feeding positioning again and gave further advice regarding removal of the formula top ups and longer term feeding.
The idea of the procedure isn’t nice but we stayed focused on the reasons for having it done and we would recommend it to anyone that’s been having difficulties due to a tongue tie. It was so great to have the procedure done in the comfort of our own home which I’m sure added to Holly’s well being.It’s so exciting to be exclusively breastfeed now and see Holly feeding effectively and thriving. I’m nearly pain free on feeding now – I’m just waiting for my nipples to fully heal but can see improvements every day.”