What is tongue tie?
The red arrow points to a posterior tongue-tie.
The frenulum’s job is to anchor the tongue and stabilize its motions. When this thin membrane, or frenulum, that attaches the tongue to the floor of the mouth is short, it is known as tongue tie (ankyloglossia). The frenulum can be connected anywhere from the base of the tongue to its very tip. It may look thin and stretchy or thick and fibrous.
Tongue-tie can be anterior or posterior. An anterior tongue-tie can typically be easily seen or felt under the tongue – where the frenulum attaches to the tongue on one side and behind the lower gum on the other. A posterior, or “hidden,” tongue-tie can be more difficult to diagnose if the person does not have experience. Essentially, a posterior tongue-tie is a band of fibrous tissue on the bottom, underside of the tongue that, when released, will allow the tongue to extend to its full potential. It is common for babies with posterior tongue ties to also have a lip tie.
These various attachments restrict normal tongue movement keeping the tongue from extending out over the lower gum, reaching the roof of the mouth, etc. These tongue movements are essential for successful breastfeeding. Tongue tie is more common in boys than girls and it does tend to run in families.
Here is the tongue after the procedure.
There are many different symptoms of tongue tie. You do not need to have all of these, or even a majority, for treatment. Every case should be evaluated individually. Some tongue ties that appear severe may not have much impact on breastfeeding; others may look very mild but the mom or baby or both may be struggling with breastfeeding. Whenever there is a concern, don’t hesitate to seek the advice of a lactation consultant!
Symptoms in baby:
- Shallow latch
- Unable to stay on breast; gradual sliding off breast
- Cannot form suction
- Falls asleep at breast before feeding
- Longer breastfeeds
- Slow weight gain/weight loss
- Irritability or colic
- Gas or reflux
- Chews or bites on nipple
- Sucking blister on top lip
- Fussy/arches away from breast
- Breast refusal (if aspiration occurs!)
- Unable to deal with a fast milk ejection
- Ineffective milk transfer (not feeding effectively)
- High palate
- Spilling milk during feed
- Coughing, choking, or gulping when feeding
- Jaw quivering after or between feeds
- Crying with tongue flat in mouth
Symptoms in Mother:
- Painful nipples
- Cracked/bleeding nipples
- “Lipstick nipple” when baby unlatches
- White stripe (compression line) at end of nipple
- Low milk supply
- Plugged ducts
- Recurring thrush
- Frustration, disappointment with breastfeeding
- Untimely weaning
Why is it important for breastfeeding?
The tongue is the most complex muscle in the human body! It has 8 layers and can move in multiple directions at the same time. When the tongue is “tied” it cannot move freely and can, therefore, impact breastfeeding: nipple pain, severe nipple damage, poor latch by baby, and/or inadequate milk being taken in by baby (which can lead to many significant problems such as low milk supply and failure to thrive).
In order to breastfeed effectively a baby must be able to grasp the breast, shape the breast to stabilize it in the mouth, and help create a vacuum that pulls milk out of the breast. Five key tongue motions are required:
- Tongue Extension – Can baby extend his tongue over the lower gum line and maintain it for the duration of a breastfeed? With tongue tie, tongue extension decreases as the mouth opens wider.
- Tongue Elevation – In order to create vacuum to withdraw milk, the front of the tongue needs to lift and touch the breast so that the back of the tongue can drop and a vacuum of negative pressure can be created to draw out milk. Baby should be able to elevate tongue more than half-way to palate with mouth open wide.
- Tongue Grooving – The sides of the tongue need to be able to lift so that it can cup the underside of the breast.
- Tongue Lateralization – The tongue tip needs to be able to touch the sides of the mouth.
- Wavelike Sucking Motion – Allows the tongue to withdraw milk from the breast and swallow it without choking.
Does tongue tie affect anything in addition to breastfeeding?
Tongue tie can also affect starting solids (choking, gagging, etc.), speech impediments, dental malformations, indigestion, snoring, sleep apnea, and difficulty extending tongue for such things as licking ice cream or kissing.
A frenotomy is a simple procedure that gives dramatic improvement to breastfeeding. By clipping the frenulum, the tongue will immediately have more movement range, allowing the breastfeeding issues to be improved if not resolved. Several randomized, controlled studies have shown division to be highly effective. The procedure is quick and easy for a skilled technician and all that is needed is sterile scissors. Alternatively, some doctors may use a laser. Young babies do not need anesthesia for the procedure and many times don’t feel a thing. In fact, it is typically less traumatizing than an immunization! It is important, however, to find a doctor who is skilled and familiar with both anterior and posterior tongue ties.
If you must wait for a frenotomy, or choose not to have this done, there are other measures that can help optimize a baby’s latch and possibly make the situation more manageable:
1. Optimum positioning – gravity can help a baby to open as wide as he’s able so laid-back nursing positions tend to work better with tongue-tied babies.
2. Latch alterations – work with a lactation consultant to help baby latch to the best of his ability One such alteration to try if baby slides to “nipple feeding”…dent breast at or just beyond the margin of the areola with one finger to form a firmed, billowed area of breast for baby to grasp = baby’s chin snuggled into hollow which helps prevent lower lip from sliding toward nipple as baby latches.
3. Finger feeding – Can be helpful when baby doesn’t maintain extended tongue and/or elevates posterior tongue too high.
4. Tongue exercises – Talk with a lactation consultant about exercises that may help in your situation.
5. Nipple Shield – When a baby is otherwise unable to latch AND only after a mother’s milk has come in…select the widest diameter nipple shield possible that still fits in baby’s mouth as a narrow nipple shield can be hard for baby to grasp.
6. Cranio-sacral therapy – the gentle manipulation of the head, neck, and back that can help relax tension and thereby tongue restriction. This is particularly effective to do alongside tongue tie revision.
When should it be corrected?
If there are breastfeeding issues and your baby is diagnosed with tongue tie, the sooner you have it revised the better. It is safe to do the procedure on a newborn and, the sooner it is performed, the less relearning the baby has to do at the breast. Even if the baby is a few months old (or older) when a frenotomy is performed, improvement should immediately be seen.
After a frenotomy, it is good to work with your baby to help her learn (or relearn) how to breastfeed properly. This may include shaping the breast and holding the teat in the baby’s mouth for the duration of the breastfeed for the first few days to two weeks (depending on how much relearning the baby needs). Be proactive to ensure good positioning and latch so she will learn to use her tongue properly. It is also a good idea to perform some simple exercises on your baby for the first two weeks to ensure it does not reattach. Sweep around the inside of her bottom gum by pushing down on the floor of her mouth. Then lift her tongue by placing your index finger next to the incision and push the tongue up and back so scar tissue does not form. Do these several times a day for two weeks.