Tongue ties and breastfeeding

I first learned about tongue ties shortly after I started studying to be a lactation consultant. Suddenly, I had an answer for so many of my most difficult patients – they had tongue ties! Now, I don’t consider myself to be a world expert on tongue ties – that honour goes, without a doubt, to Dr Bobby Ghaheri and Dr Lawrence Kotlow. But as a working lactation consultant, I see them on a weekly basis, and I’ve seen the problems that they can cause. More times than I can count, I’ve seen breastfeeding relationships ruined by a tongue tie that was never picked up. Unfortunately, very few medical professionals are even aware of tongue ties, never mind knowing how to diagnose and manage them. I’m hoping that we can create more awareness, so that tongue ties will be on everyone’s radar.

What exactly is a tongue tie?

The fancy name for tongue tie is ankyloglossia, which literally means “anchored tongue”. That describes the basic problem of a tongue tie pretty well: the tongue is anchored to the floor of the mouth so that it can’t move around normally.

The anatomy

We all have a piece of skin under the tongue which connects the bottom of the tongue to the floor of the mouth. This is called the sublingual frenulum, but we’ll just call it the frenulum for short. Usually, this frenulum retracts and almost disappears while a baby is still in the womb. In a few cases, however, the frenulum remains, forming a tongue tie. When the frenulum is unusually short and tight, or it attaches close to the tip of the tongue, it prevents the tongue from moving as it normally would. This is when it starts creating breastfeeding problems. Dr Brian Palmer describes it the best: “Trying to talk, eat or swallow with a tight lingual frenulum is like trying to run a marathon with your shoes tied together.”

Degrees of tongue tie

Tongue ties can be more or less severe, depending on what exactly is happening under the tongue. Dr Lawrence Kotlow developed a useful classification system that grades a tongue tie based on where the frenulum anchors into the tongue. Here’s a picture that explains it:

Grade 1 and 2 tongue ties are fairly obvious – you can clearly see the frenulum under the tongue. It may even cause the tip of the tongue to form a heart-shaped notch. Babies with this type of tongue tie usually can’t stick out their tongue and cup it around the breast. The tongue’s up-down movement is also restricted, which makes suckling difficult.

Grade 3 and 4 ties are where things become tricky. They are what’s known as “posterior” tongue ties, because the frenulum is attached quite far to the back of the tongue. Grade 4 ties are especially difficult to diagnose if you don’t know what you’re looking for – I regularly hear of paediatricians who claim that posterior tongue ties “don’t exist.”

There are a few things that you can look for if you suspect a tongue tie:

• There may be an obviously visible frenulum under the tongue.
• The tongue tip curls under, flattens out or pulls into a notched shape when baby tries to stick out his tongue.
• The tongue doesn’t lift up to the palate when baby cries.
• There may be a dimple or dip in the middle of the tongue, with only the tip able to lift up. This is typical of posterior tongue ties.
• There may be a white coating on the tongue, especially on the back half of the tongue. This is milk residue – the tongue can’t lift up high enough to clean itself against the palate.
• Baby may develop sucking blisters along the length of the lips. These form because baby is using the lips, rather than the tongue, to hang on to the breast.

If you suspect your baby may have a tongue tie, I strongly suggest you have it checked out by a lactation consultant. No other medical professional has such a good training in how to diagnose tongue ties. If you consult your doctor or clinic nurse, you may just be told that your baby is “just fine” when he clearly isn’t.

Problems caused by tongue ties

Tongue ties can cause severe breastfeeding problems: the tongue plays a major role in suckling, and with a tongue tie the tongue can’t move like it is supposed to. In order to latch and suckle effectively, the tongue needs to (1) extend past the baby’s lower gums, (2) cup around the breast and grip the breast, and (3) move in a co-ordinated up-down and backwards-forwards way to create suction. The tongue also needs to be able to form a funnel for the milk to run towards the throat, and to lift up to help baby swallow. A tongue tie can affect any or all of these steps, making it difficult (if not impossible) for baby to breastfeed effectively.

Immediate problems

If you are breastfeeding a baby with a tongue tie, you can expect to encounter any or all of the following problems:

• Sore nipples. Some of the worst cracked nipples I’ve seen have been caused by tongue ties. Typically, the tongue rubs against the tip of the nipple, removing the skin and rubbing it raw. Moms often describe it as feeling like sandpaper rubbing on the nipples. Ouch…
• Baby struggles to latch, or to stay latched. Because the tongue has to curl around and grip the breast, babies with tongue ties often have trouble staying latched on to the breast. Baby may pop off the breast continually, and you may hear a smacking sound as the tongue slips off the nipple. This also causes a lot of nipple pain.
• Poor milk intake. Babies with tongue tie often fail to gain weight well, because they simply can’t get the milk out of the breast effectively.
• Choking and spilling milk. Babies with tongue tie may struggle to swallow effectively, and choke a lot. Milk may also spill from the front of the mouth, or even come out of the nose.
• Stomach upsets, including winds, cramps, reflux and colic. Babies with tongue ties often swallow a lot of air, which causes cramps and reflux.
• Frequent, short feeds. Baby may take frequent feeds, but fall asleep at the breast very quickly. This is because the tongue gets tired from the exertion; baby never really keeps suckling for long enough to take a full feed. You may also notice that baby only swallows when you have a let-down and the milk is flowing with minimal effort required from him.

Long-term problems

There’s a school of thought that says you should just bottle feed if your baby has a tongue tie. But it’s not really that simple. Tongue-tied babies often also have trouble drinking from a bottle, and they still struggle with choking, milk spillage, cramps and reflux. And apart from feeding, a tongue tie can have other long-term effects, such as:

• Long-term digestive issues – reflux and GERD, colic, even symptoms resembling irritable bowel syndrome.
• As he gets older, baby may struggle to swallow solid foods. This can also cause difficulty in eating “chunky” foods and swallowing pills.
• The palate can remain high and arched, instead of being flattened by the tongue. This can lead to issues such as mouth breathing, snoring and sleep apnoea.
• Later on, the child can develop dental decay (because the tongue isn’t able to clean food residue from the teeth) and crooked teeth (because the frenulum pulls on the jawbone, which can pull the teeth out of alignment).
• Speech difficulties – because the tongue can’t move freely, it may be difficult for the child to form certain sounds. In severe cases, speech development may be delayed by years.

When a tongue tie is not a problem

It’s important to keep in mind that a frenulum is only considered a tongue tie if it’s causing a problem. Occasionally, I see a baby with an obvious lingual frenulum, but no other problems – the baby is breastfeeding well, weight gain is perfect and mom has no nipple trauma. What’s happening in this scenario is that the frenulum is long or elastic enough to allow for normal movement of the tongue. In such a case, there is no clinical tongue tie, and nothing needs to be done further.

Managing a baby with tongue tie

There are basically two ways to manage a tongue tie: the first is conservative management, where we try to compensate for the tongue’s lack of mobility without cutting the frenulum. The second is surgical, where the frenulum is cut. I will briefly discuss both.

Surgical treatment

The surgical correction of a tongue tie, where the frenulum is cut, is called a frenotomy. Frenotomies are something of a hot topic in lactation circles. A lot of healthcare professionals, especially the older generation, still believe that there is no benefit in cutting a tongue tie in a baby, and that it only needs to be done if a child has speech problems. But the research, and the experience of mothers who’ve gone through the procedure, paints a very different picture. The benefits to releasing a short frenulum are immense: better milk transfer, less pain and more successful breastfeeding.

A frenotomy is a relatively simple procedure. It is usually done by a doctor, dentist or ENT, and can be performed using a scissors or laser. Most providers do not use anaesthesia, just a numbing gel, although some providers prefer to give a light general anaesthesia. The frenotomy itself simply consists of lifting the tongue and cutting through the frenulum. A particularly tight or thick frenulum may require several cuts to free it up completely.

After a frenotomy, you need to stretch the cut area to make sure that it doesn’t re-attach. You may also need to exercise the tongue to teach it the correct suckling movements. Rather that reinventing the wheel on this topic, I’ll simply suggest that you have a look at Dr Ghaheri’s aftercare protocol, which you can find here.

Non-surgical management

There are various other ways to try and compensate for the tongue’s decreased range of motion. They are worth a try, and you will certainly need to use them while you wait for a frenotomy, but I’m afraid that their effectiveness is limited in all but the mildest cases.

Adjust positioning. Position baby very close to you, with his chin digging into your breast. This helps baby to latch deeply and stay latched on. The “laid back” position, with baby on top, is often easier for babies with a tongue tie, since the tongue can drop forwards over the gums more easily.

Stretching the frenulum. It is sometimes possible to stretch the frenulum by massage. This should only be done by a trained lactation consultant or speech therapist.

Use a nipple shield. In some cases, a nipple shield makes it possible for baby to latch on well enough to transfer milk, especially if you do breast compressions at the same time to increase the flow of milk. It’s usually not sufficient as a long-term solution, though.

Pump and bottle feed. This really is a last resort, or a temporary measure. Exclusive pumping is ridiculously hard work, so I would recommend that you do everything in your power to make it possible for baby to breastfeed.

More info

This was only a very brief overview of the topic of tongue ties – I just wanted to help you to understand what a tongue tie is and how it can be managed. If you suspect that your baby may have a tongue tie, it’s important to get into contact with a good lactation consultant – this is the best person to confirm whether a tie is present, and also to direct you to the right people to have it cut. In the meantime, have a look at the info on Dr Ghaheri’s website – there’s a goldmine of information there.

In conclusion

In short, this is what you need to know about tongue ties:

• A baby with a tongue tie can’t move his tongue normally.
• Tongue ties can cause significant breastfeeding problems, including severe nipple damage, an inability to latch on to the breast, poor milk intake and poor weight gain.
• Tongue ties also cause other problems, such as digestive issues (colic, reflux), speech problems and tooth decay.
• A frenotomy – cutting a tongue tie – is a simple in-office procedure that greatly increases your chances of having a successful breastfeeding relationship.
• If you suspect your baby has a tongue tie, it is imperative that you get in touch with a lactation consultant to assess the extent of the problem and help you to find the appropriate treatment.

I hope that you have learned something new today. Before I go, I want to share an amusing anecdote that stuck in my head the first time I heard it. In the olden days, when babies were still delivered by midwives at home, the midwives used to grow their one pinky nail long. This was so that they could quickly and easily cut a tongue tie (which was apparently part of their routine newborn examination in those days). Can you imagine that?! I’m not sure how true the story is, but it may explain why some old medical textbooks describe cutting a tongue tie as “unhygienic and dangerous.” Too bad the medical professional threw out the baby with the bathwater instead of just using a better technique!

Have you ever gone through the arduous process of breastfeeding a baby with a tongue tie? Please share your story!