By Melissa Cole, IBCLC, RLC and Bobby Ghaheri, MD., Portland OR.
“Tongue-tie” has become quite a buzz word in some circles and is still quite unknown in others. Tongue-tie, professionally known as ankyloglossia, is a congenital condition in which the lingual (tongue) or labial (lip) frenulum is too tight, causing restrictions in movement that can cause significant difficulty with breastfeeding and, in some instances, other health concerns like dental, digestive and speech issues. Mothers of infants dealing with feeding challenges are often desperate to find solutions; as awareness increases about tongue and lip tie, some mothers wonder if this is something their baby may be coping with.
Parents often want to know what some typical signs of tongue/lip tie are. Each mother/baby dyad is very unique and therefore tongue/lip tie issues can present differently for everyone. Some common symptoms that may point to the infant being tongue/ lip tied include: poor latch/inability to latch, sliding off the nipple, fatigue during feeds ,sleepy feeds, poor weight gain, clicking during a feed , maternal nipple pain/damage (can feel like the infant is compressing, chewing, gumming, pinching, scraping the nipple, etc), increased maternal nipple/breast infections, compromised maternal milk supply, dribbling milk at the breast/bottle, digestive issues (increased gassiness, reflux, etc due to extra are being swallowed and poor control of the milk during a swallow), and various other feeding related challenges. Some mothers and babies may cope with some of these issues, all of these issues or even none of these issues when a tongue/lip tie presents. We must keep in mind having a frenulum is not the problem; compromised tongue mobility and functionality that cause problems for the mother and/or baby are the problem!
Mothers are tech-savvy and often turn to the computer first to research what might be causing their feeding concerns. When moms go online, they will most likely encounter some discussion about how tongue and/or lip ties can cause feeding issues. If parents suspect a tongue/ lip tie then families will often want to see a provider in-person to have their baby evaluated and treated. Sometimes families are lucky enough to have a local provider well-versed in evaluating and treating oral restrictions like tongue and lip tie. However, many mothers may not have access to this expertise in their local communities. If you suspect that your infant may have a tongue or lip tie and you’re not able to find a provider in your community to evaluate and treat this condition, consider connecting with a local international board certified lactation consultant (IBCLC) that should be able to help connect you with additional resources. Another resource is the website for the International Affiliation of Tongue-Tie Professionals (IATP) (please note that the website is just about to be launched and may or may not be live at present, do check back if needed).
Tongue and lip ties come in various shapes and sizes and can present uniquely in every baby. Many providers have only been trained to look for very prominent, classic tongue ties that often create a heart-shaped tongue. However, tongue ties can be sneaky and restrictions that are more posterior (toward the base of the tongue) cannot be easily visualized. Proper assessment and evaluation are key when identifying these types of ties because they can easily be missed at first glance. Not all providers know how to properly assess for all types of tongue and lip restrictions. While there are various assessment tools and tongue-tied classification scales that have been published, there is still no universally accepted standard of assessment and care when it comes to tongue and lip tie. This fluctuation in assessment and treatment standards can be extremely frustrating for parents trying to seek evaluation and care for their potentially tongue and lip tied infant. If you are unsure of whether or not your provider is adept at assessing or treating various types of tongue and lip tie you may want to ask your provider the following questions:
- How do you assess for tongue/lip tie?
- How often do you treat tongue/lip tie in your practice?
- Do you treat posterior tongue ties?
- How do you perform the procedure?
- What type of follow-up care to recommend after the procedure?
Providers that routinely assess and treat babies for tongue and lip tie should be able to easily answer these questions and provide parents with enough information so that they can make an informed decision. Providers that may not be the best to assess or treat your baby include ones that rarely assess or treat for this condition, tell parents that the tongue tie will stretch or that it’s not a big deal, tell parents that they have never heard of it posterior tongue tie, or tell parents that this must be done under general anesthesia. Parents should always feel empowered to seek additional opinions and advocate for the needs of their child if they are struggling to find a provider that understands and treat oral restrictions.
If a tongue or lip tie is present and parents wish to seek treatment, what can parents expect? Various types of providers treat tongue and lip tie including: ear nose throat doctors (ENTs), pediatric dentist, oral surgeons, pediatricians, naturopathic physicians, and others qualified to do minor surgery. In most all cases, releasing the frenulum for infants is an in-office procedure, with no sedation needed. In some rare cases, or in cases with older children, sometimes light sedation is used if the parents or provider feel that the older child would be too stressed while alert, but in infants this is usually not necessary at all. Some providers release the frenulum with sterile scissors, others use laser technology. The availability and types of providers in any given community will vary as will the course of treatment. In general, this is what we tell parents coming to our practice to expect (please note that other providers may perform the treatment slightly different ways):
What to expect when your baby needs a frenotomy/frenectomy:
In general, the procedure is very well tolerated by babies. We take every measure to ensure that pain is minimized.
1) For a typical frenotomy (an incision of the frenulum), a topical numbing gel is applied once or twice and occasionally, if a frenectomy (frenulum tissue is removed) is needed, a small amount of local anesthetic is injected. Often, ice chips are applied directly to the area before (and sometimes after), as this helps numb the area.
2) Crying and fussiness are quite common, and most children lose only a small amount of blood. They will frequently drool afterwards until the numbing medicine wears off.
3) Pressure and ice are held to help minimize any bleeding, and the child will be returned back to you, where you have the option of immediate breastfeeding, bottle feeding or soothing depending on your preference.
4) Tylenol may be used afterwards but is often not even needed.
5) You may notice some dark brown stools or spit-ups afterwards as some blood may get swallowed after the procedure.
There is very little risk involved with the frenotomy/frenectomy procedure. The biggest risk of the procedure is the potential for re-attachment to occur. In order to prevent this from happening, we work with the patient’s in our practice to keep the newly-released area open and healing well by encouraging specific mouth-work after the procedure. We encourage gently massaging/stretching the incised area, targeted oral motor work to help the tongue and mouth learning patterns, supportive bodywork, and other complementary healing modalities. By incorporating this type of gentle aftercare, we do see a reduction in reattachment and better progress overall.
Over the decades, it is no doubt that many breastfeeding relationships have probably suffered greatly due to undiagnosed tongue or lip restrictions. While more providers and parents are becoming educated about ties, we must be mindful not to think that every feeding challenge is created by a tongue or lip tie or that releasing restrictions will immediately improve the feeding situation. Sometimes there is immediate improvement after the procedure and sometimes it is a gradual process as the tongue is supported in moving in new ways. Feeding challenges can be complex and involve layers of issues. In addition, tongue/lip tie can create other issues that may need to be proactively addressed. Infants and mothers may cope with muscular tightness, nipple damage/pain, milk supply issues, infant weight gain concerns, etc. that need further support before and after a tongue/lip tie is evaluated and treated. Working with a qualified, experienced board certified lactation consultant or other care providers that are familiar with oral restrictions is highly suggested. Coping with feeding challenges in a tongue/lip tied infant can be an emotional and physical roller coaster for families. It is our goal in writing this article that all mothers and babies receive the care they need and that awareness in regards to tongue/lip tie issues will continue to increase worldwide.
For additional resources on tongue and lip tie, please visit Luna Lactation’s website resource page and scroll down to the tongue tie section.
Melissa Cole, IBCLC, RLC is a board certified lactation consultant in private practice. Melissa has been passionate about providing comprehensive, holistic lactation care and education to parents and healthcare professionals for over a decade. She is an Adjunct Professor at Birthingway College of Midwifery in Portland, OR where she teaches advanced clinical lactation skills. She is active with several lactation and healthcare professional associations including La Leche League and the International Affiliation of Tongue-Tie Professionals. To contact Melissa feel free to email her at Melissa@lunalactation.com or follow her on Facebook and Twitter @LunaLactation. You can read more from Melissa at lunalactation.com.
Bobby Ghaheri, MD is a board certified ear, nose and throat specialist with The Oregon Clinic in Portland, OR. His interest in treating children with tongue and lip-tie stems from his ardent support of breastfeeding and was furthered by his personal experiences, as his youngest child benefited from treatment for it. He enjoys working with children and has an interest in traditional and non-traditional approaches to pediatric pain control. To communicate with him, feel free to email him at firstname.lastname@example.org or follow him on Twitter at @DrGhaheri. You can read more from Dr. Ghaheri at The Wrinkle Whisperer.
Coryllos, E., Genna, C. W., & Salloum, A. C. (2004). Congenital tongue-tie and its impact on breastfeeding. Retrieved from http://www2.aap.org/breastfeeding/files/pdf/bbm-8-27%20Newsletter.pdf.
Ghaheri, B., & Cole, M. (2012). General Information about Frenulum Procedures for the Infant (pp. 2).
Hazelbaker, A. K. (2010). Tongue-Tie: Morphogenesis, Impact, Assessment and Treatment: Aidan and Eva Press.
Kotlow, L. (2011). Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. European archives of paediatric dentistry : official journal of the European Academy of Paediatric Dentistry, 12(2), 106-112.