Feeding with a tongue tie
What is a tongue tie?
A tongue tie, also known as ankylogossia is where a fold of tissue known as the lingual frenulum, which connects the tongue to the floor of mouth, is too short, too tight or too close to the gum ridge, causing a restriction in tongue movement
If it impacts on tongue movement, then in turn, it can impact on the feeding process.
There are two types of tongue tie, anterior and posterior. Anterior tongue ties are usually clearly visible with the membrane/tissue seen attaching near the front of the tongue. The tongue can look heart shaped.
In posterior tongue ties the membrane is not usually visible, although to a trained eye you may notice the front of the tongue to be square shaped, bulky or heart shaped. The tissue is usually thick and very inelastic. Arguably this inelasticity creates more significant restrictions in movement, particularly tongue elevation.
Anterior tie
Posterior tie
How are the tongue movements affected?
Extension – when an infant opens its mouth in a wide gape to attach to the breast, the tongue is unable to fully extend. This impacts on the ability of the baby to draw the breast tissue deep into the mouth and place it at the junction of the hard and soft palate.
Elevation – this restriction in movement is slightly more common in infants with posterior tongue ties. Elevation plays a significant part in milk removal and is also responsible for cupping the breast in the mouth and keeping it in place during feeding. Reduced elevation of the mid tongue can lead to the baby coming on and off the breast.
Lateralisation – this is less important when breastfeeding, but very important for chewing solid foods.
How is a tongue tie diagnosed?
A tongue tie can’t be diagnosed by looking alone. In order to fully assess for a tongue tie your health care practitioner needs to both look and feel. A comprehensive assessment will include an oral motor examination to elicit, watch and feel how the tongue moves in the mouth.
How can a tongue tie affect feeding?
Nipple pain and trauma may manifest in the early days. This does not always mean there is a tongue tie present, however in the event that you are achieving a good latch but continue to feel pain, you should ask for it to be assessed.
Non-latching baby. If your baby is not able to latch at the breast this may be a sign they have a tongue tie.
Low milk supply – your baby may appear to be well latched and feeding well, but your supply may not be meeting your babies demands. Some babies with tongue ties can transfer milk but are less efficient than they could be due to their restricted tongue movement.
Some babies grow well initially, riding on the wave of prolactin that provides an abundance of milk and growth issues only appear later. This possibility should be considered and monitored in the event that the tie is identified and not divided.
Struggling to stay on the breast. Babies with tongue tie often come on and off the breast, losing their latch frequently. They may also make a clicking sound when feeding.
Aerophagia (swallowing excess air) – a baby with a tongue tie may swallow excess air. Babies who swallow more air can present with excessive wind and can be uncomfortable after feeding.
Frequent feeding – some babies can feed seemingly well without causing pain and trauma but their inefficiency means that they have to feed around the clock to take in the milk they need to grow.
Recurrent blocked ducts and mastitis can commonly occur in mothers of babies with tongue ties when there is a generous milk supply.
Bottle feeding difficulties are less common, but some babies with tongue tie will struggle. Difficulties may include staying on the teat, clicking, swallowing air and spillage of milk out of the front of the mouth.
What can I do to help?
Not all tongue ties need to be divided. For some babies optimising latch and positioning and monitoring growth is all that is needed. Following that, a stepwise approach to assessment and management is recommended. The following approaches should ideally be trialled prior to dividing the tongue tie…
Optimising positioning and attachment at the breast and facilitating a deep latch.
Cranial osteopathy may help with some of the secondary impacts of the tongue tie. Intervention can be provided pre and post tongue tie release. More information here.
Protect your breasts. If you have suffered significant trauma and are finding feeding too painful it is ok to take a break! This may mean a total break, where you pump and offer all feeds via another means, or a partial break. This should be done under the advice of an IBCLC or other qualified breastfeeding professional so that there is a clear plan for how to feed your baby and how to support your baby to get back to the breast.
Protect your supply. If there are concerns that your baby is not able to transfer enough milk from the breast then you will need to protect your supply by pumping after feeds. Seek support for a plan for how best to do this.
Breast compressions can help support your baby to remove milk.
It is important to ensure to offer both breasts at each feed and even switch feed, this is where you go from one breast to the next and then back again as much as you need.
If, despite support you are still in pain, your baby is struggling with milk removal, there are growth issues or feeding remains challenging in other ways, then a tongue tie division is indicated.
What if I decide not to divide my babies tongue tie?
You should be aware that later faltering growth or low milk supply could still be an issue. If you don’t divide your baby’s tie…
Keep a close eye on your baby’s weight gain. Weighing your baby on a 2 weekly basis until around 4 months would be recommended.
Feed very responsively, including at night - prolactin is highest in a mother’s body between 2am and 4am, so night feeds are important for maintaining milk supply.
A few times a day, offer the breast even if the baby isn’t showing hunger cues.
Avoid limiting your baby’s time at the breast and using a dummy.
Ensure you offer both breasts at each feed.
If you need breastfeeding support or an assessment and management of tongue tie you can find an IBCLC here and you can find a tongue tie practitioner here.
Images courtesy of Dr Sharon Silberstein, IBCLC and tongue tie specialist https://www.breastfeedingdoctor.co.uk/
