Sometimes breastfeeding mothers find themselves with breastfeeding problems (including sore or damaged nipples, recurrent plugged ducts, mastitis or thrush, vasospasm, low milk supply or over supply) or a baby who isn’t gaining well, has difficulty latching, makes clicking sounds, or chokes frequently, despite their best attempts to correct positioning and breastfeed frequently and effectively.
Tongue tie, tongue mobility restriction, short frenulum, ankyloglossia - all of these are names that describe the situation where a baby’s tongue does not have enough range of motion to attach to the breast, suck and swallow effectively. Sometimes tongue tied babies can’t maintain a latch for long enough to take in a full feeding, and others remain attached to the breast for long periods of time without taking in enough milk. Some tongue tied babies will breastfeed only during the mother’s milk ejection reflex, or “let-down” when the milk is spraying into their mouths, but won’t continue to draw milk out of the breast when this slows.
Tongue tie is caused by a lingual frenulum (the membrane under the tongue) that is either too short or too thick. This membrane normally recedes during embryological development around 13 weeks, but in some babies, the membrane does not recede enough to give the tongue the normal range of motion the baby will need to breastfeed effectively. Some babies with limited tongue mobility can feed easily from a bottle, but for babies with very limited mobility, even bottle feeding can be difficult. They may choke easily or leak milk from the sides of their mouths while drinking.
Many babies with tongue tie also have an abnormally tight membrane attaching their upper lip to their upper gums. This is usually called a lip tie. Babies with lip tie often have difficulty flanging their lips properly to feed and don’t make a good seal at the breast when latching. This can cause them to take in excess air during breastfeeding which often makes these babies gassy and fussy.
How can I tell if my baby’s tongue has enough range of motion?
Tongue tie is a diagnosis of function, so what your baby’s tongue looks like is less important than what it can do. There are several motions of the tongue that parents can look for. The questions to ask are:
- When your baby cries, is the front edge of the tongue at least as high as the corners of your baby’s mouth? Lactation consultants call this aspect of tongue motion elevation.
- When you trace your baby’s bottom gums with your finger, does the tongue turn and follow your finger? Lactation consultants call this aspect of tongue motion lateralization.
- When you tug gently downwards on your baby’s chin and bottom lip, does the tongue extend past the bottom gums? Or even past the bottom lip? Lactation consultants call this aspect extension.
- If you lift your baby’s tongue towards the roof of the mouth, do you see or feel a membrane that prevents you being able to lift the tongue? Is this membrane blanched (white in color due to tension)?
- If you lift your baby’s upper lip towards the nose, do you see or feel a membrane that prevents you being able to lift the lip? Is this membrane blanched (white in color due to tension)?
This list does not provide a complete assessment for tongue function, but if your baby seems to have difficulty elevating, lateralizing or extending the tongue, and if there is tension in the frenulum under the tongue, your baby may have tongue tie. If there is tension in the membrane under the upper lip, your baby may have lip tie. An experienced lactation consultant can help you determine if a tongue or lip tie is causing breastfeeding problems.
Function is the most important aspect of diagnosing tongue tie, but tongue ties and lip ties also have a characteristic look. You can compare your baby’s tongue to images in this book by Dr. Lawrence Kotlow, a leading expert in treating all types of tongue and lip mobility restrictions.
No one knows for sure how common tongue and lip tie are, but some experts estimate that upwards of 15% of babies have some kind of tongue mobility restriction. Some tongue ties involve the front or even the tip of the tongue. Sometimes the restriction is less obvious if it begins farther back under the tongue.
Some practitioners call tongue ties that are visible in the front part of the tongue "anterior tongue ties" and the restrictions that occur farther back under the mucosa of the tongue "posterior tongue ties." Many practitioners were trained only to look for tongue ties with an anterior component and will only clip the anterior part of the membrane. For a baby who is experiencing significant difficulty breastfeeding, clipping only the anterior portion of the tie often does not give the baby enough tongue mobility to breastfeed well. Other practitioners believe that all tongue ties have a posterior component and that clipping just the visible portion is not enough. This article by Dr. Ghaheri describes why he believes describing tongue ties as anterior or posterior is irrelevant and how important it is to release a tongue tie thoroughly and effectively. This video by Dr. Kotlow shows how to identify a tongue tie that is inside the mucosa of the tongue, often called a posterior tongue tie.
If you believe your baby’s tongue has limited mobility, you can work with a lactation consultant or your pediatrician to decide how to proceed. Different doctors have differing levels of experience with diagnosing and treating tongue tie and lip tie. You can find lists of providers with experience through lowmilksupply.org and the Tongue Tie Babies Support Group on Facebook.
What can be done if my baby has limited tongue mobility?
Some pediatricians, ENTs and dentists can perform a frenotomy or frenectomy - a quick procedure to cut or remove the frenulum which releases the tongue and allows the full range of motion. Some use lasers, which have the benefit of minimizing the amount of bleeding during and after the procedure and provide a more aesthetically pleasing result with lip ties. Others simply cut the frenulum or the labial frenum (lip tie) with specialized sharp scissors. Many practitioners use a local topical anesthetic to numb the area before the procedure and some use an injection of anesthetic as well. For toddlers, sometimes a sedative is given. General anesthesia is not necessary.
What if I don’t do anything?
Some parents are concerned that the frenotomy may be painful or traumatic to their baby and prefer not to have it done. Sometimes babies figure out ways to compensate for their lack of tongue mobility and manage to breastfeed well enough to gain weight steadily without causing their mothers discomfort during feeding. If that is the case, a wait and see approach may work well.
Sometimes breastfeeding may seem to be going well and a baby can compensate for the poor range of motion for the first few months of breastfeeding while mother's milk ejection reflex is strong. We sometimes say that the baby is "living off the let-down." If the baby is not emptying her breasts effectively, often by 3-4 months, mother's milk supply will decrease and her milk ejection reflex will be less strong, and her baby may stop gaining weight well. A mother who has been weighing her baby monthly or even less frequently may be surprised to learn that her baby is not gaining well and it can take weeks or months of effort to restore her milk supply. The baby may need to receive supplementation with donor breastmilk or formula in the meantime.
If a baby has limited enough range of motion that breastfeeding is difficult, speech and dental hygiene may also become concerns in the future.
If you are considering a frenotomy for your child but are unsure, take a list of questions to your appointment and make sure you understand the benefits and risks of the procedure, what level of pain your baby is likely to experience and what to expect after the procedure.
What happens afterwards?
It is important to work with an experienced lactation consultant before and particularly after a frenotomy. Many mothers and babies need support to keep the baby fed and maintain milk supply while baby is learning to breastfeed effectively. A lactation consultant can let parents know what to expect during and after the procedure, what the healing process is likely to be like and provide individualized support and encouragement.
Breastfeeding may improve dramatically immediately following the procedure, especially if the baby is less than two weeks old. For many babies though, learning to use their tongue is a process (imagine if your tongue was suddenly longer than you are used to!) and improvement is gradual over several weeks. Melissa Cole, IBCLC has excellent videos demonstrating aftercare exercises and stretches that are important to help a baby learn to use her tongue effectively.
For the younger baby:
For the older baby:
This video by Dr. Ghaheri shows another way to do the stretches:
The mouth heals very quickly and bleeding after a frenotomy is usually minimal. Afterwards it is important to stretch and massage the tongue at least 4-6 times a day for a month to prevent the tongue from reattaching as it heals. This page by Dr. Ghaheri explains how and why to stretch the revision sites.
What if my healthcare provider says my baby isn't tongue tied?
Some pediatricians and other healthcare providers do not believe in tongue tie, or at the very least do not believe that it causes breastfeeding problems. However, the American Academy of Pediatrics and others have documented the negative effects of ankyloglossia on breastfeeding. There are also several studies showing that frenotomy improves breastfeeding. Finding a practitioner who routinely works with infants with tongue mobility restriction can answer your questions and help you figure out if your baby’s tongue needs treatment.