Month: February 2014

Tongue Ties – what’s it all about?

Tongue Ties – or ankyloglossia – just what are they and why do they cause problems for some mothers and babies, and not others?

As soon as you start to talk to people about tongue ties you realise that it’s a bit of a contentious topic; some people think they are over-diagnosed, others think they don’t exist, others have never heard of them.  So why the confusion?

What is a Tongue Tie?
Between the 4th and 7th weeks of development a baby’s oral cavity develops and tissue in the mouth (and other areas of the anatomy) goes through a process of growth and regression.  During this process the tongue forms and separates from the floor of the mouth leaving the frenulum – the piece of skin that attaches the tongue to the bottom of the mouth.  In some babies the frenulum doesn’t separate as much as it could do, causing a possible tongue tie.

If the frenulum is too tight  it impacts the baby’s ability to use his tongue to feed effectively – this can impact breastfeeding and and to some extent bottle feeding, as well potentially causing future problems with oral health and development, speech, digestive problems, and others.

Some babies have an obvious frenulum but it does not cause any problems – every baby and mother needs to be assessed on an individual basis.

Why do they occur?
There doesn’t seem to be a consensus of opinion on this.  There has been discussion about a gene that may be responsible, and whether or not folic acid has a role to play.  There does seem to be a higher chance of a baby having a tongue tie if there is a family history of tongue tie though, and often if one child in the family has a tongue tie, it’s not uncommon that their siblings do too.

What does a tongue tie have to do with breastfeeding?
When a baby breastfeeds he needs to be able to keep his tongue forward over the bottom gum, use the tongue to cup and grasp the breast, bringing the breast tissue far enough back in the baby’s mouth to ensure that the nipple is not squashed between the tongue and hard palate, and create the vacuum in the babies mouth that results in the milk flow from the breast.  If the movement of the tongue is compromised in any way then some or all of these activities can be more difficult.  The baby’s tongue should be able to work in a rippling type of movement that carries the milk from the front of the baby’s mouth to the throat for swallowing.

If a baby is tongue tied some mothers experience pain that cannot be managed by improved positioning and latching, the nipple may be squashed or grazed by the tongue causing bruising and/or bleeding, cracked nipples; the baby may not gain weight well as he is unable to remove milk efficiently from the breast, leading to low weight gain, or a sleepy baby due to insufficient calorie intake.  Sometimes the baby may not gain weight well, but the mother may not experience any pain.  In some cases all seems well for the first few weeks.  The mother naturally has an abundant milk supply and the baby is gaining weight well.  However, as supply becomes dependent on the baby removing milk from the breast well (rather than hormonally driven as in the first few weeks), the baby’s weight gain starts to drop and the mother notices a decrease in milk supply.  All of these things COULD be an indication that the baby has a tongue tie.

How do you know if there is a tongue tie?
If a mother is having problems with painful breastfeeding, or the baby is not gaining weight sufficiently, then the first thing to do is check that the baby is positioned well at the breast and is latching well.  Many painful breastfeeds can be rectified by improved position and/or latch.  However, if things cannot be resolved this way, then the possibility of tongue tie should be investigated.   Tongue ties are generally deemed to fall into one of four classifications:  I, II, III and IV.  The first two tend to be easier to see and involve the tip of the babies tongue being restricted.  These are often called anterior tongue ties.  However, tongue ties are diagnosed by both appearance and function – some tongue ties just don’t cause problems for feeding and can be left alone.  Many practitioners use the Hazelbaker Assessment Tool as a consistent and reliable method of checking both appearance and functionality of the tongue in a breastfeeding baby.

Why are tongue ties more common these days?
It’s not clear why tongue ties seem to be occurring more often, or even if they really are more common – it could be that we are just hearing more about them than we used to.  You may have heard stories about midwives in the past keeping a finger nail long to cut them as soon as the baby was born.  As formula became more of the “norm” for babies and, for a while was believed to be scientifically superior, it was easier to switch babies to bottle feeding and the tongue tie was less of an issue.  It is likely that due to more mothers wanting to breastfeed again, and generally having access to better and more easily available breastfeeding help, tongue ties are again being recognised and dealt with.

How do you fix a tongue tie?
The procedure of dividing a tongue tie is called “frenotomy”.   There are a number of ways of carrying out a frenotomy – laser, scalpel, diathermy.  Laser is expensive and is deemed by some as unsuitable for use in babies.  Some midwives and lactation consultants perform frenotomies, in other areas GPs who carry out minor surgeries will do them.  A frenotomy involves the tight frenulum being cut in one or two places to relieve the tongue and allow normal movement.  There is usually very little bleeding – the risk of excessive bleeding and infection is deemed to be very low.  Usually a small piece of gauze will be placed against the cut area for a few seconds and then the mother encourage to feed the baby.  The baby is often not upset by the procedure itself, but often doesn’t enjoy adult sized fingers being poked in the mouth and under the tongue during the process.  Most of the time, mothers report immediate improvement, however some babies have got used to using their tongue in an inefficient manner and take more time to get used to the new mobility of their tongue.  In these cases tongue exercises may help:

Some mothers find that these tongue exercises can help the baby use their tongue better while waiting for a tongue tie to be checked, along with using nipple shields (to prevent further damage to the nipples), or expressing and bottle feeding until the tongue tie can be divided.

Once the tongue tie has been divided, it’s always worth going back to your breastfeeding support person to ensure positioning and latching is optimal.

References/further reading: