Tongue-tie and Breastfeeding

A tongue-tie (ankyloglossia) occurs when the connective tissue (frenum) under the tongue causes restriction in the tongue movement or function. It occurs in 2.8 – 10.7% babies, more often in boys and can be hereditary.

Anterior tongue-tie occurs when the frenum is attached at the front of the tongue, close to the tip. When the frenum is attached further back, or behind the mucosa, the term posterior tongue-tie is used. This term does not have consensus and the topic of posterior tongue tie (and lip tie) is a controversial one. Research is limited and opinions are divided.

Photo courtesy of Monica Hogan & David Todd

Signs & Symptoms

A baby with tongue-tie may not be able to poke the tongue out beyond the gum line / lips;  and /or may not be able to lift the tongue, or move it side to side. The tongue tip may look notched or heart shaped. This may interfere with correct attachment at the breast, leading to some of these problems:

Mother:

  • Nipple pain and damage
  • Low milk supply
  • Blocked ducts / mastitis
  • Early weaning
  • Frustration, disappointment and discouragement with breastfeeding

Infant:

  • Baby can’t latch or stay latched
  • Fussiness and frequent arching away from the breast
  • Clicking sound while feeding or spilling (poor suction)
  • Poor milk transfer – frequent small feeds or long inefficient feeds
  • Low weight gain
  • Chewing or chomping at the breast

How to treat:

Frenotomy is a minor surgical procedure performed using scissors. It is quick and the baby will often settle soon after. It can be performed without anaesthesia. Scissors are often used when the frenum is thin and anterior and unlikely to bleed much.

Laser frenectomy is an effective method for “posterior” tongue-tie / submucosal tongue-tie and lip tie that controls bleeding well. This is generally performed by a paediatric dentist or surgeon. Different lasers are used: water-lase is commonly used with infants.

Risks:

Infection is rare. Some babies may become fussy at the breast for a period of time afterwards. Bleeding is common – sucking/feeding straight after the procedure usually resolves this. There is a small risk of reattachment and scarring that may require a repeat procedure. Wound stretches and other oral exercises are often advised for this reason but may distress the baby and lead to oral aversion.

My approach as an IBCLC/bodyworker:

Sadly, I have seen many parents (and babies) whose breastfeeding journeys have been negatively affected due to missed tongue-ties. Babies with feeding challenges need to have an individualised, comprehensive feeding and oral function assessment. An IBCLC can rule out nipple infections and positioning and attachment issues which may potentially avoid surgery. Since becoming a craniosacral therapist, I further understand how cranial nerve compression and tension in the body can also cause similar symptoms to tongue tie. The tongue may be restricted, but not specifically due to the presence of a tight frenum. A couple of sessions of cranio/bodywork beforehand may address these issues and have a positive impact on breastfeeding. A procedure may be avoided or it may become clearer that a release is necessary. Cranio after the procedure can help to resolve any stress and to optimise function.

There is so much controversy, and limited research, around tongue ties, that it can be difficult for parents to know whether to go ahead with a procedure to release a tie – especially with posterior tongue-ties and lip ties. Where there is doubt about the presence of a tongue-tie, cranio is a gentle, less invasive approach than laser frenectomy. But ultimately, treating the tongue-tie can make all the difference to breastfeeding success.

Contact me for a lactation consultation, tongue-tie assessment or cranio pre or post tongue-tie release.

Navigating laser treatment for tongue tie. To stretch or not to stretch?

The topic of posterior tongue tie (PTT) and lip tie (LT) is a controversial one. Research is limited and opinions are divided. I have worked with mums who have found treating these issues to make all the difference in their breastfeeding journey. However I do have concerns around some current practices including:

  • routine stretches / oral exercises / active wound management
  • laser frenectomy for breastfeeding problems that have not been thoroughly assessed by an IBCLC
  • laser frenectomy for babies to prevent future issues

The Australian Dental Association (in collaboration with a multidisciplinary team) has recently released a “Ankyloglossia and Oral Frena Consensus Statement” which I feel addresses some of my concerns.

The prescription of routine stretches/exercises after a laser frenectomy varies between providers. These are well intentioned, with the idea that they will prevent the lingual frenulum from reattaching or scarring. A recent client was advised to do them 6 times a day, for 21 days! There is no scientific evidence to prove that they do in fact prevent reattachment – and what of the risks? We know that they can cause oral aversion and exacerbate feeding issues. Babies are very orally sensitive. We need to respect when they are telling us “no”. Overriding this can potentially disrupt the parental bond. As a craniosacral therapist, working with the nervous system, I have a unique perspective as I am able to assess the impact of persistent stretches on babies systems. Babies respond to difficult experiences with a fight or flight response. But because they are physically unable to run away or fight, they can easily shift into freeze – a dissociative state. This is a protective survival mechansim and, unless treated, can become a lifelong pattern. Undergoing a laser frenectomy can be a traumatic experience for both mother and baby. With care and sensitivity the body can integrate this trauma with minimal lasting impact. It is my opinion that constant stretches for weeks afterwards interferes with the integration of the trauma, instead driving it deeper into the body.

My other concern is that babies with feeding problems are able to undergo the procedure without a full feeding assessment by an IBCLC. Nipple pain and milk transfer issues may not be related to the oral anatomy. An IBCLC can help to rule out nipple infections and positioning and attachment issues potentially avoiding surgery. Also, 1-2 sessions of cranio/bodywork beforehand may address issues such as myofascial tightness / jaw issues / cranial nerve impingment that can impact breastfeeding. Then, if no improvement in feeding, laser frenectomy can be trialled, often as a last resort.

Non-surgical management strategies can be effective first-line therapies for management of functional limitations associated with ankyloglossia. Surgical management should be considered only after non-surgical management has failed to address the functional issue that led to the diagnosis.

ADA Statement

Finally, the procedure is often done to prevent future issues. Parents have a lot of fear around future issues with speech or dental issues. These aren’t yet substantiated by evidence. Social media perpetuates this fear. In my humble opinion, the only reason to treat PTT and LT in babies is for feeding issues.

“Further research is needed regarding other reported adverse health outcomes, such as problems with speech, malocclusion, lingual gingival recession and obstructive sleep apnoea as evidence of a consistent causative relationship is lacking. No evidence exists to support buccal or labial frena causing problems with feeding or speech.”

ADA statement

That said …despite no evidence, I have seen lip ties interfere with attachment/seal at the breast. And I have seen lip ties contribute to decay at the top of the central incisors.

Laser frenectomy (compared to scissors frenotomy) needs much more consideration as it is a longer and more traumatic procedure. Here in Perth, parents have a few options, my preferred referral is to one that does not recommend stretches and where it is a requirement that every baby is thoroughly assessed by an IBCLC before the procedure. The good news is, if babies do need to undergo laser treatment for tongue tie or lip tie, just one session of cranio can help them to integrate the experience, bringing them out of fight or flight or a dissociative state. This has lasting positive impacts on feeding and the nervous system.