WHAT IS A TONGUE TIE?

During pregnancy, the developing tongue separates from the floor of the mouth. Sometimes this process is incomplete and some of the tissue remains – this is called a frenulum. If the frenulum interferes with the normal movement or function of the tongue, it is called “ankyloglossia”, or “tongue tie”.

HOW CAN A TONGUE-TIE AFFECT BREASTFEEDING?

For a painless and effective breastfeeding, the baby must latch on deeply onto the breast with the mouth wide open and the tongue forward. The tongue then moves in a wave-like motion which stimulates the breast to release its milk and for milk to flow to the baby. A tongue tie can make it hard for the baby to do these things and may contribute to:

• Compressed or pinched nipples, nipple damage, soreness, and vasospasm pain.

• Slow flow of milk from mother to baby, which can lead to:

• • Long and/or frequent feedings, decreased milk production and slow weight gain.

• • Nipple blebs, blocked ducts and mastitis.

• Difficulty latching or maintaining the latch, clicking sounds, or loss of suction.

• Difficulty coping with fast flow, pulling off, choking, sputtering, parental anxiety that the baby may aspirate breastmilk (actually aspiration of small amounts of breastmilk is not bad, but actually good). See this article:

HOW IS A TONGUE-TIE ASSESSED?

Some tongue-ties are obvious, but many are more subtle and require an evaluation that goes beyond just looking. The fact that the baby can stick out its tongue does not mean there is no tongue tie. A tongue tie is evaluated by decreased upward mobility of the tongue. This is done by having a finger on either side of the frenulum and trying to lift. Of course, what is limited upward mobility may sometimes be difficult to determine, but often it is obvious. Most health care professionals have not been trained to assess for tongue ties that can impact breastfeeding and may not recognize tongue ties that are anywhere but at the tip of the tongue. At the International Breastfeeding Centre, we assess all babies for tongue-tie as it relates to breastfeeding. We do this by:

• Asking you which breastfeeding problems you are experiencing

• Watching your baby breastfeed.

• Looking at to frenulum and evaluating upward mobility, as mentioned previously.

• We also base our decision to recommend a tongue tie release on the mother’s and baby’s symptoms. Breastfeeding should not hurt, babies should be able to latch on well. If the mother has sore nipples or the baby’s latch is not good, perhaps a “borderline” tongue tie is the problem.

WHAT IS A TONGUE-TIE RELEASE?

If we believe that a tongue-tie is contributing to your breastfeeding issues, we will offer to release it. The procedure is called a “frenotomy” (also know as a “release”, “revision”, or “division”). Frenotomy takes only a few seconds and is done in your clinic room during your appointment. Your practitioner will go over all the details of the procedure, answer any questions you may have, and ask you to sign a consent form thus agreeing that we gave you adequate information to make an informed decision. Releasing a tongue-tie often helps resolve breastfeeding problems, but we cannot guarantee that. It is always up to you to decide if you would like to have the procedure done.

However, we should mention that the earlier a tongue tie is released, the more likely breastfeeding problems are likely to resolve. Indeed, we believe that tongue ties should be released on the first or second day of birth if a tongue tie is present.

The procedure can be done during any of your appointments at the clinic. Your baby will be held securely by a supervising Lactation Consultant. She will lift your baby’s tongue firmly, exposing the frenulum and allowing for a precise incision. Using sterile scissors, the pediatrician will make a small cut into the frenulum followed by a quick push with his or her finger to release it completely.

AFTER A TONGUE-TIE RELEASE:

Babies generally cry as soon as they are restrained and crying continues for varying amounts of time after the procedure is complete. Immediately after, we recommend the baby is offered the breast, with assistance as needed. Many babies latch and calm quickly while others take a little longer to settle, perhaps while being walked by a parent or caregiver. There is usually some insignificant bleeding, which usually stops as the baby calms, especially if s/he calms at the breast. Sometimes, gauze and pressure are used if blood pools under the tongue or bleeding continues for longer than usual. Rarely, other means will be used to slow or stop more significant bleeding; these will be discussed with you as necessary/if you desire.

The baby’s latch may feel different immediately or it may take a few days or longer for baby to use his/her tongue differently and for the breastfeeding situation to improve.

Most parents do not feel the need to give pain relief (acetaminophen or ibuprofen) following a release. Some babies are fussier than others and some, especially babies older than 2 or 3 months) may refuse the breast for a few hours after the release and, in these cases, a dose may be helpful. More information about giving pain relief medication will be provided to you after the release.

We occasionally hear that a baby is still fussy about feeding or refusing the breast the day after the procedure. Long-term breast refusal is very rare.

HEALING, REATTACHMENT AND TONGUE-TIE EXERCISES:

The tiny incision, followed by a push, creates a diamond shaped wound, which turns creamy white, yellow, or orange for several days before healing completely. This is normal healing in the mouth and not a sign of infection. Infection does not seem to be an issue with tongue-tie releases in babies. Indeed we have never seen it.

During healing, the surfaces of the wound tend to close together forming some degree of reattachment, which varies from baby to baby. Some practitioners recommend after-care exercises or stretches to help minimize reattachment. In our experience, how effective stretches are to  prevent re-attachment is debatable. The stretches are often challenging and unpleasant for both the baby and parents. Our recommendation about doing stretches has changed frequently, over the years. At present our lactation consultants recommend doing them.

If there is significant reattachment (which is uncommon), a second release might be suggested.

For more information, you can visit these websites: www.tonguetie.net, www.kiddsteeth.com

LIP TIES

Many babies have a small piece of tissue connecting the top gum to the underside of the top lip.  If this tissue is tight and/or broad and seems to restrict the ability of the lip to form a tight seal at the breast or causes rubbing of the lip against the breast, it is called a “lip tie”.

Lip ties are a debated topic in breastfeeding right now. Because there has been no research in this area. We may offer to release a lip tie, usually along with a tongue tie release, if it seems to be contributing to your breastfeeding concern(s) (especially nipple pain and difficulty latching or maintaining a latch).

A lip tie release takes only a few seconds and can be done immediately after a tongue-tie release.  There will be bleeding from the area similar to what is described regarding tongue-tie release. With lip tie release, no after-care exercises are recommended. We cannot guarantee a lip tie release will help with breastfeeding.  It is always up to you to decide if you would like to have the procedure done.

NOTE REGARDING VITAMIN K:

A vitamin K shot to help prevent bleeding problems in newborns is routine in hospital births. Babies less than three months old who did not receive the vitamin K shot should have it at least 24 hours before the clinic appointment if a release is anticipated. We cannot do the procedure if the baby has not had a vitamin K shot. For more information about this, please contact us at 416-498-0002 ext. 224 or clinic@ibconline.ca.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

©IBC, November 2016, October 2021

Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).

Make an appointment at the Newman Breastfeeding Clinic.