Tongue-tie occurs when tongue movement is restricted by the presence of a short, tight membrane (the lingual frenulum) that stretches from the underside of the tongue to the floor of the mouth. This strand of tissue is visible when the tongue is lifted and is a normal part of the anatomy. However, when it is short, tight, and inelastic, extends along the underside of the tongue, or is attached close to the lower gum, it will interfere with the normal movement and function of the tongue and is known as a tongue-tie. The baby has difficulties building up a good vacuum during the feed as well as emptying the breast efficiently due to the malfunction of the tongue. It is more common in boys and around ten to 20 per cent of babies will be born with a tongue-tie. However not all require surgical intervention.
Recently, knowledge about tongue-tie has increased and luckily the number of midwives, doctors, health visitors, and nurses who are able to diagnose or at least suspect a tongue-tie is growing, although there is still much room for improvement and it is not standard practice to check or treat them in the hospital after birth. Many health care professionals are still not convinced that tongue-tie is a real diagnosis, even though the condition has been described and treated centuries ago and is today described in the Nice guidelines.
Tongue-ties may be graded I-IV or from 25-100 per cent, depending on the location of the frenulum attaching from the underside of the tongue to the gumline or floor of the mouth.
Some forms of tongue-tie are easy to diagnose; these are also known as “anterior” tongue-ties, meaning the frenulum attaches to the tip of the tongue. Others require skilled assessment.
Some signs of tongue-tie in mums are painful feeding; cracked nipples; misshapen, white nipples; painful latch and engorged breasts; recurrent blocked ducts; mastitis.
Baby’s symptoms can be: a white membrane visible under the tongue when crying; a heart-shaped tongue; inability to open the mouth wide; restricted tongue mobility; slow weight gain; clicking sound during feeds; sucking cheeks in; gulping and spluttering; very windy and colicky; screaming after feeds; fussy on the breast; sliding off during a feed; needing repositioning; dribbling down the side of the mouth; reflux; spitting up.
The criterion for treatment is feeding difficulty. If the mother has received breastfeeding support and correcting latch and positioning don’t have enough effect, then surgical treatment as soon as possible is advisable. This will help mothers to continue breastfeeding instead of switching to formula.
Some bottle-fed babies also require treatment. Restricted tongues have the inability to build up a vacuum. Those babies often dribble while feeding and are often very unsettled, due to swallowing a lot of air. This can lead to symptoms of reflux and colic and many babies are treated for reflux with medication, which may attend to the symptoms but not the cause. Many babies cough, splutter, and choke on the bottle, as the limited mobility of the tongue doesn’t allow for managing the milk flow towards the back of the throat.
Tongue-tie can have long-term consequences. It can lead to difficulties weaning on to chunky foods, as the tongue can’t move the food around the mouth. Many tongue-tied babies are fed finely puréed food and struggle to drink from a cup. Speech problems can occur due to limited tongue movement. Orthodontic issues due to restricted jaw growth can lead to overcrowded and crooked teeth. Many adults with untreated tongue-ties report problems with TMJ pain, clicky jaws, snoring and mouth breathing.
The tongue-tie procedure is usually performed without anaesthetic up to one year of age (varying between services and experience of the practitioner) and is usually well tolerated. The baby is swaddled and head and shoulders need to be held to minimise movement. The frenulum is usually cut with sterile surgical scissors, but some practitioners use laser. There should be minimal bleeding and it is encouraged to breastfeed (or bottle feed) the baby straight afterwards, for comfort and so the tongue can press down on the wound.
Complications such as prolonged bleeding or infections are very rare (1:10,000) and most babies recover and heal well. If the baby is older than two months it is permissible to give paracetamol before and after the procedure, but it may not be necessary.
There are some exercises that will encourage tongue movement and need to be done four to five times a day for three to four weeks. Make sure a deep latch is practised after the procedure as this is a good way to keep the tongue moving. Unfortunately, about two to four per cent of cases reattach and will have to be revised if symptoms return.
Dr Sharon Silberstein is a medical doctor, International Board certified lactation consultant and tongue-tie specialist and the owner and director of Dr Silberstein Clinic. She has been working in the field of breastfeeding medicine for ten years. Dr Silberstein Clinic is dedicated to infant feeding, tongue-tie and associated services for infants and their families. Experienced lactation consultants, osteopaths, speech and language therapists provide holistic care. Families can also purchase breastfeeding equipment such as breast pumps, items for nipple and breast care and and other essentials on-site. Courses are offered, such as baby massage, paediatric first aid, baby weaning and newborn care, with more planned.
