Tongue Tie (Ankyloglossia)

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 can be 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, potentially resulting in a tongue tie.

If the frenulum is too tight or too short, it may impact the baby’s ability to use his tongue to feed well – this can affect breastfeeding and to some extent bottle feeding as well, anecdotally also having the potential to cause future problems with oral health and development, speech, digestive problems, and others.

A visible frenulum is quite normal - we all have a frenulum - but if it is too short or thick, or attached to the floor of the mouth in a less than ideal position, it may cause problems. However, every baby and mother needs to be assessed on an individual basis, in person. Ties cannot be assessed simply by looking at a photograph of the inside of the baby’s mouth, or just by looking at what the baby looks like when feeding. Assessment is a combination of many factors.

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 his bottom gum, use his tongue to cup and grasp the breast, bringing the breast tissue far enough back in his mouth to ensure that the nipple is not squashed between the tongue and hard palate, creating a vacuum that assists in the milk flow from the breast. If the movement of his 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 back 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, or 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 postpartum), the baby’s weight gain starts to drop and the mother notices a decrease in milk supply. All of these things MAY 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 and all other strategies have been exhausted, 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 may be left alone if all else is going well.

Many practitioners use a combination of assessment tools such as the Hazelbaker, BTAT or TABBY assessments – all include looking at both appearance and functionality of the tongue in the breastfeeding baby, as well as taking a full history, including details of the mother’s pregnancy, labour and birth, breastfeeding history with the new baby as well as any other children she has fed.

Are tongue ties more common these days?
It’s not clear whether tongue ties really are occurring more frequently than before.
As formula became more of the “norm” for babies a few generations ago, and was believed to be scientifically superior for a while, it was easier to switch babies to bottled formula feeding. Any potential tongue tie was then less of an issue as the mother was not in pain; subsequently knowledge and experience of ties dwindled. You may have heard stories about midwives in the “old days” keeping a finger nail long to cut a tie as soon as the baby was born!

It is likely that due to more mothers wanting to breastfeed, and generally having access to better and more easily available breastfeeding help, tongue ties are again being discussed, 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, scissors, scalpel are a few examples. Laser is more expensive than scalpel or scissors. Some midwives and lactation consultants perform frenotomies, in other areas GPs or paediatric dentists will carry out the procedure. With scissors or a scalpel the tight frenulum is usually cut in one or two places to relieve the tongue and allow normal movement. There is usually a 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 encouraged to feed the baby. With laser, the tight frenulum is removed and there is usually very little bleeding. The baby is often not upset by the procedures itself - no matter the method used, but often does not enjoy adult sized fingers being poked in the mouth and under the tongue during the process.

Some mothers report immediate improvement, however most babies take more time to get used to the new mobility of their tongue. Tongue exercises are reported to help many babies learn to use their tongue more efficiently and effectively: http://vimeo.com/ 55658345 The tongue is a muscle; the baby is learning to use their tongue the entire time they are in utero, sucking, swallowing and often putting fingers in their mouths. When the baby’s tie is release, there is a period of learning how to use their newly mobile tongue in a different way. Whenever any of us has to learn to use a muscle in a different way, it takes time and can be tiring.

There is more and more discussion supporting the use of osteopathy or craniosacral therapy for babies that have had a tie released. Ties can result in tightness in the baby’s jaw, neck, and shoulder areas, which can exacerbate feeding problems. It is becoming more common for mothers to be advised to seek bodywork for their baby before and after a tie has been revised.

There are times when what looks and behave like a tongue tie, is actually resolved by body work. This was reported by Alison Hazelbaker a few years ago, and has led to more practitioners advising bodywork prior to tongue tie treatment.

Once the tongue tie has been divided, you should revisit your breastfeeding support specialist to ensure positioning and latching is optimal, and to get support with helping your baby to feed well.

References/further reading:
http://www.lunalactation.com
http://www.kiddsteeth.com/articles.html
http://www.brianpalmerdds.com/
Congential Tongue Tie and its Impact on Breastfeeding: https://www.researchgate.net/publication/301346077_Congenital_tongue- tie_and_its_impact_on_breastfeeding

Tips for bottle feeding a breastfed baby: http://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/
Side lying bottle feeding:
https://youtu.be/oWrTfzQXhRQ
Bobby Ghaheri: Post release procedure stretches: https://vimeo.com/255055551
Tongue Exercises:
http://vimeo.com/55658345
Book: Supporting Sucking Skills in Breastfeeding Infants, Catherine Watson- Genna