What is tongue-tie?

By Cordelia Uys, NCT Breastfeeding Counsellor, August 2021

In this article I explore the possible impact of a tongue-tie (Ankyloglossia) on breastfeeding and bottle-feeding.

The piece of skin under our tongue is known as the lingual frenulum. If a lingual frenulum is tight, this is referred to as a tongue-tie. It’s estimated that between 10% and 11% of babies are tongue-tied. Tongue-tie is one of the most common causes of breastfeeding difficulties.

What happens inside a baby’s mouth?

When a baby latches on to their mother’s breast, in order for breastfeeding to be efficient and pain-free, and for the baby to get good quantities of milk, the baby has to take a deep mouthful of breast, their tongue needs to reach forward over their lower gum, and the mother’s nipple needs to reach to the junction of the baby’s hard and soft palate. (You can feel this area by putting your thumb, nail-side down, into your mouth as far as it will go.)

Possible effects of tongue-tie

Pain and damage: a tongue-tied baby may struggle to fully extend their tongue, resulting in the tongue pushing the nipple up against their hard palate. This can cause a mother pain and damage. However, if she has longer nipples, and/or there is some “give” in her breasts, her nipples may be able reach further back in the baby’s mouth, reducing the likelihood of pain.

Reduced milk supply: a tongue-tie can also make it harder for the baby to get a deep latch, to create a seal, and to transfer good volumes of milk. Since milk production relies on milk being removed regularly and effectively, this can result in reduced milk supply. Sometimes this is immediately noticeable, but if a mother has a naturally generous milk supply, the effect might not become apparent for a few weeks.

Difficulties latching or staying latched: some tongue-tied babies can’t extend their tongue enough to latch, others manage to latch, but constantly lose their grip, resulting in a clicking noise and/or a baby who keeps popping off the breast.

Tummy discomfort/wind: when babies keep losing their grip, they can end up swallowing lots of air.

Feeding for a long time or very frequently: for a baby with a tethered tongue, breastfeeding can be like eating a bowl of porridge with a very small spoon.  

Mastitis: when a baby struggles to remove milk efficiently, mothers are more at risk of developing blocked ducts, which in turn makes them more prone to mastitis.

How much the baby is affected by a tongue-tie will depend on each individual baby’s tongue muscle mobility and control. It is therefore very important to seek out a specialist breastfeeding assessment when a tongue-tie has been noted.

Bottle-feeding and tongue-tie

Tongue-tie can make also make bottle-feeding more challenging. Babies can struggle to create a seal on the bottle teat, resulting in milk dribbling out of their mouth.

Types of tongue-tie

An anterior tongue-tie is when the baby’s lingual frenulum extends partly or completely to their gum line. This tends to be easy to spot when the baby cries.

A posterior tongue-tie is when the lingual frenulum is thicker and further back in the baby’s mouth. It is usually hard to detect without feeling inside the baby’s mouth.

Frenulotomy

Releasing a tongue tie (known as a frenulotomy) is a quick, low-risk procedure, which is carried out by a tongue-tie practitioner, using sharp, sterile scissors which are blunt at the end. In young babies, this is done without anaesthetic as there are few nerve endings in that area of the mouth. If possible, mothers are encouraged to put their baby to the breast immediately afterwards, as breastmilk has pain-killing and antibacterial properties. There isn’t usually much bleeding. As the wound heals, babies develop a white or yellow patch under their tongue that lasts a few days. Some dentists use a laser to treat tongue-tie, but this takes much longer and can leave babies traumatised.

To treat or not?

Not all tongue-ties need to be released in the first instance, especially if the mother isn’t in any pain and the baby is gaining weight as expected. However, it is important to recognise that a baby who is feeding with a tongue-tie may feed less efficiently than other infants and is at risk for feeding-related problems.

Possible issues include:

• Slow weight gain.

• Reduction in breast milk supply.

• Lengthy feeds.

• Blocked ducts and mastitis.

If you decide not to treat your baby’s tongue-tie, it is advisable to:

• Keep a close eye on your baby’s weight gain. Weighing your baby on a 2-weekly basis until around 4 months is recommended.

• Feed very responsively, including at night when prolactin levels are highest.

• A few times a day, offer the breast even if your baby isn’t showing hunger cues.

• Avoid limiting your baby’s time at the breast.

• Avoid using dummies, which can mask a baby’s hunger cues.

• Ensure you always offer both breasts at each feed. Switching between breasts 3 or 4 times during a feed can encourage more active drinking.

• Use breast compressions.

Post frenulotomy exercises

If parents decide to get their baby’s tongue-tie divided, after the procedure, it is important to help the baby re-learn how to use their tongue well. There are rare occasions (about 1:100) when a particular type of tongue-tie (posterior) can grow back again, so to ensure the best results, please follow the tips below.

In the 24 hours after the tongue-tie release is done, it is important to keep the tongue moving as often as possible. Breastfeeding is the best way to get the tongue moving in the correct way again, as long as mum pays careful attention to good latching, so please encourage the baby to breastfeed as often as the baby is willing.

Another way to loosen the baby’s tongue so that it can work well, is to play a ‘mirroring game’ with the baby. This involves getting the baby’s attention and when it has focussed on your face, stick your tongue out. The baby will look for a while and then will try to copy you by sticking its own tongue out. Most babies love this game and the freedom they feel when their tongues move well!

In addition, after 48 hours: 

• You and baby can play ‘tug of war’ with your finger in the baby’s mouth. Let your child suck on your finger, slowly trying to pull your finger out while they try to suck it back in

• Slowly rub the lower gum line from side to side and your baby's tongue will follow your finger. This will help strengthen the lateral movements of the tongue.  

Cogs Sutherland writes about her experience of having a tongue-tied baby

We had our baby’s tongue-tie divided very late at 16 weeks. I attended Cordelia's introducing solids workshop when my first baby was 4 months old and whilst she was holding him (when I went to the loo) she spotted what she and the tongue-tie practitioner later called a "corker" of a tongue tie. We had been told at birth at UCLH that he had a mild tongue-tie and it was recommended to just leave it and we saw various health professionals between then and Cordelia seeing him and I still don't know why no-one realised it was so significant. Although his weight gain had been a bit slow the lactation consultants at the breastfeeding drop-in were amazed he had managed to thrive so well and had found a way to feed and take on enough milk. He was an extremely chubby baby and I must have had a lot of milk. Then when I thought about it, it might have been because he fed ALL DAY LONG (and night!). He also got very tired feeding, but I had nothing to compare it too so I didn’t know how a baby should be feeding. So now I always wonder what our early breastfeeding experience would have been like without the tongue-tie - easier I suspect.

I had concerns about having it done at this late stage because I wondered if would be more traumatic for him at this age than in the first few weeks. The benefits of having it done at 16 weeks that were explained to me outweighed those concerns and we decided to go ahead. The procedure was over very quickly and although he screamed, (and I had to swallow my tears) I stuck him straight on the boob and we had lots of cuddles that evening and skin to skin and no after effects at all. Half an hour later he was smiling and flirting with passengers on the train home! It improved his suck almost immediately and made feeding much more efficient and he was definitely less vommie and windy. He used to be very uncomfortable on his back too, in the first 3 / 4 months. I’ll never know whether it was just his gut maturing or the procedure that helped!

I wish I’d got his tongue-tie released earlier because when we did get it fixed I realised what a hindrance it had been even though I had absolutely no pain - very luckily.

With my second baby I knew what to look out for and did experience pain immediately (with my first I had no pain beyond the first week or so) and got her tongue tie divided on day 5.

Links:

https://www.tongue-tie.org.uk/

Find a tongue-tie practitioner: https://www.tongue-tie.org.uk/find-a-practitioner/

https://www.nhs.uk/conditions/tongue-tie/

http://www.cwgenna.com/ttidentify.html

https://journals.sagepub.com/doi/abs/10.1177/0890334404266976

What is Breast Compression? - Breastfeeding Support  

https://www.laleche.org.uk/my-baby-needs-more-milk/

https://www.cordeliauys.co.uk/howtotellyourbreastfedbabyisgettingenoughmilk

Average Weight Gain for Breastfed Babies • KellyMom.com