What is Tongue Tie?
Tongue Tie occurs when tongue movement is restricted by the presence of a short, tight membrane (known as the lingual frenulum) which 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 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 a tongue-tie. The baby has difficulties building up a good vacuum during the feed as well emptying the breast efficiently due to the malfunction of the tongue. It is more common in boys (2:1) and around 10-12% of babies will be born with a tongue tie.
Why do we suddenly hear so much about Tongue Tie?
Recently the knowledge about Tongue Tie has increased and luckily the number of midwifes, doctors, Health Visitors and nurses who are able to diagnose or at least suspect a tongue tie is growing, although there is still a big room for improvement and it is not standard practise to check or treat them in the hospital after birth.
How are Tongue Ties being classified?
There are a few ways of classifying tongue ties, the most obvious is dividing them into "anterior" and "posterior" ties. Anterior ties are easily visible, often they cause the tongue to have a typical heart shape. Posterior ties are not as simple to spot as they are often embedded and need to be diagnosed by a professional trained in diagnosing and treating Tongue Ties, such as a lactation consultants, some ENT doctors, some specialised dentists.
What are the signs of Tongue Tie?
Some signs of Tongue Tie in mums are: cracked nipples, misshapen, white nipples, painful latch and engorged breasts.
Baby's symptoms can be: a white membrane visible under tongue when crying, a heartshaped tongue, inability to open their mouths wide, tongue mobility is restricted (baby can't stick his tongue out, although it doesn’t mean that baby doesn’t have Tongue Tie when he/she can stick his/her tongue out), slow weight gain, clicking sound during feeds, sucking cheeks in, gulping and spluttering, very windy and colicky, screaming after a feed, fussy on the breast, sliding off during a feed, needs repositioning, dribbling down the side of the mouth and others.
Does every Tongue Tie require treatment?
Some Tongue Ties are, even when very visible, asymptomatic and require no treatment. Some mild cases might resolve when baby grows and can feed more efficiently.
The criteria for treatment are feeding difficulties. 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 babies require treatment, even when they are bottlefed because of the inability to build up a vacuum. Those babies often dribble while feeding and are often very unsettled because they swallow a lot of air.
Can Tongue Ties have other implications other than breastfeeding difficulties?
Yes, Tongue Ties can lead to speech problems due to the limited tongue movement and orthodontic issues due to restricted jaw growth, which can lead to overcrowding and crooked teeth.
What about Lip Ties?
Some very severe lip ties can have an influence on breastfeeding but most cases will be resolved by just revising the Tongue Tie. In the UK the official guidelines state that as opposed to Tongue Tie Division there is not enough evidence to support the benefits for breastfeeding and is therefore not performed as a standard procedure.
How is the Tongue Tie Revision (Frenotomy Procedure) done?
When performed on a newborn up to 4 months the surgical treatment is usually performed without anaesthetic and is usually very well tolerated. The baby is swaddled and head and shoulders need to be held to minimise movement. The frenulum is cut with sharp, blunt surgical scissors. There should be minimal bleeding and it is encouraged to breastfeed baby straight after that for comfort but also so that the tongue can press down on the wound. Complications such as prolonged bleeding or infections are very rare (1:10000) and most babies tolerate it very well. If baby is older than 2 months it is permissible to give paracetamol before and after the procedure, it may not be necessary.
Aftercare includes keeping the site very clean, do not let baby suck fingers that haven't been washed thoroughly with soap, if baby uses a dummy or bottle, make sure it is sterilised.
Massaging the wound several times a day to prevent the regrowth or reattachment of the frenulum can potentially help but there has not been any scientific prove for or against it yet. There are some exercises I show the parents which will encourage tongue movement and need to be done 4-5 times a day for 3-4 weeks. Certainly making sure a deep latch is practised after the procedure is a good way to keep the tongue moving. Unfortunately about 2-4% of the cases will reattach and will have to be re-revised if the symptoms return.