‘Tongue tie’ is the term used for babies who have a tighter than usual frenulum connecting their tongue to the floor of the mouth, effectively tethering the tongue’s movement. This can cause nipple pain during breastfeeding and create difficulty transferring milk for successful weight gain.
What should I look for?
Often, a tongue tie is visible, and you can see the tongue makes a U or W shape when the baby’s mouth is open because the frenulum is pulling the middle tissues of the tongue downwards. Sometimes, it isn’t visible, but still causes problems.
The same condition can happen with the upper lip, pulling the upper lip back towards the gum, which prevents the upper lip from being able to make a complete flange for a correct seal. You might be able to feel the frenulum of your lip with your tongue. Lip ties are less important than tongue ties, and don’t happen in isolation without a tongue tie. You shouldn’t ever see a lip tie cut without a tongue tie being cut, and most often they are left alone unless they are really seriously restricting the baby from making a good seal/latch.
Why is this so confusing?
Tongue ties can be really tricky to figure out. Sometimes we can see them, but they don’t pose a problem in either the parent or the baby. Sometimes we can’t see them, but they are there, and causing lots of problems. Often the situation is somewhere in between. It’s always best, when tongue tie is suspected, to have it ruled out by a pediatric dentist or ENT.
Babies with these tethered oral tissues have limited mobility of the tongue and/or lip, and therefore have a very difficult time breastfeeding, as they are unable to properly move their tongue to pull the nipple deeply into their mouth for a deep latch and ‘milk’ the nipple to extract milk. Because they struggle to maintain a good latch or proper seal, they take in more air with feeding, causing more gas and spit up. All of this can lead to poor weight gain and discomfort in the baby.
It also leads to pain during feeding and severe nipple damage for the lactating parent, as the nipple is being compressed in the hard palate with a shallow latch. These symptoms in both the baby and the parent are usually apparent within the first few days of birth and will not improve, even with continued work on latch and technique.
Where should I get help?
If you are dealing with this cluster of signs in the baby or the lactating parent, it is crucial to get help immediately, both to address the immediate needs, and before any injury or weight loss becomes too severe. Sometimes, dealing with a tongue tie will lead to a premature end to breastfeeding, despite a family’s earlier commitment to it.
The first step is usually to find a Lactation Consultant who will evaluate the baby’s mouth, watch them feed, and weigh them before and after the feed to assess how much milk they are transferring. The information they gather will help them assess the problems and if they believe that a tongue tie is a concern, they will refer you to a dentist or ENT who will release the tie in a brief procedure called a Tongue Tie Revision, where the frenulum is simply cut, or “released” with scissors or a laser. It can be hard to get on these providers’ schedules, so don’t delay in following up if you decide to do the procedure.
In the meantime, the Lactation Consultant will help you come up with a schedule to feed, pump and supplement to increase and/or protect your milk supply, and to ensure your baby is getting enough milk. (Remember the old Triple Feed?!)
In most cases, a tongue tie revision successfully resolves the breastfeeding problems, and the parent-baby dyad is able to continue their lactation journey. There is some recovery, some exercises to prevent scarring in the mouth, but overall, it’s not a difficult procedure that can have a lot of advantages.
Why is this such a tough decision?
It’s extremely common for people to have mixed feelings about having their newborn undergo a procedure so soon after birth. Please do ask all the questions you need of your providers to get the assurance you need that this is necessary and to feel confident it’s the right choice for your family! Also make sure that you have a good tongue tie release provider with good recommendations from your lactation consultant, who has seen the results of their work.
For those who are feeling uncertain, I usually offer these thoughts:
You’re not wrong that the internet is a conflicted mess about it all. Strong thoughts pro and con abound. Try to avoid Dr. Google and listen to providers you trust who have actually seen your baby. Put stronger weight on the advice of people who are trained in breastfeeding and in the anatomy of the mouth (in other words, what the pediatrician and the nurses at the hospital saw should matter less than what the lactation consultant and pediatric dentist see).
Yes, there is more discussion of tongue tie these days. But if you look in the past, it was actually always there. There are stories of midwives cutting ties that they could see upon delivery. It’s a procedure we used to do without thinking about it, because babies who couldn’t breastfeed were much less likely to survive. Then when formulas were introduced, babies who couldn’t breastfeed simply moved to the bottle, and the procedure dropped out of our collective social memory. As breastfeeding rates have increased, the issue and procedure is being remembered. The problem we now have is that it is a bit of an orphan; lactation consultants can’t diagnose or treat it, pediatricians aren’t trained in it, dentists and ENTs do diagnose and treat but aren’t the primary providers. There are almost no good studies to provide an evidence base. This issue is in flux. The limited evidence we do have says that breastfeeding mothers largely feel positive after the procedure, in that it improves their pain and improves feeding.
The procedure, in the hands of a good provider, is not terrible for your baby. Think of it much more along the lines of getting a shot than a surgery. It takes the same amount of time - it is a literal snip - and your baby will make the same shocked cry, but that’s it. There are few nerves or blood vessels in that piece of tissue so the pain is minimal, although providers will usually use a local anesthetic. Babies are often latched immediately following the procedure and typically you can feel the improvement instantly.
If you are one of our bundled clients, you may choose to use your hour of Infant Feeding Counseling to share and discuss your concerns about tongue tie. You are not alone in feeling confused and nervous and it often helps to talk it through.
~ Naomi, Infant Feeding Expert
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