Tongue-Tie and Breastfeeding
Catherine Watson Genna
New York City NY USA
From: LEAVEN, Vol. 38 No. 2, April-May 2002, pp. 27-29.
Tongue-tie or ankyloglossia
(from the Greek for “crooked tongue”) is the condition where the lingual
frenulum, the band of tissue that attaches the tongue to the floor of
the mouth, restricts tongue movement. In tongue-tied infants, the frenulum
is usually attached close to the tongue tip, leaving little or no “free
tongue,” but it can also be placed further back and be unusually short
or tight. For generations, this condition was diagnosed and treated
at birth to prevent breastfeeding and speech difficulties, but with
the decline of breastfeeding in the 1940s and 1950s, treatment fell
out of favor. With the resurgence of breastfeeding, tongue-tie was again
identified as a potential problem, and researchers have subsequently
begun identifying diagnostic and treatment criteria that are appropriate
for supporting breastfeeding mothers.
Normally, the free tongue measures
at least 16 millimeters by the time a child is 18 months old (Kotlow
1999). The tongue tip should be able to extend to lick the lips, lift
the front half of the tongue to the roof of the mouth, and sweep along
the gums. If a tongue-tied baby tries to extend the tongue, it may not
be able to extend past the lower lip, or the tongue tip might be forced
downward over the lower lip. If the tongue is particularly tight, the
back of the tongue will lift while the front remains tied down to the
floor of the mouth, which is sometimes called “tongue humping.” If the
baby attempts to lift a tied tongue, it often leaves a dent in the tip
of the tongue, reminiscent of the top of a heart. The sides of the tongue
will lift more than the center if the baby is tongue-tied. When the
tongue tip attempts to reach either side of the mouth, the baby will
twist the tongue and will not be able to bring the tongue tip to the
back of the gums. A severe tongue-tie will prevent the baby from getting
the tongue tip over the lower gum ridge. The presence of the tongue
over the gum ridge inhibits the baby’s bite reflex. If the breast touches
the bare lower gum the baby will reflexively bite.
The tongue is the
major “player” in breastfeeding. It helps pull the breast into proper
position in the mouth, then grooves along its length to make a channel
to keep the breast in place in the mouth and to catch milk to hold it
at the back of the tongue in preparation for swallowing. Cineradiographic
(motion picture x-ray) and ultrasound studies have identified tongue
movements during breastfeeding (Ardran 1958; Bosma 1990; Woolrich 1986).
The tongue tip elevates and traps milk in the front of the breast, then
a wave of compression moves back along the tongue from front to about
halfway back, pressing milk from the areola toward the nipple. The back
of the tongue drops toward the floor of the mouth to decrease the pressure
in the mouth, and milk is expelled from the nipple by the combination
of positive (compression) and negative (vacuum or suction) pressure.
Breastfeeding difficulties caused by tongue-tie are usually proportional
to the tightness of the frenulum, the shortness of the free tongue,
and the flexibility of the floor of the mouth. Even with a complete
tongue-tie where the frenulum attaches to the tongue tip, the baby might
be able to breastfeed without treatment if the floor of the mouth is
flexible and can be pulled up to allow more tongue movement, but the
compensations involved are fatiguing and make feeding less efficient.
Conversely, some infants have the frenulum attached far back from the
tongue tip, but it is so short that it keeps the tongue from lifting
and extending. An infant with an untreated tongue-tie usually needs
to feed longer and more frequently than an infant without ankyloglossia.
An untreated tongue-tie may also predispose infants to dental and breathing
problems due to failure of proper tongue movements during breastfeeding
to spread the palate (Palmer 1998).
Infants attempt to compensate for
tongue-tie in several ways. The most common is to use the jaws to increase
the positive pressure exerted on the breast. In this instance, the mother
reports that the baby is biting or chewing the breast. The nipple usually
exits the mouth looking squashed or beveled, like the end of a new lipstick,
with a distinct compression ridge running across the nipple. The nipple
may blister at the apex of the compression ridge at the tip of the nipple,
or the skin may burst, leaving a crack in the nipple. The mother’s pain
is proportional to the amount of nipple compression and tissue damage.
The baby also fatigues more readily when using excessive compression,
and in severe cases, jaw tremors occur from muscle fatigue and interrupt
the feeding.
A shallow latch accentuates the excessive compression that
tongue-tied babies use when attempting to breastfeed. When a baby has
a shallow latch on his mother’s breast, his tongue is less stable. A
less stable tongue means that the baby must exert more pressure to get
milk. Pain can slow the mother’s milk ejection reflex, and the amount
of pressure the baby uses will increase in an attempt to get more milk.
Once milk begins to flow, baby reduces his sucking pressure and the
milk reduces friction by lubricating the nipple, both of which temporarily
reduce mother’s pain.
Another common compensation is to use the lips
(instead of the tongue) to try to move milk from the breast when the
tongue is tight or the latch is shallow. During breastfeeding, the infant’s
lips should maintain a seal around the breast, but should not move much.
If the lips are turned outward like “fish lips,” the baby may be using
them to move milk from the breast instead of the tongue. The baby may
also be using the lips to try to maintain a grip on the breast. Tongue-tied
infants may “fall off” the breast often during a feeding.
Infants with
a tight frenulum can often breastfeed with special attention to a deeper
latch that maximizes tongue contact with the breast. An asymmetric latch,
where the nipple is presented to the infant’s upper lip so the baby
extends the head back slightly, opens wide, and latches on with the
lower lip and tongue tip as far away from the nipple as possible can
help achieve this goal (Eastman 2000). It may also be helpful for the
mother to position the lower lip on the areola, and roll or pivot the
baby onto the breast. If the baby chokes or sputters during feeding,
leaning back so baby is almost lying on mother’s chest can improve his
ability to handle the flow of milk. The mother can be encouraged to
be patient with the baby and not expect him to be as efficient as other
infants. A tongue-tied infant is especially vulnerable to failure-to-thrive
if feedings are timed or rigidly scheduled.
The most important consideration
in determining whether the baby might need to be evaluated for treatment
is how well the tongue functions. If the tongue looks very tight, but
the baby is sucking properly and gaining well, swallowing comfortably,
and the mother is not in pain or distress, there is less concern than
if the tongue does not look classically tied but the baby has difficulty
moving milk or the mother is in pain from the baby’s sucking.
Several
health care professionals can assess and treat a restrictive lingual
frenulum (tongue-tie), including oral surgeons, otorhinolaryngologists
(also known as “ear, nose, and throat specialists” or ENTs), pediatric
surgeons, and some pediatricians and general dentists. The mother can
ask her health care provider to give her a referral to a specialist.
There are several treatment options for a tongue-tie. The simplest and
most commonly used in infants is the frenotomy, in which the frenulum
is snipped with sterile scissors under a local anesthetic. Frenotomy
involves very little bleeding and is a low-risk procedure. The baby
can usually go directly to breast after the frenotomy, and mother may
notice an immediate difference in the effectiveness and comfort of breastfeeding.
Other infants may take a week or two to figure out how to use their
newly freed tongue. If the baby seems to need help sucking properly
after frenotomy, the mother may check with myofunctional therapists,
speech and/or feeding therapists, or lactation consultants to see if
they have experience working with this situation.
A Leader’s primary
role is to offer the mother support and information about treatment
options. If tongue-tie seems to be an issue, the Leader can help the
mother treat any soreness she may be experiencing, as well as share
information about this condition with the mother and encourage her to
find help for her infant. If the mother is hesitant to broach the topic
with her baby’s health care professional, the Leader can help the mother
role-play communicating with him or her (Sachetti 1998). Some parents
decline to even have the tongue attachment medically evaluated and some
health care providers deny the need to treat ankyloglossia. If either
of these situations occurs, the Leader respects the parents’ decision
and supports the mother through breastfeeding her infant, and, possibly,
finding another health care provider who will treat it, recognizing
that feeding by any method will be less efficient for a tongue-tied
baby.
References
Ardran, G., Kemp, F., Lind J. A cineradiographic study
of breastfeeding. British Journal of Radiology 1958; 31(363): 156-162.
Bosma, J., Hepburn, L., Josell, S., et al. Ultrasound demonstration
of tongue motions during suckle feeding. Developmental Med Child Neurol
1990; 32: 223-229.
Eastman, A. The mother-baby dance: positioning and
latch-on. Leaven Aug/Sept 2000; 63-68.
Hazelbaker, A. K. The Assessment
Tool for Lingual Frenulum Function. Columbus, Ohio: Self-published,
1993.
Kotlow, L. A. Ankyloglossia (tongue-tie): a diagnostic and treatment
quandary. Quintessence Int. 1999 Apr; 30(4): 259-62.
Marmet, C., Shell,
E. Training neonates to suck correctly. MCN 1984; 9: 401-407.
Marmet,
C., Shell, E., Marmet, R. Neonatal frenotomy may be necessary to correct
breastfeeding problems. J Hum Lact 1990 Sep; 6(3): 117-21.
Merewood,
A. and Philipp, B. Breastfeeding: Conditions and Diseases. Amarillo,
TX: Pharmasoft Publishing, 2001.
Messner, A. H. Ankyloglossia: incidence
and associated feeding difficulties. Arch Otolaryngol Head Neck Surg
2000 Jan; 126(1): 36-9.
Nicholson, W. L. Tongue-tie (ankyloglossia)
associated with breastfeeding problems. J Hum Lact 1991 Jun; 7(2): 82-4.
Palmer, B. The influence of breastfeeding on the development of the
oral cavity: a commentary. J Hum Lact 1998 Jun; 14(2): 93-8.
Sachetti,
D. (ed.) Leader’s Handbook, revised edition. Schaumburg, Illinois: La
Leche League International, 1998.
Wiessinger, D., Miller, M. Breastfeeding
difficulties as a result of tight lingual and labial frena: a case report.
J Hum Lact 1995 Dec; 11(4): 313-6.
Woolridge, M. The ‘anatomy’ of infant
sucking. Midwifery 1986; 2:164-171.
Woolridge, M. Aetiology of sore
nipples. Midwifery 1986; 2:172-176.
Different kinds of frenulums
A frenum, or frenulum, is a fold of mucous membrane that connects two
parts, one more or less movable, and serves to check the movement of
that part. “ . . . In addition to the lingual frenum, there are several
other frena in the mouth. Buccal frena connect cheeks to gum, and labial
frena connect lips to gum; the superior labial frenum runs from the
center of the inner lip to the gumline.
A baby who cannot flange his
upper lip [because of a tight upper labial frenulum] may need to alter
his nursing position so that his lip remains close to his upper gum.
For at least some mothers and babies, that position may interfere with
effective nursing. A mother with a short nipple and inelastic breast
tissue might have trouble even achieving latch-on with such a baby,
if latch-on itself requires substantial lip flanging. It may be that
a short or tight inferior labial frenum could cause similar problems,
by preventing the lower lip from flanging.”
Wiessinger, D. and Miller,
M. Breastfeeding difficulties as a result of tight lingual and labial
frena: a case report. J Hum Lact 1995 Dec; 111(4): 313-6.
Ed note: Sheila
Fitzgerald of Irvine, California, USA shared the story of her son’s
tight frenulum in the March-April 2002 issue of New Beginnings. Patty
Spanjer, of Dalton, Georgia, USA, told the story of her son’s tight
frenulum in the September-October 2000 issue of New Beginnings.
For More Information
Dr. Brian Palmer’s Web site
includes a presentation on frenulums from a dentist’s point of view:
Frenums, Tongue-Tie, Ankyloglossia 2001.
This downloadable PDF (portable
document format) presentation on the oral structural effects of ankyloglossia
can be viewed at : www.brianpalmerdds.com/frenum.htm
Tongue-Tie: Impact
on Breastfeeding, by Dr. Evelyn Jain, is an 18-minute video about tongue-tie
for the physician and the lactation consultant, demonstrating frenotomy
techniques. It is available from: Lakeview Breastfeeding Clinic 6628
Crowchild Trail S.W. Calgary, Alberta, Canada T3E 5R8 Fax: 403-249-0156
www.drjain.com
|
Page last edited Sun Oct 14 09:31:36 UTC 2007.
