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.
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