If breastfeeding is painful for you and you have been looking on the internet to work out what is wrong you may have come across “tongue-tie” and be wondering if your baby has one. Although it is currently very fashionable on social media to blame everything on your baby’s tongue function, bear in mind not every breastfeeding problem involves a tongue-tie. Working with an IBCLC lactation consultant and checking Why Does Breastfeeding Hurt? will help rule out other causes such as latch or positioning.
This article looks at what tongue-tie is, how it might affect breastfeeding, how to know if your baby has a tongue-tie, treatment options and where to find help.
What is tongue-tie?
Tongue-tie is the term used to describe a restricted tongue caused by a cord like membrane (known as the lingual frenulum) under the tongue. If the frenulum is particularly short or tight, it can tie the tongue to the base of the mouth so it can’t move freely. Sometimes the frenulum under the tongue isn’t obvious as it is hidden under the moist mucous membrane (the mucosa) beneath the tongue. If the tongue can’t move freely this can affect breastfeeding negatively. The movements the tongue needs to make during breastfeeding are explained by Diana West IBCLC in the following article:
Having a tongue that is tied to the base of the mouth can make it hard for a baby to breastfeed because there are several motions his tongue needs to make to remove milk effectively. It must extend comfortably past the lower lip so that it can grasp an adequate amount of breast for latching deeply. The sides of the tongue need to be able to cup the breast to stabilize it in his mouth. The tip of the tongue needs to be able to lift higher than halfway when the mouth is open, and the back of the tongue needs to lift and then drop to create the vacuum that pulls out milk.
How can tongue-tie affect breastfeeding?
Breastfeeding problems that may stem from a tongue-tie (but can have other causes) include:
- Nipple pain, deep breast pain, misshapen nipples, nipple blisters, nipple vasospasm or very sore nipples for mother
- A baby who has difficulty latching on, latching deeply enough, opening his mouth wide enough or staying latched on
- A baby who has very short frequent feeds because he has to work his tongue hard to pull against the frenulum and may get tired or fall asleep at the breast before the end of a feed or a baby who seems to feed all the time but doesn’t gain much weight
- Sucking blisters on baby’s lips—because the lips are having to compensate for poor tongue function
- Clicking sounds during breastfeeding—the sound of losing suction with the breast and/or difficulty coping with milk flow
- Reflux may sometimes be associated with a tongue-tie
In later life a tight frenulum could cause difficulty with chewing, speech or dentition 1.
Rule out other causes
Breastfeeding issues sometimes attributed to tongue-tie could be from other causes such as a shallow latch, poor positioning, difficulty with flat or inverted nipples, food sensitivity (in the case of reflux) and more. A hungry baby who is not gaining weight can have high tone and poor tongue function. Another possibility discussed in breastfeeding reference books is the idea that tension or compression from a baby’s birth can also influence tongue function and that some types of restriction can be helped with physical therapy such as cranial work 2 3. Your breastfeeding specialist can help identify if there are any correctable issues with positioning and latch or high muscle tone that could be causing pain or difficulty breastfeeding.
Is my baby tongue tied?
Identifying a tongue-tie requires assessing tongue function, not just looking at the appearance of the tongue or ticking off a list of symptoms. A website or virtual breastfeeding forum can’t diagnose a tongue-tie, your baby needs a face-to-face consultation with a specialist. A good place to start is by seeing an IBCLC lactation consultant who will take a full breastfeeding history—and assess both breastfeeding and tongue function. Where appropriate, your lactation consultant can arrange a referral to a tongue-tie practitioner or you might be able to self-refer depending on the referral system in your area. A tongue-tie provider might be a paediatric surgeon, midwife, or other health professional trained in dividing tongue-tie.
Assessing tongue function?
Just because there is a frenulum to see, even if it is pulling on the tip of the tongue to create a heart shaped tip, it may not prevent your baby from breastfeeding, it depends how much it restricts the tongue’s movement. Equally just because there is nothing to see under the tongue, doesn’t necessarily mean there isn’t an issue with the tongue function. Your experienced lactation consultant will know how to assess your baby’s tongue function alongside the appearance. They will assess whether your baby can extend his tongue past his lip or gums, whether he can lift his tongue, cup the breast, how the tongue moves during sucking and more.
Can I check my baby’s tongue function myself?
Although there is no substitute for an assessment by an experienced professional, Cathy Watson Genna has a website with a sequence of photographs to guide you through a basic self-assessment of tongue function.
Getting the right help
If your baby’s breastfeeding problems are associated with a tongue-tie you will need to find the right help. Tongue-tie practitioners can vary in how they approach tongue-tie treatment. In some areas tongue-tie is over diagnosed whereas in others the health professionals do not believe tongue-tie is a problem requiring treatment.
Posterior vs anterior
Tongue-ties are often described as anterior or posterior. An anterior tongue-tie describes the tongue that is tied to the floor of the mouth by a membrane near or at the tip of the tongue. A posterior tongue-tie describes the membrane at the back of the tongue which may not always be visible (submucosal). Both types have potential to cause problems with breastfeeding if very tight. However, some practitioners will only divide an anterior tongue-tie, but not a posterior. Others say that there is a posterior tie behind every anterior one and to restore tongue mobility both must be divided 4. Alison Hazelbaker, tongue-tie author takes the view:
enough tissue must be removed (without cutting into muscle) to restore optimal tongue mobility
Where can I find a practitioner?
- Your IBCLC will usually be able to recommend practitioners in your area who are familiar with the diagnosis and treatment of tongue-tie. See Why Hire an IBCLC? for links to IBCLC directories in UK and internationally.
- The Association of Tongue-Tie Practitioners maintains a list of tongue-tie practitioners in the United Kingdom.
What is the treatment for tongue-tie?
A restrictive tongue-tie can be treated by a frenotomy (or frenulotomy), this is a medical procedure that involves cutting (dividing) the membrane under the tongue by scissors or laser. A comprehensive approach for a restrictive tongue-tie will include a combination of improved positioning at breast, bodywork or tongue exercises if appropriate, and/or frenotomy. The most common method of dividing frenulums in the UK is to use sharp, blunt-ended surgical scissors. A tongue-tie practitioner describes the procedure:
The baby is wrapped securely in a towel or blanket so they cannot wriggle or put their hands to their mouth. The head is then held still by a parent, nurse or other helper. The practitioner performing the procedure lifts the tongue using the finger or fingers of one hand. (Some practitioners prefer to use a Brodie Director, a small metal spade shaped instrument with a central slit to isolate the frenulum and lift the tongue). With the scissors in the other hand the practitioner slides the blades under the tongue so they are on either side of the frenulum and snips.
There are said to be very few nerve endings or blood vessels in the lingual frenulum and a frenotomy is thought to cause only momentary stinging. Some babies sleep through the procedure or go straight to the breast for soothing. However some babies can be unsettled for a few days afterwards with difficulty feeding and with increased crying (Oakley, 2015).
Occasionally a tongue-tie can reform after a frenotomy. Many practitioners find the natural tongue movements of frequent breastfeeding help to prevent the frenulum reforming and, where needed, gentle tongue exercises can help strengthen the tongue 5. Some practitioners advocate that parents actively stretch or massage the wound daily to prevent the tie returning 6. More research is needed on whether stretching a wound is safe or effective7, particularly as some parents have found massaging the wound can cause their baby considerable pain and distress or breast refusal 8.
What about lip-ties?
The membrane that connects the inside of the upper lip to the gum is known as the labial frenulum. The idea that latching problems could be caused by this membrane being too short or tight (a lip-tie) seems to be a relatively new idea. During breastfeeding the upper lip need only be in a neutral or slightly everted position at the breast not flanged out like the lower lip910 and there isn’t any published research supporting the idea that lip-ties are associated with feeding issues 11. In many cases “lip-ties” are confused with normal anatomy 1213 1415 and the presence of an upper lip frenulum tight enough to disrupt breastfeeding is unusual. Tension in the upper lip can be associated with a shallow latch, unstable positioning at the breast, high muscle tone or a tongue-tie, and any of these could lead to a misdiagnosis of lip-tie 16 17. See Lip-Tie and Breastfeeding for more information.
If breastfeeding still hurts
A frenotomy does not always improve breastfeeding comfort and may not be a magic wand for a baby not gaining weight. A tight frenulum may not have been the cause of the problem after all 18. If you are still finding breastfeeding painful stay in contact with your IBCLC lactation consultant for follow ups in case there is another problem yet to be solved.
A tongue-tie describes the situation where the membrane that joins the underside of the tongue with the floor of the mouth is particularly short or tight and restricts normal tongue function. If a baby’s tongue can’t move normally, breastfeeding will likely be painful for his mother, and it will usually be difficult for the baby to get enough breast milk which may lead to slow weight gain. Poor tongue function can also be frequently seen with a shallow latch, poor positioning or physical issues such as tension from a difficult birth. If breastfeeding is not going well, find an IBCLC lactation consultant to take a full history and assessment of breastfeeding to pinpoint the most likely causes of your difficulties and to find the right care plan for you and your baby. If a frenotomy (surgical division of the tongue-tie) is recommended, it is important to find an experienced and knowledgable tongue-tie practitioner. More research is needed as there are gaps in knowledge relating to the best tool to use (scissors or laser), best wound care, the role of bodywork or the value of lip-tie frenotomy 19.