What is a Tongue-Tie?
The term “tongue-tie”, formally known as Ankyloglossia, describes a congenital (in utero) condition whereby an infant or child has a short and/or thick frenulum (fascial string-like tissue anchoring the tongue to the floor of the mouth). A tongue-tie can restrict tongue movement and impact the function of the tongue. Around 50% of infants with a tongue-tie experience feeding difficulties because of the condition. [1]
Anterior and Posterior Ties
A tongue-tie can manifest in two distinct ways; the Anterior Tongue-Tie (ATT) and the Posterior Tongue-Tie (PTT). Both of these can make feeding problematic.
In the case of an anterior tie, the frenulum has attached toward the tip of the tongue. Sometimes the anterior tie is recognized because of the infant’s misshapen or heart shaped tongue. A posterior tie is less visible. When the tongue is lifted, the frenulum may appear short and thick, or may not be visible because it’s often hidden by the mucosal covering of the tongue.[2] Without a more obvious visual cue, the posterior tie is often indicated by impeded feeding and is assessed by touch.
Lip Ties Can Affect Feeding As Well
Similar to tongue-ties, lip-ties can also be the cause of feeding difficulties for infants. An upper lip-tie is the result of a tight maxillary frenum (a small piece of tissue connecting the upper lip and the upper gum). This condition can cause infants to have difficulty latching because it limits the upper lip’s ability to curl/flange upward, thereby affecting a proper seal on the areola or bottle. When present, the upper lip-tie can cause both air and milk to pass through the imperfect seal.
How Do Tongue and Lip Ties Affect Breastfeeding?
Breastfeeding effectively requires a functional latch. An infant achieves a proper latch and is able to suckle and trigger the release of milk from the breast through a complex and highly choreographed series of muscle and jaw movements. When this choreography is disturbed by a tongue or lip tie, breastfeeding is affected in a variety of ways.
Restricted range of motion
When infants breastfeed or bottle feed effectively, their lower jaw is raised during suckling. They use their top gum and the tip of the tongue (which rests on the lower gum) to hold the nipple of the breast or bottle in place. The tongue, cheeks, and jaw all have a role to play.
A tongue or lip tie can affect the infant’s ability to position the nipple properly in his or her mouth. It can also prevent him from taking enough breast tissue into the mouth to properly latch. This is referred to as a “shallow latch” and can result in compromised feeding as well as an uncomfortable breastfeeding experience for the breastfeeding parent.
A tongue-tie can also inhibit the wave-like motion of the tongue. This motion is needed to move food from the front to the back of the mouth before swallowing. When the tongue’s ability to move freely is compromised by a tie, it can result in a poor suck, swallow, breath pattern.[3,4,6]
Discomfort and pain during breastfeeding
The restricted motion and compromised latch that can result from tongue and lip ties often means an uncomfortable or painful breastfeeding experience for the breastfeeding parent. Tissue restrictions can cause friction which can result in damaged, even bleeding, nipples.[3,5]
Frequent and Ineffective Feedings
When an infant’s ability to effectively latch to and draw milk from the breast is compromised due to a tongue or lip tie, they are less likely to consume enough milk during a feeding before becoming fatigued and falling asleep. The strained feeding experience is hard on an infant and, depending on the severity of the situation, may require them to put out more energy than they are able to get from the feeding. They may become frustrated during feedings or show signs of hunger despite having just fed. 3,5 Often, a baby who is feeding frequently but ineffectively will not gain weight quickly enough which can be alarming and stressful for everyone. (3,5)
Digestive Issues
An issue specific to tongue-tie is the dimpling of an infant’s cheeks or a clicking sound while feeding. Both of these, as well as a jaw tremor, are the result of atypical latching and sucking motions that often indicate a tie.
A poor latch is as frustrating for the infant as it is for the breastfeeding parent. Infants with tongue-tie are sometimes fussy and may pull away from the breast or bottle frequently. [3]
This behaviour can be a sign of frustration and strain. It may also happen when an infant is uncomfortable because of reflux-like symptoms. Reflux in infants is commonly due to the air swallowed when there is a poor latch. The digested air results in a distended (swollen) belly (formally called aerophagia) that can put extra pressure on the stomach and the cardiac sphincter (valve at the top of the stomach). This makes it difficult for the valve to remain closed and reflux can easily occur.
Beyond Breastfeeding: Tongue-Ties Can Affect Development
It may be surprising, but something as seemingly insignificant as a tongue-tie can deeply affect a person’s structural stability and functional movement. The mobility of the tongue greatly influences the deep front line of fascia, otherwise known as "the core". Tongue tied babies tend to be very uncomfortable during tummy time as a result of the fascial tension. The aversion to this position can be strong and many parents, seeing their baby in distress, stop putting babies on their stomachs all together. As discussed in a previous post, tummy time is a necessary step towards crawling. It is vital for good coordination and neural development.
How Do You Know If It’s A Tongue-Tie?
If you suspect your baby may have tongue-tie or lip-tie, speak to your doctor or midwife about getting a referral to see a specialist. Specialists that train in this area include:
Speech language pathologists with specialized knowledge in tongue tie or lip tie
Midwives
Pediatric dentists
Oral surgeons or Otolaryngologists (ENTs)
Once A Tie Is Confirmed, What Can You Do?
If it is determined that you were correct and a tie is present, there are several options for treatment. Getting the tie “clipped” (formally called a frenotomy) is a common option. It involves snipping the short or tightened frenulum to release the tie and restore free range of motion to the tongue or lip. Other surgical procedures involve using lasers to revise the frenulum. If surgery is not an appropriate or desired form of treatment, an IBCLC can work with the breastfeeding parent and infant to adjust feeding techniques for either breastfeeding or bottle feeding.
When a tie is identified and treated, it is important to include manual body work in your baby’s recovery. The fascial restrictions that are often present as a result of the tie may have created less than ideal sucking patterns which will need to be addressed. Manual body work will also be helpful in helping the baby adjust to the changes in their feeding habits. Taking a whole-body approach to treatment will encourage the best feeding outcomes for the infant.
Sources
[1] Buryk, at el. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics. Aug 2011; 128(2): 280-288.
[2] Potock Melanie. Tip Back that Tongue! The Posterior Tongue Tie and Feeding Challenges. The ASHA Leader Blog. 26 May 2015. www.asha.org.
[3] Henry Lydia, Hayman Rebecca. Ankyloglossia and Its Impact on Breastfeeding. Nursing for Women’s Health. Apr/May 2014; 18(2): 122-129.
[4] Kotlow, Lawrence. Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. Journal of Human Lactation. 2013; 29(4): 458-464.
[5] Potock Melanie. Just Flip the Lip! The Upper Lip-tie and Feeding Challenges. The ASHA Leader Blog. 10 March 2015. www.asha.org.
[6] Edmunds at el. Tongue-tie and breastfeeding: a review of the literature. Breastfeeding Review. Mar 2011; 19.1: 19