My first child was born via c-section. When we got to our room I tried to latch him and OH MY GOD it hurt. Okay, okay, I had heard it would hurt. I can do this. I’m tough. By the second feeding I was bleeding. When my son started crying I noticed the middle of his tongue didn’t lift up and the tip of his tongue had a divot in it causing a heart shape. I suddenly remembered an article I read during my pregnancy about tongue ties. The pediatrician came in and I said “I think he has a tongue tie and it hurts really bad to feed him.” The pediatrician told me he would “grow out of it.” That didn’t sound right to me because how would he eat until the point he outgrew it? I asked to be discharged and thankfully our regular pediatrician knew this was an issue and directed us to help.
My son was also unable to latch to a bottle, so an IBCLC recommended by our pediatrician came to our home and taught us to feed him by the finger feeding method. This is a syringe and tube taped to your finger. You have the baby suck on your finger and slowly drip the milk into their mouth.
I learned quickly that there is a lot of miseducation about ties, the issues they cause, and the need for revision. I learned that most often you need professional help to work through them, but if you don’t know the right information as a basis you can be led in the wrong direction. This will be a two part blog, but hopefully you stick with me and at the end you know more about ties and what to do if you need help working through one.
Feeding my oldest via the finger feeding method, about one week old.
A tongue tie is the term used to identify a tight frenulum. If you lift the center of your tongue up to your palate, hold it there and open your mouth you’ll see the frenulum tethering your tongue to the floor of your mouth. In some people, the frenulum is too short and can cause a host of issues. You may also see a labial frenulum, commonly known as a lip tie, that runs from inside the upper lip to the front gum, right in between where the two front teeth will go. This doesn’t often cause an issue with breastfeeding but it can if it is so tight the lip cannot easily flange upward toward the nose. If you see a lip tie there is over a 90% chance there is a tongue tie, and tongue ties are the main culprit of feeding issues.
So what does having a tongue tie DO? To answer this we have to know the mechanics of breastfeeding. When a baby latches onto the breast, they should have a wide open mouth, flanged lips, and the suction will pull the nipple all the way back to the soft palate. The middle of the tongue will rise, then fall, making a wave like motion creating negative pressure that pulls the milk from the breast. If the frenulum is too short the midline of the tongue is tethered to the floor of the mouth. The tongue cannot do this wave like motion and the baby is physically unable to breastfeed efficiently, or at all in more severe cases.
This will cause a range of symptoms. Since your baby cannot use their tongue they will use their gums to chomp onto your nipple. They’ll chomp until your body responds with a letdown, but it may not be quick and it may be painful. Since your baby cannot move the tongue correctly, they’ll continue to lose suction and you may hear an audible click as they suck, like when you smack your tongue off of the roof of your mouth (breaking suction). They will also struggle to handle the flow of your milk and will try to slow it down by chomping down harder or pulling back. All of this compensation they’re doing could hurt you, cause damage, and wear the baby out. You’ll notice your baby fall asleep before they are full (remember signs of fullness are loose open hands.. in this case you’ll see your baby fall asleep with tight fists. They’re tuckered out from working so hard to eat!). This also means they’re not very efficient at the breast so you could see supply issues and weight gain issues as well.
Without a proper seal on the breast your baby will take in more air during a feeding. You may see symptoms of reflux- arching back, fussing, or spitting up. This is actually discomfort from having a lot of air in their belly. Your baby may be excessively fussy or “colicky,” but again it’s discomfort. They may have forceful gas, infrequent bowel movements or very forceful bowel movements (the air they take in is coming out). These same issues may be present even when fed by bottle.
Ties can also effect breathing and sleep. If your baby sleeps with their mouth open and breaths through their mouth instead of their nose it is a sign the tongue is not resting properly in the mouth. Mouth breathing prevents quality, restful sleep and in babies can cause fussiness, and in children can present as behavior issues.
Your baby may have oral aversions, may not like the pacifier, and may not want to take a bottle. If they do take a bottle it could be very messy. Dribbling milk while nursing or taking a bottle is another sign of an improper seal. As they get older they may struggle to manage eating solids, excessively gag, or have choking episodes. Remember, you need your tongue to work properly to be able to move food around in your mouth and swallow safely.
You also need your tongue to work properly so you can speak. Speech delays and speech impediments are not uncommon with tie issues.
The symptoms you may see in the nursing parent are pain and damage to the nipple, frequent clogs, recurrent mastitis, milk blisters, undersupply or oversupply (supply is not regulating to baby’s needs), blanching nipples, misshapen nipples following a feeding, and vasospasm.
When deciding if a tie needs to be revised you need to look not only at the oral anatomy of the baby but the whole picture of what the nursing parent and baby are experiencing. If a tie is present and causing symptoms in baby and/or parent then it worth considering a revision. If a frenulum appears to be there but there are no notable issues then you can use your judgement and tap into that parents intuition I’ve discussed before. Decide what is in the best interest of your family at that time.
There are two common methods of revising and you would see either an ENT or pediatric dentist for the procedure. One method is clipping with scissors, another is by laser. While a scissor revision is an option for many, know that it will not always reach the posterior portion of a tie (more underneath the tongue). A laser is able to reach the posterior portion. Do your research and find a provider knowledgable in ties and couple this care with a lactation consultant to make the best decision for your situation. You don’t want to get a scissor revision when you know the posterior portion of the tie is tight as well because you may not see much improvement and will end up needing a second revision by laser.
Both procedures are very quick. The tongue is gently lifted to expose the tie, the tie is cut, and baby is handed right back to the parents. You can feed your baby right away, either nurse, offer a bottle, or pacifier to calm them depending on where you are with feeding at that time and what you’re comfortable trying. You will have some stretches to do to prevent the wound from healing tightly. You will notice you’ll have good feedings and bad but noticeable improvement over the week or two it takes to heal. You may notice your baby is a little extra fussy the next day, but beyond day 2 they should be pretty content. They may not love the stretches, but you wouldn’t like someone sticking their fingers under your tongue either. It’s important to continue them so they heal correctly.
The thing about ties that is easy to overlook is they can cause muscle tightness in the fascia throughout the head, neck, shoulders and trunk. Body work is often recommended along with a tongue tie revision. Chiropractic and cranial sacral therapy (CST) are beneficial and effective, but as with all things do your research to know which you would prefer. You should also practice latch and suck training to train the baby’s tongue to move in a way that will help them use their tongue correctly. The tongue is a muscle and muscles have memory. This is a whole new way of moving that they’ve never been able to do! This should be done under the guide of an IBCLC.
Ties are not just a breastfeeding issue. Correct use of the tongue is essential for drinking, eating, breathing, sleeping, and speaking. My next post will talk about issues ties can cause in childhood and adulthood, as well as common misconceptions about ties, the background of them, and some important resources. These resources are essential! It is incredibly difficult to navigate this situation with no support, so having an IBCLC on your care team to assess your personal situation is vital to helping you reach your goals.