I was contacted by a very upset mum a couple of weeks ago who’s baby was extremely unhappy. Cheryl was at her wits’ end after several visits to her GP, Health Visitor and A & E with her daughter resulted in no clarity whatsoever as to what was going on with poor Jessica.
Cheryl was desperate and wanted to try the babocush as soon as possible but I knew, after seeing photos of Jessica’s swollen tummy that it would take more than the babocush to sort out whatever was going on.
The first thing we did was get Jessica an urgent appointment with a chiropractor in her area, who found that there was a lot of tension in her neck and back. This was great but I knew there had to be more to what was going on.
A few days later, it came to me! TONGUE TIE! That would explain Jessica’s swollen tummy – not getting a good grip when feeding meant she could be swallowing lots of air which could be causing the bloating in her tummy and I remembered her mum telling me she could sort of hear the milk hitting her stomach each time she swallowed. Poor baby!!
I contacted Cheryl and sent her some details about who to go to in her area for advice, (her health visitor and doctor were no help) and the following day I received this message:
“Oh Kerry I feel so relieved that this might actually be the case. And that lady I spoke to earlier was interested in how we've been going to see the chiropractor as she recommends a chiropractor after the treatment. She said the tension in Jessica’s neck and back could be related to the tongue tie!!! I can't believe it! Everything's falling into place now! I've been reading testimonials on the milk matters page and they all sound like Jessica! Unsettled all the time, screaming, pulling off the bottle, back arching, sick, taking a long time to feed, suffering with reflux, colic etc etc.......I so hope this is the reason behind it all! I can't wait for her to be seen and then see how she is in the next couple of weeks! She might be a completely different baby!!! You’re probably right - I bet a lot of parents are going through this xxx”
“Kerry I can't believe it! Just feeding her now (well she's over my shoulder at the moment!) But the clicking sound when she's feeding is so obvious now!! xxx”
After seeing tongue tie specialist:
"Hi Kerry, just getting home now. Well, the tongue tie was 50% up her tongue! They snipped it and she struggled feeding today but I’m guessing that’s maybe because her tongue’s sore and she’s not used to taking feeds well so that may take time to settle as she has a muscle there that now moves properly!”
A tongue-tie (also known as Ankyloglossia) is caused by a short or tight membrane under the tongue) and can cause all sorts of problems for young babies, especially when feeding.
Where the membrane is attached at, or close to the tongue tip, the tongue tip may look blunt, forked or have a heart shaped appearance. However, where the membrane is attached further back, the tongue may look normal.
Signs that your baby may be tongue-tied
- Persistent very sore or damaged/blistered nipples – however it’s important to note that there may be no nipple pain/trauma.
- Compressed nipples (change in shape) and/or blanching after feeding.
- Excessive weight loss or slow weight gain (may not occur if topping up).
- Difficulty establishing breastfeeding or baby refuses to latch.
- Excessive hunger/weight gain in baby.
- Excessive sucking need – baby wants to feed or suck very frequently/constantly.
- Baby only swallows infrequently or swallows well for initial “milk ejection” (letdown), but then swallows become less frequent/sporadic. In young babies this may result in falling asleep quickly at the breast.
- Cannot maintain a seal at the breast/bottle, often has gaps at corners of mouth which milk may spill out from.
- Mammoth feeds – or falls asleep quickly and then wakes hungry as soon as breast/bottle is removed.
- Baby doesn’t seem satisfied after a breastfeed.
- Very frequent feeds.
- Fussing at the breast shortly into a feed or takes very short, fast feeds, baby may pull away and cry, arch back – bobbing on and off.
- Parents may comment they can hear air being gulped, milk hitting the tummy, or baby is a very “noisy feeder” with loud swallow sounds.
- Low milk supply.
- Mastitis/blocked ducts.
- Frequent hiccups.
- Food intolerances due to digestive disruption.
- Baby rarely/never settles to a deep restful sleep – some “catnap” and are described as very poor sleepers.
- Windy/squirmy and unsettled when sleeping.
- Excessive flatulence.
- Green stools.
- Sucking blister on upper lip.
- Latch trouble or slipping down the nipple when feeding ie as though struggling to remain attached at times- resulting in “nipple hanging."
- Clicking sound when feeding. May pop on and off.
- Disorganised suck/swallow pattern – may result in coughing/spluttering/gagging and give an appearance of oversupply, (Bottlefeeding mums may note this happens even with the slowest flow teat).
- Weak suck/poor sucking reflex.
- Oral aversion/increased sensitivity – frequently refuses breast and/or bottles and/or spoons. May gag frequently.
- If baby led weaning, may be very slow to start solids compared to peers, may appear keen but spit rather than swallowing food.
- If breastfeeding may refuse bottles/cups.
- Tongue tremor whilst feeding.
- Noisy breathing/snoring sounds when sleeping.
- Opens mouth to attach but doesn’t, shakes head or bobs on and off before becoming frustrated.
- Small mouth gape.
- Gape is wider horizontally than it is vertically when crying.
- Unable to protrude tongue (some with tongue tie can, protrusion does not rule out tongue tie).
- Excessive drooling/bubbles at the mouth.
- Displays stressed body language when feeding – hands up near face, fingers splayed.
- Breastfeeding requires “advanced” techniques such as nipple flipping or pin point accurate positioning which mum struggles to replicate at each feed when not assisted. Mum may feel a need to support the breast from the side to keep in baby’s mouth or he/she slips off (due to ineffective seal).
- Restricted tongue elevation when crying.
Sometimes these babies will have a much larger than average weight gain, perhaps due to obtaining larger quantities of lactose (sugar) rich fore milk or maybe due to frequent feeding. These babies are more likely to slip through the system and even receive medication for reflux/colic. Tongue tied infants present in a wide variety of ways, often not related to severity of tie.
This video shows how to assess whether a baby has tongue tie or not -
Is Tongue Tie Painful For Baby?
Many sources state a restricted tongue is not painful for baby. However, several tied adults have commented they experience a burning sensation when certain tongue movements are performed (depending upon where the tie is). Certainly many babies express discomfort when their tongue is lifted if it is tied so is it therefore safe to assume baby feels some discomfort from this restriction.
In order to breastfeed effectively, a baby needs to have full movement of the tongue – they need to be able to create a seal will their lips and tongue to form a vacuum. The tongue needs to cup the breast and also be able to elevate, not only to perform a correct suck/swallow pattern (without excessive air intake), but also to undulate during feeding and create the negative pressure that = milk transfer. They need to be able to maintain this throughout the feed to trigger subsequent milk ejections.
To bottle feed well the baby needs to make and maintain a seal and move the bolus in an organised way to the pharynx for swallowing too. Otherwise, feeds can be extremely slow or very rapid and ‘gulpy’. Gaps may be visible at the corners of baby’s mouth and he may leak milk (sometimes profusely), or simply intake air with each suck, resulting in excessive flatulence or trapped wind.
A tongue tie often can’t be easily seen, therefore it takes someone skilled in lactation to piece things together. To consider breastfeeding history, observe a feed, evaluate babies tongue function and oral presentation alongside mum’s comments. Simply peering into a baby’s mouth or just feeling under the tongue at the front, is not a reliable method of evaluation (eg you may not be able to feel a submucosal tie and tongue may appear typical).
If they find anything unusual they will discuss their observations, and if they do not treat tongue tie themselves or perform the full oral assessment to confirm, they should advise seeing someone who specialises in this field. This can be easier said than done.
Unfortunately the number of people holding the above skills are very limited and posterior ties are regularly missed by Paediatricians, Midwives, ENT (ear, nose and throat) Consultants, Breastfeeding Counsellors, Health Visitors and sadly, even some Lactation Consultants (IBCLC) and/or Infant Feeding Advisors. Some only recognise a tie at the front of the tongue and state baby is not tied if they can’t easily see the frenulum, some might even tell parents posterior tongue ties don’t exist! Despite the fact that evidence highlights posterior tongue tie, indicates a problem poorly recognised in the community.
It seems many paediatricians and ENT specialists do not receive specific tongue tie education during training, (I’m not sure whether any do). Therefore if any of the above state they suspect a tongue tie, or you have problems nobody else can seem to help resolve, it is worth seeking out someone who states clearly that they specialise in this field. Regardless of how you feed your baby, you can still contact many IBCLC tongue tie specialists for help.
What makes diagnosis even more difficult is that other things can impact on oral function beyond tongue tie. As the nerves that control the tongue and jaw run through the head and neck, compression can inhibit the jaw and tongue movement. This may be from positioning in the womb, a long first stage or a difficult or traumatic delivery – resulting in the infant displaying similar symptoms to those described above.
In addition, other oral differences can occur with a tie, or as a result of birth or genetics; these include a bubble, narrow or high palate or a lip tie. All are more common in a baby with tongue tie – the tongue smooths to help shape the palate in utero and repeated incorrect pressure once born can also impact on the oral cavity. This means the palate can often give important clues as to what else may be going on! However it should also be noted that a high arched palate can also be found without a tie, and a tie can be found with a palate that appears typical – see why it really takes someone specialising in this field?!
What other problems can an undiagnosed or untreated tongue tie cause?
As discussed above, not all ties need intervention to breastfeed, however parents should be aware that a tongue tie can impact in other areas at a later stage – when treating is a much bigger procedure.
- Ongoing colic/wind/reflux or unsettled sleep patterns
- Eating difficulties – as the tongue requires a full action to process food, infants with tongue restriction may refuse spoons, gag/choke easily, or refuse to move on from runny foods. Some may be classified anywhere from “picky eaters” to “food phobic” depending upon severity.
- Dribbling/drooling – which may be prolonged and continue into childhood.
- Dental problems which may be severe and wide ranging due to the palate.
- Speech may be unclear due to several aspects, especially coordination.
- Ongoing acid reflux/indigestion.
- Sleep Apnoea.
Tongue tie can also prevent the tongue from contacting the front of the palate. This can then promote an infantile swallow and hamper the progression to an adult-like swallow which can result in an open bite deformity. It can also result in mandibular prognathism; this happens when the tongue contacts the anterior portion of the jaw with exaggerated thrusts.
The specific challenges an adult with a tongue tie may face include:
- Clicky jaws.
- Pain in the jaws.
- Protrusion of the lower jaws.
- Burning sensation when elevating tongue.
- Effects on social situations, eating out, kissing, relationships, appearance.
- Dental health: a tendency to have inflamed gums, and increased need for fillings and extractions. The high or bubble palate also changes the shape of the oral cavity, which can result in hindered dental development, ill-fitting teeth or too many to fit the space (ie if palate is high it will naturally make it narrower), overbite/underbite, or tongue thrust (the tongue protrudes forwards when at rest impacting on teeth).
- Acid reflux/indigestion/bloating/gas from incorrect chew/swallow mechanism and sucking in of air.
- Sleep Apoena.
It’s important to remember that not all ties need treating to facilitate good feeding; some babies have a tie that is stretchy and doesn’t impede the function of the tongue. Tongue tie practitioners should assess whether the tongue, mouth and lips move as expected and whether the baby is feeding using a good technique, or is compensating on the breast or bottle because of the restriction.
“Up to the year 1940, tongue ties were routinely cut to help feeding. When this changed – because of a fear of excessive/unnecessary surgery and a reduction in the practice of breastfeeding – the belief that tongue tie was not a “real” medical problem but an idea held by over-zealous parents became widespread.”
“Early intervention is ideal since it avoids habit formation and the negative effects of failure: whether it is due to messy or slow eating, funny looking teeth or speech problems. When there are no strong habits to eradicate there is a better chance of success in correcting the difficulties that poor tongue mobility has caused.”
“Once a tongue tie has been diagnosed, the primary need is to correct the structural anomaly causing the problem. After the structural problem has been successfully corrected, it is reasonable to expect to improve function, and to treat secondary problems successfully. The type of treatment that is most appropriate depends on the problems that have been experienced.” (tonguetie.net)
Treatment is often called: snipping, dividing or clipping which describe a, “frenulotomy”. A pair of blunt ended sterilised scissors are used to simply snip into the frenulum (which has few nerve endings and blood vessels) before the mum puts baby immediately to the breast.
Some studies have noted a sleeping baby may not even wake during the procedure; in one study 3 out of 36 babies continued sleeping, and in another, the figure was 39 out of 215 (NICE Division of ankyloglossia (tongue-tie) for breastfeeding). Some parents note their child cried at being held for a moment to allow access, but that this crying did not increase in intensity when the frenulum was clipped. NHS guidance suggests an average crying time of 15 seconds (Bath and North East Somerset, Tongue tie information for parents).
Feeding immediately after the procedure is not only soothing, swooshing the area with the antibacterial and anti-inflammatory properties of breastmilk, but also allows baby to try out their new tongue action which would be hindered if the area was numb from anaesthetic.
“Although division in the outpatient clinic can still be done in many older children, general anesthesia may be required in some patients. Division of tongue-tie is a simple, easy and safe procedure. Early and aggressive treatment is recommended. It is best managed without anesthesia during infancy and before teething, at the outpatient clinic. Delayed treatment may put some children under the risk of general anesthesia.” (Outpatient division of tongue-tie without anesthesia in infants and children, Ming-Lun Yeh, World Journal of Pediatrics)
Other oral specialists agree:
“Based on 30 years of clinical observation I have sufficient documentation to state that:
- Frenulums do not go away by themselves.
- Frenulums can have significant consequences on oral cavity development and total health.
- Side effects are minimal, benefits are significant.
- #1 reason surgery is not performed – fear of litigation.
- Procedures not taught in medical or dental schools.
- Myths / misinformation abound on the topic.
Are there risks to Frenulotomy?
It is estimated the risk of infection is 1 in 10,000 infants. Saliva contains some antibacterial properties, and breastmilk also has many antibacterial and healing characteristics. As a small amount of localised bleeding may occur, babies with any blood clotting disorders may be at increased risk. Baby may become fussy or mum may not note an improvement for 24-48 hours post frenulotomy.
NICE guidelines state:
“You may have been offered the tongue-tie procedure for your baby. NICE has decided that the procedure is safe enough and appears to work well enough for use in the NHS.” (Division of ankyloglossia (tongue-tie) for breastfeeding).
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