Tongue Tie: the brief but definitive guide

You may have heard a lot about tongue tie. Your neigh­bour’s baby had one, your sis­ter­’s baby had one, the reflux sup­port group sug­gests invest­ig­at­ing wheth­er your baby has one. Surely you won­der what is this thing and surely not every baby is tongue tied?

Altern­at­ively you may have heard noth­ing about tongue tie, you’ve had all sorts of prob­lems with breast­feed­ing, maybe you still do, maybe you gave up but even bottle feed­ing is a chal­lenge and you can­’t fig­ure out why. Some­how you’ve landed here.

This is a brief but defin­it­ive guide to tongue tie, what is it, how can you find out if your baby has one, is it is a prob­lem if they have and what should you do about it anyway?

What is tongue tie?

We all have a lay­er of tis­sue along the bot­tom of our mouth that con­nects to our tongue. When we raise our tongue this looks like a line con­nect­ing the tongue to the floor of the mouth. We call this ‘the lin­gual frenulum’
This lin­gual frenu­lum is actu­ally a mid­line fold of the tis­sue on the floor of our mouth. It var­ies as to where this fold con­nects to the tongue, to the roof of the mouth and as to how elast­ic and long it is. When the lin­gual frenu­lum is par­tic­u­larly short or inelast­ic and restricts the baby from mak­ing typ­ic­al move­ments with its tongue; move­ments which are needed to feed we describe this as a tongue tie.

How can I find out if my baby has a tongue tie?

Some­times you will find someone glances in your baby’s mouth and defin­it­ively states ‘he has/doesn’t have a tongue tie’ but it’s not always that easy. Some babies will have a frenu­lum that is very vis­ible because it is attached to the front of their tongue but it may be long, elast­ic and not inhib­it­ing the baby’s abil­ity to feed in any­way. Oth­er babies will have a frenu­lum that is attached fur­ther back on the tongue and is there­fore less vis­ible at a glance but it is very short and inelast­ic and maybe attached to the back of the gum ridge, this baby is likely to be restric­ted in the move­ments his tongue can make and there­fore feed­ing is often a problem.

We have a vari­ety of tools to use to assess tongue ties which give us a score and an indic­a­tion of how much the frenu­lum is restric­ted and how much this restric­tion is impact­ing on the baby. Some exper­i­enced prac­ti­tion­ers feel they don’t need to use a tool but either way to check for a tongue tie any prac­ti­tion­er is likely to take a care­ful his­tory from you and then want to watch your baby in order to observe the move­ments she makes with her tongue and to look in her mouth to see the frenu­lum, where it is attached to the tongue and gum and to feel how she’s sucks and how elast­ic her frenu­lum is. They should be able to describe to you how your baby’s indi­vidu­al abil­it­ies to move her tongue are impact­ing on feeding.

For example

Many babies with tongue tie find it hard to stick out their tongues bey­ond their lip, this can make it harder to scoop up the breast and you will see your baby try­ing to attach and maybe need­ing many tries to do so or not suc­ceed­ing at all

Many babies will struggle to cup the breast or bottle with their tongue as they can­not main­tain that tongue pos­i­tion, you might see them slide off the breast or down towards your nipple or dribble milk out on bottle or breast because they can­not main­tain a seal. Some­times they will struggle with a dummy and are unable to keep it in. You might hear click­ing sounds as the baby drops off the breast.

If the prac­ti­tion­er uses a tool, there will usu­ally be a scor­ing sys­tem which can tell you how likely treat­ment is to help.

What is the problem with tongue tie?

Typ­ic­ally in a baby with tongue tie, you get a range of feed­ing problems

• The baby may not attach to the breast at all or they may try mul­tiple times to attach before they man­age to do so.
• The baby may attach to the breast and then fall off or slide off lead­ing to a much smal­ler latch.
• The moth­er may get sore or cracked nipples because the baby is unable to make the nor­mal move­ments of the tongue to trans­fer milk or because the baby can­not get or main­tain a good attach­ment to the breast.
• The baby may feed a lot (often described by moth­ers as con­stantly) because they aren’t able to get the milk out efficiently.
• The baby may act hungry and unsettled because they are strug­gling to get enough milk.
• The baby may fall asleep on the breast because they can­’t get the milk out effectively.
• The baby may lose a lot of weight ini­tially or gain weight more slowly than expected.
• The baby may dribble milk out on breast or bottle.
• The baby may have long slow bottle feeds and struggle to get milk out fast enough.
• The baby may struggle with milk flow and choke and splut­ter on the breast or bottle.
• Some people feel the baby is more likely to struggle with wind and col­ic because they can­’t main­tain a good seal on breast or bottle but we don’t have good evid­ence for this.

What about later problems I hear tongue tie causes speech issues?

While tongue tie is known to con­trib­ute to speech and dent­al issues occa­sion­ally, this is rel­at­ively rare. Because it is so rare, we don’t tend to treat tongue ties in babies in order to pre­vent later issues. If a child feeds well but later has speech or dent­al issues because of a tongue tie then it is pos­sible to divide them even into adult­hood although this may require a gen­er­al anaesthetic.

So how many babies have tongue tie?

Around 10% of babies have a frenu­lum that is caus­ing suf­fi­cient restric­tion to be described as a tongue tie.

Wow that’s a lot? Do they all need something done about it?

No, if a baby is feed­ing well, gain­ing weight and there are no con­cerns then we don’t treat tongue tie. If there are con­cerns around feed­ing then assess­ment is mer­ited and treat­ment can be dis­cussed after that assess­ment. We only have strong evid­ence for treat­ing babies who have breast­feed­ing issues how­ever as many bottle feed­ing par­ents report improve­ment after tongue tie treat­ment, many clin­ics includ­ing ours will also treat bottle fed infants and babies who are hav­ing issues trans­ition­ing onto sol­id foods.

Treatment? What is the treatment?

The nor­mal treat­ment for tongue tie is to divide (cut) the frenu­lum so the tongue is freer to move. The baby is wrapped tightly and held still, the prac­ti­tion­er opens their mouth and cuts the frenu­lum most often with a small pair of sterile scis­sors in a good light. Occa­sion­ally if the frenu­lum is par­tic­u­larly short or tight this may take two cuts, then the baby is handed to you for a feed.

Is it painful or dangerous?

Like all pro­ced­ures it car­ries some small risks which your prac­ti­tion­er will dis­cuss with you. It does­n’t seem to be very pain­ful for most babies, the vast major­ity settle imme­di­ately. Occa­sion­ally an older baby may need paracetamol or sim­il­ar if they are very unsettled after the procedure.

Are there any alternatives to cutting the frenulum?

Maybe. Often sup­port with feed­ing can help man­age the restric­tion in the frenu­lum without the need for divi­sion. A lacta­tion con­sult­ant can help with pos­i­tions that will man­age the par­tic­u­lar issues you may be hav­ing with breast­feed­ing. Side lying and laid back pos­i­tions are help­ful or the koala hold where the baby sits upright while feed­ing. For some babies aids like nipple shields can be help­ful. As babies get big­ger and more cap­able, feed­ing tends to improve. Bottle fed babies often man­age flow bet­ter as they get older.

Some people have sug­ges­ted ‘body­work’ or cra­ni­al osteo­pathy may be help­ful. Some tongue tie prac­ti­tion­ers spe­cial­ise in doing this before con­sid­er­ing divi­sion and many oth­ers will sug­gest a refer­ral either before or after divi­sion if it seems likely to be help­ful. The the­ory is that stretches/massage etc may loosen the tis­sue at the bot­tom of the mouth mak­ing the frenu­lum more elast­ic and the tongue more able to move freely. We don’t as yet have good evid­ence for this approach but many par­ents have found it help­ful and it may be some­thing you want to consider.

So can I book an appointment?

You abso­lutely can. The link to book an appoint­ment with us is here? If you don’t live in our area, there’s a list of prac­ti­tion­ers avail­able here on the Asso­ci­ation of Tongue Tie Prac­ti­tion­ers website.