What is a Tongue-Tie?
In our mouths we have many pieces of skin or tissue called frenula; a frenulum or frenum secures or restricts the movement of other more mobile tissues. There is a frenulum under the tongue, inside the upper and lower lip and even at the side of the jaw bones connecting to the cheek (buccal frenula).
Frenula rarely cause problems but occasionally they can present an issue and one example of this is known as “Ankyloglossia” or “Tongue-tie”. Ankyloglossia is when the frenulum under the tongue causes symptoms – most commonly identified in the first few weeks of life when the infant and mother experience problems with breastfeeding. There is little consensus on the percentage of infants in the population that have a tongue-tie but studies quote up to 10% of the population. Not every child who has a tongue-tie will experience difficulty with feeding – this is dependent on how restrictive the frenulum is and how it effects the movement and function of the tongue when feeding. Tongue frenula can vary widely in their appearance and a more accurate assessment of whether a tongue-tie restricts movement is obtained from clinical examination (involving suck, swallow and feeding assessment) rather than assessment of photographs or the appearance of the frenulum. Tongue-ties are classified according to the position of the frenulum relative to the tongue and the floor of the mouth. A very obvious (anterior) tongue-tie may cause no symptoms at all but equally a very subtle (posterior) tongue-tie may cause pain for the mother or poor weight gain in the infant, and visa-versa.
The most important movement of the tongue during breastfeeding is lifting the middle portion of the tongue. If the tongue is too tightly tethered it reduces the infants ability to elevate or lift their tongue adequately. This reduces the efficiency of their feeding and they have to work harder to draw the same volume of milk from the breast. As a result the child may fall asleep given the effort involved and then wake to feed again soon after, this leads to prolonged and/or frequent feeding times. The infant may also compress the mother’s nipple between the upper and lower ridge of the jaw bones to try and extract milk causing pain and nipple damage.
- Difficulty latching onto the breast and/or maintaining latch
- Clicking sounds whilst feeding and little evidence of swallowing while on the breast
- Poor weight gain or failure to thrive
- Baby unsettled/hungry and feeding most of the time
- Prolonged feeds with short breaks
- Significant dribbling during feeds
- Nipple pain/damage or distortion in the shape after feeding
- Painful breasts
- Poor initiation and maintenance of maternal milk supply
I think my child has a tongue-tie, who can help?
A Lactation Consultant is best placed to help if you are experiencing difficulties with breastfeeding. They are trained to perform a suck, swallow and feeding assessment and ascertain whether a tongue-tie may be a causative factor in the breastfeeding problems you are experiencing. Breastfeeding counsellors, public health nurses and midwives will often also have a special interest or particularly helpful insight. They may have experience helping mothers and babies with breastfeeding issues that may be caused by a tongue tie and can help you to find ways to achieve more comfort and efficiency with feeding. It is not in the scope of practice of a breastfeeding counsellor to examine inside a baby’s mouth. We recommend you contact a lactation consultant, with an expertise in tongue tie assessment, to assess your feeding if you are having difficulties. You can find a list of all the Lactation Consultants here. Should a lactation consultant recommend, after a full suck, swallow and feed assessment, that your child has a visit for the diagnosis and treatment of a tongue-tie they can refer you to our surgery. An appointment will not be made until we receive the referral form.
Tongue -Tie Division
Historically, the presence of a tongue-tie resulted in its division immediately after birth, usually by the attending midwife. The need for this practice came into question in the mid 1900s, in part, brought about by the rise in popularity of bottle-feeding. There is now an ever growing body of evidence to support the surgical division of a tongue frenum where the tongue is restricted or “tethered”. This procedure is called a lingual frenotomy. There is also a body of evidence (and practitioners) who believe that tongue ties should not be divided.
The National Institute for Health and Clinical Excellence in the UK has published evidence supporting performing frenotomy for infants with tongue-tie and feeding problems. (NICE guidelines)
The surgical division of a tongue-tie can be performed by cutting the frenum with a scissors or a scalpel or by ablating it with a laser. Here in The Dental Suite we perform the procedure using a blunt ended scissors. The procedure is completed in seconds. For most babies the procedure is comparable to having a blood test or the heel-prick test or even a vaccination. Nearly all babies will cry following the procedure but this typically lasts for less than a minute. We will ask you to try and bring your baby a little bit hungry as we would like them to latch and feed directly after the procedure – this gives better results for you and your baby.
Vitamin K is important for blood clotting; new born babies do not have any stores of vitamin K in the first few weeks of life so they are given an injection of vitamin K at birth. They will make vitamin K as they start feeding and their gut matures over the first 3-6 months. The injection offers protection until the baby produces sufficient amounts of vitamin K. If your baby did not receive Vitamin K at birth or is being given Vitamin K orally (drops) it is very important you mention this to your lactation consultant and the team at your appointment.
Speech effects and other possible effects of a tongue-tie
There is no way of predicting which babies who have a tongue-tie will have speech problems later in life. Most children with speech problems have a difficulty with understanding and processing language rather than the mechanical problem which tongue-tie can cause. The effect of a tongue tie could be a lisp or a reduced speed or volume of speech. Tongue tie may interfere with the ability to articulate certain sounds like “L” ,“d” ,“z”, “s”, “th” or roll an “r”.
There are many other reported effects of a tongue-tie but these are mainly theoretical and there is little science to support these claims. These include issues such as difficulty wiping the teeth clean with the tongue, licking an ice cream or play a wind instrument effectively.
HSE information on tongue-tie;
NICE information for parents on tongue-tie division;