Sarah was desperate. Her three week old baby Tom was unsettled, squirming at the breast and because he wasn’t sucking well, she had been topping him up with formula so her milk supply was rapidly diminishing. She had seen a paediatrician who told her Tom had 'behavioural problems' and she was feeding him too often. Her baby health nurse had told Sarah she needed to learn ‘tired signs’ because her baby was ‘over-stimulated’.
It turned out nobody had watched Sarah actually feed her baby. Tom had a very disorganized suck, he kept sliding off the nipple, he was making clicking noises and gulping in air because he couldn’t get a good seal. Milk dribbled out of the corners of his mouth whether Sarah was breastfeeding or topping him up with a bottle.
I checked Tom’s mouth and assessed the mobility of his tongue –when I touched Tom's bottom gum, he couldn’t poke his tongue beyond his gum and when I rubbed his gums at the side of his mouth, instead of his tongue following my finger, his tongue tipped sideways. When he cried, Tom’s tongue formed a ‘trough’ anchored in the middle and curled up at the sides – he couldn’t raise his tongue up to the roof of his mouth.It turned out Tom had a posterior tongue tie that was restricting the movement of his tongue, making it almost impossible to latch and feed effectively.
In some babies, like Tom, the little membrane called the frenulum, which joins the middle of the tongue to the floor of the mouth, is too tight and ‘ties’ the tongue so that the baby has difficulty moving his tongue effectively. This means that the baby will be unable to bring his tongue forward far enough to latch onto the breast and draw the nipple far enough back into his mouth to feed well. If the baby’s tongue is restricted it won’t create an effective peristaltic action, rippling from the front of the tongue to the back, efficiently drawing out milk and maintaining milk flow. If a baby has a lip tie – the frenulum beneath his upper lip may restrict movement so he won’t be able to flange his top lip as he feeds (some babies can feed effectively despite having lip ties).
Tongue and lip ties usually make feeding very tiring for babies, they can’t form a tight seal on either a breast or bottle so milk will often dribble from the side of the baby’s mouth as he feeds, sucking may be noisy with clicking or ‘snapping’ back on the nipple as he slides off and grasps at the nipple again while feeding, Babies, whether breast or bottle fed can be hungry and have poor weight gains because feeding is so exhausting that they may fall asleep while feeding. Often, early weight gains are adequate because initially mothers tend to have an abundant supply but with ineffective breast emptying over time this can reduce milk supply.
Babies with ties often suck in air as they feed so they can be very unsettled and may be diagnosed with reflux that doesn’t respond to treatment because the underlying cause is air swallowing due to a poor latch. They are also often referred for sleep training, when the pain and crying is a symptom of the tongue tie that has not been addressed, not a baby with a ‘behavioural problem’ or a mother who is doing something ‘wrong.’
Although Sarah didn’t experience painful feeds, most likely because Tom wasn’t actually attaching, babies with tongue and lip ties can cause severe pain for their mothers as they breastfeed: the baby may latch onto the nipple, and ‘gum’ or chew it, causing severe pain and eventually, nipple damage such as blanching (white nipples), cracks and grazing that can sometimes be followed by infection or mastitis.
How does the latch FEEL(whatever it 'looks' like)?
Elle, mother of two week old Mia, had severely damaged nipples but had been dismissed by health professionals because to them, her baby’s latch ‘looked fine’ . She was told that her nipples would ‘toughen up’. Luckily Mia was persistent in seeking help. Even if the latch ‘looks fine,’ if your nipples hurt or look ‘squashed’ after a feed – Elle’s nipples were cracked and bleeding, as well as squashed like the point of a lipstick after Mia fed – please seek help. This is not how breastfeeding is meant to feel and there may be other reasons for nipple pain besides a tongue tie that can be simply addressed by some expert adjustment of your baby's feeding position. Thankfully, after revision by a dentist who specializes in treating babies with tongue ties, Mia latched deeply for the first time and Elle was able to breastfeed pain free within a few days.
When ties show up later
Not all babies with tongue tie have immediate or obvious feeding problems, although there are often ‘clues’ that something isn’t right. According to Mel, mother of fourteen month old Poppy, “she fed like a trooper from the start.” Mel had no pain while breastfeeding – until Poppy cut her first two top teeth. As Poppy fed, Mel felt as though she was pinching and her nipples were left with deep dents where Poppy’s teeth rested. She started having recurrent bouts of mastitis – always in the same area, probably because Poppy couldn’t drain that part of the breast. As Poppy started eating family foods, she gagged on meat, she couldn’t suck out of a straw or sippy cup when Mel offered her water. Then, when the next two top teeth came through, feeds became even more painful. One day Mel thought perhaps Poppy had some food in her mouth and tried to check under her top lip but she couldn't flange Poppy’s lip and noticed the frenulum between Poppy’s top teeth. This is when she called me to see whether Poppy had a lip tie.
It turned out that Poppy had an upper lip tie and a posterior tongue tie. Since having these revised by a dentist who uses laser, Poppy can proudly drink from a straw, she eats well, is starting to talk and, best of all, she started sleeping much better. Looking back, Mel now sees signposts that all wasn’t well – although Poppy was thriving, she fed frequently day and night, she was prescribed reflux medication which didn't really help and when offered a dummy, it always slipped out of her mouth.
Could it be hereditary?
Tongue-tie is often hereditary – if either you or your partner have or had (you may have had your frenulum snipped as a baby) a tongue tie, there is a higher chance that your child will also have this condition. Often I will find a baby with tongue tie and then discover that one of the parents’ own mothers had difficulty with breastfeeding and, on checking, it turns out the parent also has a tongue tie. Often too, there will be stories about speech therapy or intensive dental work when this parent was a child.
It’s not just breastfeeding that can be affected by tongue or lip ties. Difficulties can happen when the child starts eating solid foods and speech can be affected (think Jamie Oliver). Tongue and lip ties can also affect dental development, from misaligned teeth due to improper palate and jaw development, to tooth decay due to not being able to use the tongue to remove food stuck on the teeth. Children and adults with tongue ties can also develop sleep apnoea and some of the delightful pleasures of life can be affected like licking an ice cream and kissing, and social interactions can include problems such as spitting or dribbling excessive saliva when talking.
A tongue tie can be easily fixed by seeing a specialist doctor or dentist who will asess your baby and whether revision is advised, then discuss your individual baby's issues and implications with you. If revision is indicated, the specialist will either snip the frenulum or use a laser to revise it (the younger the baby, the easier it is). You will be able to feed your baby straight away and you may be surprised how much more easily your baby feeds – and sleeps – after this procedure.
For further reading about tongue tie, check these links:
Is my Baby Tongue -tied – (includes clear photos) By Catherine Watson Jenna, Lactation (US Lactation Consultant IBCLC, author of ‘Supporting Sucking Skills in Breastfeeding Infants’)
Top Ten Tongue Tie Myths by the Analytical Armadillo (a UK Lactation consultant IBCLC)
Tell Me About Tongue Ties! By Norma Ritter, IBCLC, RLC
