TONGUE TIE BABIES
The benefits of breastfeeding are very well documented, especially how important it is to breastfeed a baby through the first year. Breastfeeding is not an easy task for mothers (that is why it is also considered as the fourth trimester). Still, for the love of your baby, we mothers take extra steps to make it successful because we understand its significance.
But breastfeeding can be difficult for babies with ankyloglossia, commonly known as tongue-tie.
Many people are unfamiliar with the term lip and tongue ties, and even many healthcare providers are not trained in identifying lip or tongue ties. This may lead to misdiagnoses and shorten and drawn breastfeeding relationships.
If your newborn is diagnosed with tongue-tie OR If your breastfeeding is causing you a lot of pain, even though you’ve taken classes, consulted friends and family, or visited a professional? Then your baby could be tongue-tied.
WHAT IS A TONGUE TIE?
It’s a condition present at birth when the short band (frenulum) that attaches the base of the tongue to the floor of the mouth is too short and thick and thus limits the tongue’s movement; the tongue will often have a heart-shaped appearance when the child tries to stick it out. If a newborn is diagnosed with a tongue-tie, then it can affect the ability of a baby to breastfeed, or in later years, his ability to eat and speak.
WHAT ARE THE SIGNS OF TONGUE TIES?
Below are Infant and Maternal signs that indicate tongue-tie or lip tie condition in a baby.
- Poor Latch
- Clicking Signs
- Sliding Of Breast
- Poor Weight Gain
- Fussiness At Breast
- Falling Asleep At Breast
- Nipple Trauma
- Sore Breasts
- Low Milk Supply
- Plugged Ducts
- Untimely Weaning
If the tongue can’t reach past the gum line or opening of the mouth, or difficulty lifting their tongue or moving it from side to side, If the tongue curls into a little heart shape. At the same time, they are breastfeeding If the baby is chewing rather than sucking on the breast or Makes a clicking sound while feeding or the mother is having difficulty latching the baby if the mother is experiencing pain or sore nipples. If the baby is not gaining weight, it may be time to discuss this problem with health care.
CHECKING FOR TONGUE OR LIP TIES
If you believe your baby may have one of these conditions, here are a few steps you can take to diagnose the issue.
How to Examine the tongue – Lay your baby down on your knees, facing you. Run your little finger with the pad of finger down under their tongue. Does this membrane feel short, strong, or excessively thick? A usual tongue will allow for a smooth and uninterrupted swipe underneath the frenulum.
Your child’s tongue may also appear “short”, because they cannot stick it out properly due to the excessive tissue.
Checking the lip tie is also quite easy. With your child in the same position, “flip” the upper or lower lip open, and feel for any resistance which could be caused by lip ties. Look at the small band of tissue that connects the lips to the gums. It should be relatively thin and flexible. If it looks thick, it seems too short, or if the lip is challenging to move, lip ties may be present.
If you observe any sort of tie is present on baby’s lip or tongue, or even if you have any doubts about its presence then, it’s time to take professional help. A prompt diagnosis is key, and if you believe that your baby may have either a tongue or lip tie. The longer a tie goes without correction, the greater the chance the breastfeeding relationship will be drawn.
TONGUE-TIE IS CLASSIFIED INTO 4 TYPES
Type 1 – “A small, medium, or large Fence” — is considered almost always a problem.
You will notice a classic heart-shaped tongue that most doctors feel is the only real tongue tie. The tie inserts into the tip of the tongue.
- Frenulum attached to the tip of the tongue
- Heart-shaped tongue
- 100% attachment
Type 2 – “Small speed bump” — is a potential problem.
This type is considered to be an anterior tie, this tie inserts just behind the tip of the tongue. You don’t see a heart-shaped tongue, but the tie is still clearly seen.
- Frenulum attached to the mid tongue and the middle of the floor of the mouth
- 50% attachment
Type 3 – “Large speed bump” — is highly likely to be a problem.
This is classified as a posterior TT; the distinction between this and a class 4 TT is that class 3 still has a thin membrane present. In these babies, the front of the tongue may elevate just fine, but the posterior restriction won’t allow the mid-tongue to elevate, again affecting the latch.
- The frenulum is 2-4mm behind the tongue tip
- Attaches on or just behind the alveolar ridge
- 75% attachment
Type 4 – “Smooth floor of mouth” — no problem
This is a case where No thin membrane is present, so this type of tie is the most commonly missed. The front and sides elevate, but the mid-tongue cannot.
- Frenulum attached against the base of the tongue
- Thick, shiny, and inelastic
- 0% attachment
If the membrane feels like a very thin, strong wire, push on it and look for tongue tip indentation and a slight bow of tongue.
BREASTFEEDING STRUGGLES WITH A TONGUE-TIED BABY
A baby with a tongue tie may be able to breastfeed without any problems, or he may not be able to breastfeed well at all. It depends on the baby and the type of tongue-tie.
Children use their tongue when they latch on to the breast. They extend their tongue out to take the nipple and some of the surrounding areolae into their mouth. They also use their tongue to form a good seal around the latch. But, a baby with a tongue-tie may not be able to open his mouth wide enough to latch on to the breast and seal the latch well.
If your baby is having trouble latching on, talk to a lactation consultant about using a nipple shield.
However, if you do decide to use a nipple shield, learn how to use it correctly, wear the right size, and work closely with your doctor. If you don’t wear it as directed, a nipple shield can cause even more breastfeeding issues.
If your nipples are too sore from breastfeeding and you need to rest them to heal, use a breast pump to maintain your breast milk supply and provide your child with your expressed breast milk in a bottle. If your supply of breastmilk is decreasing, take steps to boost production and increase your supply.
Do continue to see the doctor at regular intervals to monitor your baby’s health and weight gain.
WHEN TO TREAT?
“Consider treatment whenever the infant and mother have difficulty Breastfeeding.”
Prof Mary Fewtrell, from the Royal College of Paediatrics and Child Health, said: “For some, tongue-tie can be the cause of poor breastfeeding, and maternal nipple pain and the procedure can correct the restriction to tongue movement and allow more effective breastfeeding for baby, and comfort for mum.
However, parents need good breastfeeding support and advice before considering surgery because, as this study shows, it can sometimes be avoided with the right support.
TREATMENT OF TONGUE-TIE
Doctors have different approaches when it comes to tongue-ties. Some recommend you correct it as soon as possible — perhaps even before discharging your newborn from the hospital. Others take a more laid-back approach and will tell you to wait and see.
The lingual frenulum may loosen over time, resolving tongue-tie. In other cases, tongue-tie persists without causing problems. Lactation consultants can assist with breastfeeding, and speech therapy with a speech-language pathologist may help improve speech sounds.
Surgical treatment of tongue-tie may be needed for infants, children, or adults if tongue-tie causes problems. Surgical procedures include a frenotomy or frenuloplasty.
1. Frenotomy or frenectomy
- Simple procedure (an anterior to posterior snip of frenulum)
- Bleeding is minimal less traumatic than ear piercing
- Breastfeed immediately after the procedure.
A frenotomy is a simple surgical procedure that’s usually done in the doctor’s office or hospital nursery, Anesthesia is not necessary for performing frenotomy, and the cut is made in a single motion in less than a second. Bleeding is minimal and less traumatic than ear piercing, and most mothers can breastfeed immediately after this procedure.
The procedure involves holding the tongue with a tongue elevator or may also be lifted with the index and middle fingers on either side of the frenulum, and the frenulum clipped with sterile scissors from a suture removal kit. 2
The only risk is excessive bleeding. Scarring is also possible, or the tissue could reattach over time if proper aftercare is not done.
2. Frenuloplasty [FREN-yoo-loh-plass-tee]
- Transverse cutting and vertical repair requires general Anesthesia
A Frenuloplasty might be necessary if the lingual frenulum is too thick or requires additional repair. General anesthesia is required during this procedure. Doctors use surgical tools to cut the frenulum and then close it with sutures. Possible complications are similar to frenotomy.
Tongue-tie treatment isn’t always necessary — sometimes, tongue-tie resolves itself over time. If not, then surgical procedures are relatively mild, and your baby should recover in no time.
HOW TO CHECK IF TONGUE TIE IS FULLY RELEASED AFTER SURGERY?
The tongue tie that is fully released has a diamond-shaped wound. If there is no diamond, then the release is incomplete. The alternative way to know for sure that no further tie exists is to release the tie until the muscle is seen.
Watch this video from Fauquier ENT that shows what tongue tie is and how it is treated close-up. This procedure can be performed in the clinic without sedation in newborns. Although clamp and scissors are used in this video, alternatively, a laser can also be used. Keep in mind, video is for frenotomy release and NOT Frenuloplasty.
Managing Breastfeeding Without Frenotomy
- Maintain milk supply – Try and maintain your milk supply by expressing milk seven to eight times/ day with an electric breast pump.
- Maintain practice at the breast
- Focus on the deep asymmetrical latch – Breastfeeding positions which facilitate the deepest asymmetrical latch possible-chin to breast and philtrum to the nipple and laid back breastfeeding positions will assist the tongue-tied infant in breastfeeding.
- Nipple Shield – The use of a silicone nipple shield may also assist the non-latching infant with tongue-tie. The widest diameter nipple shield should be used as it will fit completely into the mouth and assist their restricted tongue grooving.
- Oral Exercise – Reduce posterior tongue elevation and retraction with oral exercises.
Post Treatment Therapy
There are specific movements and lifts of the mouth, which are important to do several weeks following up to the operation. However, do not start these exercises until 24 hours after the procedure.
Also, it is important to make the exercises fun/ game for an infant. Make sounds (like you are playing with him) while doing exercise so that your baby feels you are playing and lets you do it. Always respect the infant; if he does not want to participate or is resisting, then respect his actions.
- Respect the infant
- Exercises must be fun/a game for infant
- The infant should be in quiet alert or early active alert state
Post Treatment Therapy
- Finger Feeding
- Press down
- Tongue massage
- Increasing tongue lateralization
- Desensitizing the palate
Lift the tongue to prevent healing together
Place both of your fingers below your baby’s tongue on either side of the wound and lift the tongue towards the roof of their mouth. Hold for 3 seconds and repeat three times.
According to Patricia Pine, RDH, Orofacial Myofunctional – Re-training the baby’s tongue to suck properly takes time and patience. Suck training/retraining can be used to prevent sore, damaged nipples for the mother as well as to encourage nutritional sucking for the baby. Facilitate sucking by placing your index finger or little finger (pad side up) into the baby’s mouth. Once the baby begins to suck, you can turn your finger over (pad side down) and let the baby suck.
After 5 or 6 sucks with tongue cupping and grooving on your finger, move the baby to the breast. If this hurts after 3 or 4 sucks, remove the baby from the breast and repeat the suck re-training with your finger. Repeat this activity 3 to 4 times.
You can also use a pacifier with a rounded nipple such as the Avent Soothie to teach a baby to suck using a cupped/grooved tongue. Dipping the pacifier into already extracted breast milk or formula is an option. Place the rounded nipple into the baby’s mouth onto the tongue. Then, gently pull it away from the lips, and you should feel the sucking pressure. Play with the pacifier, make it a game, and teach the baby to suck on the tip of the pacifier as you pull it slowly out of the mouth. It is best to use a relatively short pacifier, so it does not gag the baby. It is also important to remember that pacifiers are used to suck training and to calm as needed. Overuse of a pacifier can inhibit the development of mature swallowing and vocalization. 3
Use your finger to trace the gum line, top, and bottom.
Hook your finger inside the cheeks and just gently pull them apart.
Lift The Lip
Using your fingers, place them on either side of the wound and flip the upper lip towards the nose. Hold for 3 seconds and repeat three times.
Put the baby to breast frequently with proper attachment (sometimes all that is required), and Exercises need to be customized to address each infant’s needs. Your infant must show signs of effectiveness early on, and exercise should be changed if ineffective.
Watch the below video of Gentle post-frenotomy care and mouth work by Melissa Cole, MS, IBCLC of Luna Lactation & Wellness
Finally, don’t stress too much and do not put too much pressure on yourself. This is difficult and exhausting as you try to comfort your crying baby who is unable to latch and is overly hungry and cries out of frustration.
In the end, I would say give supplement when needed and pump when possible. Based on your situation, do what you feel is right.