Jo: Having a tough start to breastfeeding Primrose made me determined to get things right from the outset with Wilf. Almost two years of research and time spent in Facebook support groups and the La Leche League meant I was far more knowledgeable than I was first time around. In the hours after he was born, I was just grateful he was feeding but, MY GOODNESS, it was painful – within a few hours, I felt bruised, and dreaded nursing him. From hearing accounts by other ladies, I was sure he was tongue tied, however, the midwife who carried out his newborn checks seemed non-committal and eventually conceded that he had what she referred to as a ‘minor tie’. I got the distinct impression she was saying it to appease me and knew that, for a less-experienced new mama, the possibility of a tie would not have been raised until further damage (physically and emotionally) had been done.
Within 36 hours of being born, we took him to a private Lactation Consultant, Suzanne Barber at Babytobreast Ltd (Bedford, UK), who divided his tie, helped with my position and his latch, and kindly agreed to share her knowledge and bust some myths for us. Some of you will have asked her questions on a Facebook post late last year – hopefully you’ll find these answered below.
Over to Suzanne…
Types of Tongue Tie
Around the world there are many types of descriptions of tongue ties ranging from ‘anterior’, ‘posterior’, ‘midline’ or ‘mild’, ‘moderate’ or ‘severe’, or graded between 1-4. Remember, at this point, the visual inspection is only half the story. The very definition of a tongue tie is best described as a frenulum which restricts the function of the tongue and impacts on the organisation of the suck, swallow and breathe mechanisms of the baby. It is very possible to have a visually mild or slight tongue tie which has significant impact on feeding.
A typical anterior tongue tie is attached to the tip of the tongue and to behind the gum margin. This impacts a baby’s ability to lift the tongue, protrude the tongue and move side to side. (Figure 1)
A midline tongue tie is demonstrated by an attachment halfway down the tongue’s underside onto the floor of the mouth, creating a sail-like structure that restricts a baby’s tongue movements. (Figure 2)
Posterior tongue ties can be very short, subtle attachments underneath the tongue which physically hold the base of the tongue to the floor the mouth, this affects the baby’s ability to lift to tongue and scoop the breast deeply into the mouth. In the before (Figure 3) and after division photographs below you can see a diamond shaped wound (Fig.4) with a tongue which is now fully able to lift and to move more freely.
With the wealth of information on the Internet it is sometimes difficult to distinguish what is evidence-based, research-based information and what is someone’s opinion. Importantly, there is a lot of discussion about lip ties on the Internet and how they may impact on infant-feeding. In other international countries where dentists perform the tongue tie division they frequently remove any tethering. There is currently no strong evidence to show the impact of lip ties on breastfeeding and most professionals in the UK will not support any surgery on this area unless it becomes an issue later in life with issues such as speech or dental hygiene. The Association of Tongue-Tie Practitioners have collaboratively published a statement on their website which I would encourage you to read if you are concerned. For example, we know that 80% of babies who are being diagnosed with lip ties have normal lip tethering which, as the baby grows, will move upwards and become insignificant.
Accurate Diagnosis of Tongue Tie
You need to trust your instincts if you feel that something is not right, with a thorough assessment by an experienced practitioner. Ideally you will find an International Board-Certified Lactation Consultant (IBCLC) who will also assist you with your infant feeding after a division has been carried out. Sadly, there is generally a lack of expertise about tongue tie within the NHS which often results in parents becoming confused and uncertain about how to help their babies feed. Getting an accurate diagnosis is a bit of a lottery.
It is important that parents do not try and diagnose the tongue tie in their baby on what they see visually. A functional assessment is essential to decide whether a tongue tie division is going to be beneficial. If you’re breastfeeding, there are symptoms that should been not ignored. Pain on feeding, baby being unable to maintain latch, excessive weight loss or poor weight gain are early indications that the latch is sub-optimal and milk transfer is not effective. Sometimes, help with positioning and attachment is all that is required but, if problems continue, it may be due to your baby’s anatomy that these problems exist. For this reason, bottle-fed babies can also experience issues with feeding with a tongue tie. They may excessively lose milk out of the side of the mouth whilst feeding, take a long time to transfer small amounts of milk from the bottle and suffer with excessive wind.
Tongue ties are often assessed as ‘mild’, ‘moderate’ or ‘severe’ based purely on their appearance alone. The important point is not how they look, but how the frenulum, a little bit of skin under the tongue, affects the function of the tongue. In some areas there are dedicated clinics for the treatment of tongue ties which may be supported surgeons and/or midwives. These clinics assess for tongue function, treat within individual parameters, and often have criteria which affects the availability of the service… You may have to have an exclusively breastfed baby, a baby under a certain age, or have a baby who is failing to gain weight. There is no current evidence to suggest at what age a division of the tongue tie would be beneficial but, often, trust services are financially limited so implement a cut off for treatment by age.
There are also discussions internationally about the best aftercare for babies who have had tongue ties divided (Figure 4). Particularly in the USA, dentists advocate disruptive wound massage, which means lifting the tongue and rubbing the wound bed in order to try and prevent scarring. There are no robust studies that suggest that this prevents scarring any more than allowing a baby to feed and mobilise the tongue independently. Babies are hugely oral creatures and ongoing pain or discomfort is likely to produce breast aversion or feeding aversion.
There is guidance within the UK on Tongue Tie Division for babies published by the National Institute for Health Care Excellence (NICE 2005). They discuss the potential risks of the procedure as infection, bleeding, scarring and failing to improve feeding. The guidance concludes the risks are rare and states that the benefit of the baby’s feeding being improved (thus hopefully prolonging the breastfeeding relationship) far outweighs the risks. There are no known risks in the long-term to having the procedure.
Myth, Opinion or Fact?
A question I’m often asked is whether folic acid taken in pregnancy can increase the risk of tongue ties. National guidance is for all pregnant women to take folic acid in the first 12 weeks of pregnancy and before pregnancy to ensure a reduced risk of neuro tube defects. Surprisingly some advice on the Internet is to discontinue at 12 weeks to reduce the risk of tongue tie. This is not research-based advice and, if tongue tie were caused purely by folic acid intake, I doubt I would have seen parents and grandparents with the same anatomy as the baby, given that their parents wouldn’t have taken folic acid supplements. In short, tongue ties are hereditary.
I frequently get asked if tongue ties are on the increase. My colleagues and I do not believe there is an increase in the prevalence, we believe that we are just getting better at identifying causes of feeding issues and recognition of the cause.
Future Concerns with Undivided Ties
There are limited studies suggest that some children with undivided tongue ties are at increased risk of
having speech distortion or speech impediment. Some toddlers can be slow to develop vocally and are often frustrated at making themselves understood. Frequently when I meet parents I am already assessing the impact of any potential tongue ties by listening to the parents’ speech. There are subtle lisps, mumbling and stutters which are often perceptible in the parent with a similar anatomy to the baby. Clarity on rapid speech is almost always impossible for a tongue-tied person to achieve. (Editor’s note: Suzanne suggested that my husband was tongue tied during our appointment, just by listening to him talk! Sure enough, upon inspection, the tie was clear to see! – Jo)
In Figure 5 you can see the tongue is inhibited by shorter tighter frenulum. This effect impacts on the tongue’s ability to sweep food debris away from the back molars often leading to dental decay.
In Figure 6, you can see the tongue is tied at the tip and behind the gum margin and this has impacted by pulling the front two incisors inwards into V shape.
In the nine years I have been dividing tongue ties, I have many parents who have often shared the psychological impact of being tongue tied with me and were frustrated by feeling self-conscious.
A world-renowned lactation consultant, Alison Hazelbaker, summarises that social issues may arise from being tongue tied. Self-esteem, social sensitivity, and sexual performance deficits related to the use of the tongue can all be comprimised, and those with untreated ties can experience difficulty engaging in the activities of daily living such as playing certain musical instruments, and licking lips, lollipops, and ice cream cones. Research quantifies these issues. Despite the lack of research evidence, anecdotal reports show that those issues can have found impact on the individual and should be seriously considered when making decisions about whether to divide a baby’s tie. Early treatment may prevent the development of problems in later life, when treatment is much more complex and invasive. Treating tongue later sometimes means extensive speech therapy, psychological counselling, and orthodontia.
For further information and NHS or private practitioners in your area please see the website of the Association of Tongue-tie Practitioners (ATP). The ATP also hosts a Facebook group called ‘Infant Tongue Tie UK Support Group for Parents & Health Professionals‘ (NOT to be confused with similar named groups!) which provides parents the opportunity to reach ATP practitioners for support and information and to network with other parents.’
For The Mother Side,
(Independent Midwife – International Board-Certified Lactation Consultant – Tongue Tie Practitioner- Secretary to the Association of Tongue Tie Practitioners – www.babytobreast.com)