Ankyloglossia or “Tongue Tie”
Some babies have a lingual frenulum – a band of tissue that connects the tongue to the floor of the mouth. In some babies, the frenulum can restrict movement of the tongue, interfering with the breastfeeding process.
A frenulum may keep a baby from moving his or her tongue past the bottom gum, or from lifting or cupping the tongue adequately. This may make latching to the breast difficult, as the baby is unable to obtain a deep “grasp”, often causing sore nipples or poor transfer of milk and low weight gain. The poor gain may not be evident until baby is three to four weeks of age or older.
A frenulum may be thin and stretchy or it may be short and thick. It is hard to tell if a frenulum will cause a problem just by looking at it. The issue is whether it interferes with a baby’s ability to breastfeed comfortably and remove milk well.
Clipping, or releasing, a frenulum is a minor procedure. The frenulum may be divided with a pair of scissors, or with a laser. In either case, a sterile retractor is used to life a baby’s tongue and expose the frenulum. Sterile scissors or a laser are used to release the frenulum and free the tongue. A piece of gauze is usually applied briefly as the procedure may result in a very small amount of blood. A baby may be put to breast immediately.
Sugar water may be given for pain before the frenotomy and Tylenol may be given after to babies who are older than two months of age. A parent may be encouraged to “stretch” the area where the frenotomy was released daily, however, there is no research indicating that this is beneficial. Latch difficulties may resolve immediately, or it may take a few days for a baby to learn to use their “new” tongue correctly.
If the frenulum attaches near the tip of the tongue and a newborn is having difficulty latching or removing milk, some parents may opt to pursue a frenotomy procedure sooner rather than later. Other parents may choose to wait until a baby is gaining well and a mothers’ milk supply is well established. If breastfeeding is going well, a frenotomy may not be necessary. A very tight frenulum that severely restricts the tongue has the potential to cause speech or dental problems as a baby gets older. In this case, a parent may choose to consult with a pediatric dentist or an Ear, Nose and Throat specialist (ENT).
A “tongue tie” may not interfere with bottle feeding, as a baby does not need to “grasp” and compress the bottle in the same way as the breast. However, some babies with a tongue tie do have trouble drinking from a bottle and will lose milk out of the sides of their mouth or choke on the fast flow. In recent decades when most babies were bottle fed, a tongue tie was usually left alone, unless it resulted in problems with speech or teeth later in life. As more and more mothers began breastfeeding, frenulums have been recognized as a cause of difficulty with latch and/or milk removal.
Randomized, controlled trials have found that clipping the frenulum if it is causing problems with breastfeeding can be helpful. The largest study to date (conducted in 2002) of 2,763 breastfeeding mothers having breastfeeding problems once home from the hospital, ~13% of their babies had a tongue tie. A frenotomy (clipping the frenulum to loosen the restriction) was performed without any complications on all infants when indicated. In all cases, latch improved and maternal nipple soreness decreased significantly (Pediatrics. Vol.110, No. 5, November 2002, pp. 63).
A 2008 study looked at a small number of babies (8) and determined that milk transfer was significantly improved by a frenotomy (Pediatrics. Vol. 122, No. 1, July 2008).
A randomized, controlled study published in 2011 showed that a frenotomy decreased maternal pain.
Some babies may also have what is referred to as a labial frenulum, or a lip tie. This is a piece of skin that connects the upper lip to the upper gum. There is no randomized, controlled research showing whether releasing a lip tie improves breastfeeding. A 2016 study looked at specific types of tongue and lip ties, and improvement in pain and milk removal, as well as symptoms of reflux, following laser release of the ties (all but one infant had a lip and tongue tie released at the same time):
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