How do you know if your baby has a tongue tie?

How do you know if your baby has a tongue tie, and what can be done if they do? We asked three experts to share their knowledge and advice on the condition and its effects on babies, breastfeeding and beyond.

For many mums suffering through breastfeeding complications, a diagnosis of tongue tie for their baby may come as a relief. They may feel that once the tongue tie is treated their breastfeeding challenges will be over. However, the issue is not quite that simple, and there are a number of factors to consider. To help shed some light on the topic, we asked paediatric dental surgeon Caitlin Agnew, lactation consultant Cathy McCormick and osteopath Kim Collard for their perspectives and advice. 

WHAT IS A TONGUE TIE, AND HOW IS IT TREATED?
The medical term for tongue tie is ‘ankyloglossia’, which comes from the Greek ‘ankylo’, meaning stiff or rigid and ‘glossia’ meaning tongue. A tongue tie occurs when the frenulum, a piece of tissue which fastens the tongue to the floor of the mouth, is abnormally thick, tight or short. It affects approximately 10% of newborns and is more common in boys. Some tongue ties are clearly visible, others are not. To release a tongue tie, a tiny incision is made in the frenulum with scissors or a laser. The procedure doesn’t need an anaesthetic and the incision generally heals quickly.

WHAT IMPACT CAN TONGUE TIE HAVE?
Caitlin: For babies, it can result in a poor latch, poor depth of nipple placement, poor milk transfer and inefficient feeding. This can lead to prolonged feeding, infant fatigue, poor weight gain, and pain for the person on the other side of the nipple – Mum! There’s also an increased risk of women developing milk blisters, blocked ducts and mastitis. Also, some babies with tongue tie may take in excess air and be grumpy and irritable during or after feeding.

This array of problems can be heartbreaking for a mother and can understandably cause a rollercoaster of emotions at an already emotional time. The pressure of looking after a newborn and dealing with breastfeeding issues is tough. Who knew that a tiny piece of attached tissue could cause so many issues?!

Older children with tongue tie may be prone to things like difficulty eating (for example, moving food around the mouth or licking an ice cream), poor oral clearance (the ability to clear food and liquids from the mouth and the teeth), dental caries, orthodontic issues and impaired speech. However, there is some good news! Not all tongue ties lead to feeding problems or other issues further down the track.

Kim: From an osteopathic perspective, if tongue movement is significantly restricted long-term, that may impact posture and neck tension. People who have had their tongue ties released as adults have reported a decrease in chronic headaches and find talking less tiring.

DO ALL TONGUE TIES NEED TO BE RELEASED?
Kim: It’s possible to have a tongue tie that doesn’t affect function enough to warrant a release, but proper assessment is essential to determine this. Osteopathy can help the tongue movement and function using gentle non-invasive techniques, but if we don’t get enough change to make feeding easy, I’ll refer on to a specialist.

Cathy: Through my practice I’ve found there’s a small percentage of tongue-tied newborn babies who benefit from a release, and this alone will fix a breastfeeding problem and relieve nipple pain/trauma if it’s done in the first few weeks. However, in my experience, not all tongue ties need to be released. I’ve facilitated many mothers’ support groups and found that kind, caring support, combined with patience and time spent working holistically to help breastfeeding issues has been a very successful way to help women succeed in their own breastfeeding journey. 

WHAT STEPS SHOULD PARENTS TAKE BEFORE DECIDING TO HAVE A TONGUE TIE RELEASED?
Caitlin: Lactation support is a good first step. Breastfeeding advice and assessment is important to determine whether or not the tongue tie is interfering with feeding and whether division is appropriate. A conservative approach, such as altering feeding position, can sometimes be enough to manage any issues.

Kim: Lactation consultants and experienced baby osteopaths can be good places to start, as they tend to look at making conservative, non-invasive changes first. They can also refer your baby on for further treatment or release if necessary. The expert should make recommendations based upon how the tongue tie is affecting your baby, as no two situations are the same, and what worked well for one baby may not work well for another. Online information and hearing other people’s experiences can be helpful in terms of support, but useful advice can only really been given individually after your baby is assessed.

Cathy: Some parents will be very clear that they want it sorted, regardless, but I think some aren’t fully aware that a tongue tie release isn’t always a quick fix. For example, the baby could have a poor latch that has damaged the mother’s nipples or caused other breastfeeding issues, like blocked ducts or mastitis. Talking to your midwife is a good starting place, then a lactation consultant and/or a GP. Keep asking until you find someone who you feel comfortable with – some paediatricians, GPs and midwives don’t believe in tongue ties at all. Chat to other parents about their experiences, but remember that many different factors affect how parents and babies respond to a tongue tie being released or not.

ARE THERE RISKS ASSOCIATED WITH RELEASING THE TONGUE TIE?
Cathy: Yes – and it may not fix the problem! There could be feeding issues and ongoing scarring which may need more surgery or cause an even bigger problem. Bleeding can be an issue as well as oral aversion (when a baby doesn’t want anything in their mouth). And, if a medical procedure is undertaken with no improvement in breastfeeding, the mum’s anxiety can be compounded even more.

DO YOU THINK TONGUE TIE IS OVER-DIAGNOSED?
Caitlin: This is the million-dollar question! The diagnosis and treatment of tongue ties has increased in the past decade, however it’s difficult to know whether or not tongue ties are being ‘over-diagnosed’. What is known is that in recent decades there has been a resurgence in breastfeeding, increased public knowledge about tongue ties, and more women asking for help.

We need to remember that a tongue tie release is just one of many tools which can be used to resolve breastfeeding issues. Conservative management of breastfeeding problems is always the aim, but, if it’s deemed that a tongue tie release may lessen breastfeeding issues, it should go ahead.

Kim: It may be being over-treated. There are standardised diagnostic criteria, so if a baby has a proper assessment and the criteria are met, then the diagnosis is correct. Looking at tongue tie in isolation is itself an issue. It’s just not as straightforward as saying, if a baby’s tongue tie is contributing to feeding problems then releasing the tongue tie will fix the feeding problem. To support successful breastfeeding, we need to look at the bigger picture and the interplay between mother and baby, and consider and address any other factors that may be contributing to feeding difficulties. I believe that by doing this, fewer babies would be treated for tongue tie, and there would be better success rates in the ones who were treated.

Cathy: Tongue ties can be diagnosed when in fact the issue is the normal variations of a baby’s mouth. If a woman has a breastfeeding issue, tongue tie is often seen as the culprit, when in fact it could be a multi-faceted issue, such as birth trauma, tight jaw or poor latching.

A mother is in a vulnerable position as she heals – physically and emotionally – from a birth. The rollercoaster of hormonal changes can make her feel very anxious about whether her baby is getting enough milk, and this has a huge impact on a mother’s confidence when it comes to feeding. If a tongue tie is diagnosed and then released, in some ways the mother then needs more support to ensure the breastfeeding issues she was experiencing are resolved, as this is her expectation. Also, many babies need time to adjust to a new tongue function and breastfeeding is not 100% after a release. Patience is required!

WHO IS QUALIFIED TO DO THE PROCEDURE?
Cathy: Again this is an area that needs more discussion. Most hospitals have a free service of midwives who are trained in simple tongue tie releases of the classic tongue tie. Anything more complicated is referred through strict guidelines to public or private Ear, Nose and Throat specialists. Some GPs cut tongue ties. Some parents also investigate laser options.

WHAT'S INVOLVED IN TONGUE TIE RELEASE?
Caitlin: Numbing or anaesthesia is not usually required (it can be distressing for a young infant), but sugar syrup can be given to act as  a natural pain reliever (as a children’s dentist, this is the only time I ever recommend sugar!). The baby is swaddled and stabilised, the tongue retracted, and the frenulum is divided with either scissors or a laser. The tiny incision creates a diamond shaped wound which turns creamy white for several days, before healing completely. There will be a tiny drop of blood at the site, and you’ll be encouraged to breastfeed straight away. You’ll be asked to wait at the clinic for 20 minutes afterwards. Back home, it’s important to sterilise all feeding/pacifying equipment for two weeks. 

Caitlin Agnew is an Auckland-based specialist paediatric dentist who is currently on maternity leave. You can find osteopath Kim Collard at restoreosteopathy.co.nz and lactation consultant Cathy McCormick at holisticbaby.co.nz.