Tongue Ties Explained by a Melbourne Advanced Paediatric Osteopath and Lactation Consultant

Tongue ties are a hot topic in breastfeeding circles. So what’s all the fuss about?

Ankyloglossia, commonly known as tongue tie, is the name given to the condition where the tongue is tethered (or “tied) to the floor of the mouth by an abnormally short, thick or restrictive frenulum. The lingual frenulum is the thin piece of connective tissue that is found in the midline under the tongue. When considered alongside other tied oral tissue, such as upper lip ties and buccal ties, they are commonly grouped together under the term “tethered oral tissues” (or TOTs).

In medieval times up and through the early 1900s, tongue-ties were released routinely by either a midwife with a sharpened fingernail, or a surgeon using instruments. In fact, the instruments necessary to clip a tongue-tie appeared in circumcision trays because both procedures were commonly performed before a newborn was sent home from hospital.

In the post-war ear of the 1950s, the culture in the United States and Australia changed with the introduction of baby formula and rates of breastfeeding fell dramatically. By the 1960s and 1970s, ankyloglossia was considered to be an outdated topic, and many pediatricians denied that tongue-tie existed or that it caused a problem with feeding in newborns. The natural childbirth movement in the 1970s brought renewed interest in breastfeeding as a first choice for infants, and with this change came increasing recognition of tongue-tie as a potential road block to successful breastfeeding. A few case reports and observational studies appeared, proposing a link between ankyloglossia and breastfeeding difficulty.

Over the past few decades, ankyloglossia has emerged as a topic of great professional interest, the subject of much clinical research and of significant public awareness. As breastfeeding rates have increased and more tongue ties are being diagnosed and treated, ankyloglossia has become a hot topic in the community, prompting position statements to be developed by many professional bodies including pediatricians, feeding and speech therapists, allied health practitioners, lactation consultants, dentists, and ENTs.

What Exactly Is It?

It is important to understand that not all oral frenula are restrictive. The visible presence of a frenulum does not necessarily mean there will be a diagnosis of tongue tie. It is vital when thinking about oral frenulum and assessing for tongue tie, that we understand that ankyloglossia is a functional diagnosis. That means the health professional assessing the tongue must understand how it should normally function, in order to be able to accurately recognise when it is not. This examination needs to also include a breastfeeding assessment. Tongue tie is a diagnosis of dynamic dysfunction, not a diagnosis of observation only. This is why it cannot be diagnosed from a photograph. 

In a true case of ankyloglossia, baby’s short frenulum prevents their tongue from remaining elevated and in contact with mother’s nipple throughout the sucking and swallowing cycle. This commonly results in compensatory sucking mechanics whereby baby keeps their jaw relatively narrow to reduce the distance the tongue needs to move. This leads to a shallow latch, and thereby makes breastfeeding less efficient for baby and painful for mum.

So What Does It All Mean?

It has been suggested that in some instances a tongue tie can be responsible for the following breastfeeding challenges:

* sore, cracked or bleeding nipples

* a poor latch & slipping off the breast

* recurrent plugged ducts and breast engorgement

* mastitis and breast abscesses

* poor milk supply/production

* unsettled baby

* frequent and lengthy feeds

* unsettled at the breast during feeds

* colic

* inefficient transfer of milk

* poor growth

* failure to thrive, and

* early weaning

A Good Latch Is A Deep Latch

As we know, for pain-free breastfeeding a good latch is everything. It is the primary factor that determines the success of a breastfeed. A good latch is a deep latch. And the tongue is the chief driver of that all important latch. When baby’s oral cavity is sealed by the correct position of her lips on mum’s breast and the mid-portion of the tongue elevates and depresses with each suck, this creates a vacuum (or negative pressure) which causes the milk to be drawn from mums breast into baby’s mouth.

Tongue ties can affect the mobility of the mid-tongue and thereby the ability to create and maintain the necessary sufficient negative pressure for effective milk transfer.

A deep latch is maintained by generating this vacuum. If baby can’t produce a good vacuum, they tend to come on and off the breast during feeding, or they may produce an audible click with their tongue, they may become unsettled and frustrated at the breast, they may leak milk while feeding and they may spend long periods of time at the breast without necessarily consuming sufficient quantities of milk.

As milk production is largely a supply and demand equation after the first few months, if a baby is inefficient at removing milk, mum’s supply can begin to falter and baby can begin to slow down on their growth.

For mum, if her baby does not drain her breasts well with each feed, she is susceptible to plugged ducts and mastitis. In addition, a tongue tie commonly causes nipple pain and damage for mum, because the latch it shallow, which leads to abrasion or pinching on her nipples. This damage can make her susceptible to thrush and infections and mastitis, as well as lead to early weaning because of the pain associated with breastfeeding.

In Summary

A thorough and careful assessment of a baby’s mouth and tongue should be included in any case with the above mentioned clinical scenarios. The oral assessment must include a functional assessment of tongue mobility, in addition to the physical appearance of the frenulum and a breastfeeding assessment. If symptoms do not improve with usual lactation consulting methods, such as improving positioning and latching, a referral for further tongue tie assessment may be appropriate. This should be done by a health professional trained and experienced in treating tongue ties, and who has specific breastfeeding knowledge.