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    Tongue Tie and Breastfeeding

    tongue ties

    Ankyloglossia is the scientific term for tongue tie. The tongue is made up of a group of eight muscles and is always at work. The tongue is involved in feeding, swallowing, jaw development, speech and impacts our breathing. Being able to move properly and without restriction is important for all it’s functions to be performed properly. When it can not move freely, it affects our whole system.

    The tongue is connected by the lingual frenulum to the floor of the mouth. The frenulum is a band of tissue which is part of the fascial system.(1) Everyone has a frenulum under their tongue and it is a normal part of our anatomy. A tongue tie refers to a frenulum that restricts the tongues ability to move and properly function. 

    Did You Know?

    The tongue is connected through the fascial system through the body all the way down to the toes.(3) This is very important to understand. It means that if there is a tongue tie, there is likely tightness in other areas of the body that can also impact the babies ability to comfortably and efficiently nurse. 

    Fascia is a system of connective tissue below the skin that surrounds and supports muscles, organs, nerves and bones. When the fascia is tight, it impacts the ability of our body to move freely and comfortably. It is like wearing clothes that are too tight making it hard to bend and move. We want our fascia to be loose, unrestricted and able to bend and move with ease. If we pull one part of the fascia tight, like having a tongue tie, the consequence is it pulls on everything else connected to it.(4) Breast/chest feeding is a whole body experience for your baby and not just about what their latch might look like.

    The tongue normally separates from the floor of the mouth in utero. Tongue tie is a birth defect found in 4% - 10% of babies.(2) This may be on the low side because not all practitioners are proficient at assessing ties and many ties go undiagnosed until later in life. Undiagnosed oral restrictions have led many parents to stop their breast/chest feeding experience short. There are solutions!

    The tongue during breast/chest feeding

    As your baby opens their mouth nice and wide and you bring them towards you to latch, their tongue will be out over their bottom gum line and cup the areolar tissue drawing it into their mouth. The nipple extends back toward where the hard and soft palate meet on the roof of the mouth. The lips form a seal at the breast. While the tongue remains extended, cupping the breast, it begins to compress the breast tissue, moving in a rhythmic wave-like pattern front to back requiring the entire tongue to be able to have the freedom to move upward away from the floor of the mouth. 

    If the tongue is tied down and unable to lift properly, the baby may compensate by not latching as deeply on to the breast/chest. This also reduces the amount of milk they are able to remove which can decrease the parent’s milk supply as well as cause poor weight gain for the baby. 

    As your baby continues to suck, a bolus of milk collects and the tongue aids in swallowing while allowing the baby to breathe.(7) When a baby has a full range of motion of the tongue, the process of suck - swallow - breathe sounds smooth and is comfortable. When there is a restriction, it may sound disorganized or sporadic rather than rhythmic. Without being able to use the back of the tongue, swallowing can be a challenge and your baby may sound like they are sputtering or gagging. Clicking is heard when there is a loss of suction when the tongue is not able to keep contact with the breast/chest tissue. 

    When not active, the tongue should rest on the roof of the mouth. The muscle of the tongue is what helps to spread the palate wide and away from the nasal cavity.(5)  When it remains low in the mouth, the palate remains high and the jaw develops in a narrow rather than a wide arch. Babies can sound stuffy or like they have nasal congestion when their palate is high. This narrow, high palate impeding on the nasal cavity can make it harder to breathe and you may see your baby keep their mouth in an open position. Sometimes this is noticed only while they are asleep. 

    A tongue tie can not be identified by just looking at a baby’s latch, just looking in their mouth and definitely not from just a photo. 

    Symptoms the lactating parent may experience:

    • Pain while nursing
    • Lipstick shaped nipple after nursing
    • Plugged ducts or mastitis
    • Low milk supply
    • Cracked, bleeding, or damaged nipples

    Symptoms the baby may have:

    • Difficulty latching
    • Shallow latch
    • Clicking sound while nursing
    • Gas and hiccups
    • Tires quickly while feeding
    • Low weight gain
    • Falls asleep quickly at breast
    • Reflux
    • Difficulty handling milk flow, choking or sputtering
    • Strong gag reflex
    • Torticollis
    • Seems hungry all the time
    • Difficulty drinking from a bottle
    • Difficulty with solid food

    If you are checking off any of the symptoms above, it is time to find an IBCLC (International Board Certified Lactation Consultant) who is experienced with oral function and habilitation. Not all lactation providers or pediatric providers have taken the continuing education required to obtain the skill set needed for assessing and helping to correct the compensations babies and parents make when ties are present. Your IBCLC will also help coordinate with the other care providers needed to properly resolve the ties and affects oral restrictions have throughout the rest of the body.

    The Role of the IBCLC  

    An IBCLC spends the time to take a complete health history for you, your baby and your feeding experience. Not everyone experiences the same symptoms with tongue ties so this collection of information is very important for helping determine other areas of the body that are being affected from the tightness under the tongue and together you will develop a care plan that is individualized for you and your baby. 

    Seeing how your baby nurses and/or bottle feeds and listening to the symptoms you and your baby are experiencing are important since each parent and baby dyad are unique. An oral assessment can be performed in person or virtually as your IBCLC guides you. An oral assessment includes looking for signs of restriction under the tongue as well as the other frenum in the mouth which are the upper lip (labial), lower lip and 4 areas of the cheeks (buccal).

    Your IBCLC will also assess your baby’s reflexes and make observations of their whole body to determine where there is muscle tension and strain patterns that are contributing to their feeding challenges. Babies and parents make compensations to transfer milk. Although these compensations are helping to feed the baby, it is not optimal for comfortable and efficient milk removal, milk supply or the development of the baby. 

    After Assessment

    • Your IBCLC will give oral exercises and body exercises to begin loosening tension and fascia tightness. There is not a one size fits all plan and the exercises may change as you are working together. 
    • Bodywork will be a part of the care plan to address structural issues
    • Release provider - If the release provider does not require you to work with an IBCLC and have bodywork done before and after the procedure, discuss this with your IBCLC or find a different release provider.

    The preparation done by you at home with instruction from your IBCLC as well as the bodywork your baby gets allows the release provider, often a pediatric dentist, to be able to more easily do their work. Preparation helps the baby gain as much mobility with their tongue as possible, relan muscles being overworked and strengthen other muscles needed for better outcomes after the tissue is then released. When the prep work is not done, it can result in no change in symptoms, worse symptoms, reattachment  of the tissue or breast refusal. 

    Your IBCLC will give you information for what to expect during the process of releasing tongue ties and the aftercare involved. When your baby is restricted, it is like having a rubber band that if we stretch it, it may loosen but the tension is not gone. When the tie is released, oral exercises and bodywork therapy continues. The tongue muscle learns how to move properly with it’s full range of motion. The body has more freedom of movement with less tightness making positioning at breast/chest more comfortable. 

    Symptoms in older children & adults

    Tongue tie symptoms extend beyond breast/chest feeding. If restrictions and strain patterns exist, they can be maintained, but will not go away without addressing the cause. Some parents experience no pain during feeding and their baby gains weight just fine. Symptoms may not be recognised until later in life.(6)

    • Difficulty with solid foods
    • Gag on foods or throwing up after eating
    • Speech delays
    • Difficulty forming certain sounds
    • Mouth breathing
    • Cavities
    • Crowded teeth
    • Poop sleep
    • Allergies
    • Behaviour problems
    • Difficulty concentrating
    • Bed wetting
    • Chronic sinus infections
    • Enlarged adenoids or tonsils 
    • Headaches
    • Chronic neck and shoulder pain
    • TMJ pain
    • Jaw clicking
    • Recessed gums
    • Sleep apnea

    Myths about tongue tie

    1. Your baby will outgrow the tongue tie
    2. Tongue ties stretch over time
    3. You have to wait until your child is 1 - 2 years old to release a tie
    4. Lip ties don’t affect feeding
    5. If your baby is gaining weight, there is no need to release a tongue tie
    6. If the baby can stick their tongue out over their bottom gum line, they aren’t tongue tied
    7. Posterior tongue tie doesn’t exist
    8. Treating tongue tie is just a new fad

    There are a lot of myths and mis-information given to parents about tongue tie and oral restrictions. Understanding how the tongue works and its connection to the rest of the body can help connect the dots of symptoms experienced by the parent and baby if you suspect a tongue tie. Remember, not all providers have the same continuing education or skill sets for proper assessment. If you are recognizing symptoms of ties with you and your baby, step one is to call an IBCLC who has experience in oral function. Correcting a tongue tie early with the proper preparation and follow up care can lead to better overall growth, development and wellness.


    Footnotes:

    1. https://www.hindawi.com/journals/ijoto/2020/1820978/
    2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949218/#:~:text=Ankyloglossia%20is%20a%20common%20finding,between%204.2%25%20and%2010.7%25.
    3. https://airwaymatters.blog/2018/10/08/tongue-to-toes-the-whole-body-connection/
    4.  https://www.ncbi.nlm.nih.gov/books/NBK493232/
    5. https://www.brianpalmerdds.com/bfeed_oralcavity.htm
    6. https://tonguetie.net/consequences/?fbclid=IwAR08_BEbDKV67gW0Rs__F5626XThbx3uSsaL90FdUsdyS4E3M03hLNMjtrw
    7. https://www.livescience.com/7468-hyoid-bone-changed-history.html





    Resources:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390887/


    https://www.ncbi.nlm.nih.gov/books/NBK493232/


    https://www.researchgate.net/publication/301346077_Congenital_tongue-tie_and_its_impact_on_breastfeeding


    https://tonguetie.net/consequences/?fbclid=IwAR0Ws4LxsCo5QaUvm0gD9K3bYSGeSIFq_yb-Ryiml91mHsQ8Gdu26UI_7HY


    http://www.tonguetieindia.com/tongue-tie-compensations.html


    https://askthedentist.com/pediatric-sleep-disordered-breathing/?fbclid=IwAR00LunqS6DY74YGfuRomAKB902MTVZ4Oy_MY4THtn1q7wrCMbHFJ90mLTc


    https://www.drghaheri.com/blog/2014/3/1/how-tongue-tie-affects-breastfeeding-mechanics?fbclid=IwAR1GAj29h6aZnl7o4j-D79RKGuXtldZIMVy5Sql8nuz2T94bJTZ4gdBkPkc


    https://holisticibclc.blogspot.com/2018/12/tongue-tie-clips-reattachment.html?fbclid=IwAR1SgmgDQlF9OZCSXCOCZbBqwunbg5zHZrjFahzC1oF2FDMjNodtJmlcBd8




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