Tongue-Tie Troubleshooting for Breastfeeding Moms

You’re an expecting mom, thinking about birth and motherhood, all of the unknowns and potential stresses accompanying this time in your life. Here’s another thing to consider! Yay huh!? Seriously though, tongue and lip-ties can impede your breastfeeding relationship. No, I’m not trying to stress you out, but I am trying to make you aware of potential issues and offer effective solutions so that, should you have breastfeeding difficulties, you aren’t defeated.

What is a tongue-tie? What is a lip-tie?

Most people have a small piece of flesh (called a frenulum) that anchors the tongue to the floor of the mouth, and another that anchors the top lip to the gums above the teeth. Sometimes a frenulum is too tight (graded 1-4 depending on these factors: tightness, stretchy or non-stretchy, and functional or non-functional), anchoring too far up the tongue (tongue-tie), which doesn’t allow the tongue to come out under the nipple, or too far down the gum line (lip-tie), which doesn’t allow the upper lip to flange around the areola (see photos). Both of these are important for the mother to feed comfortably and the baby to drink enough milk. When they don't happen, the mother’s nipples can blister, and the baby can’t adequately drain the breast.

Tongue-tie

Lip-tie

Are tongue and lip-ties a new thing?

No, babies have been born with tongue and lip-ties for as long as we know. Yet, their occurrence has been increasing in frequency due to MTHFR and folic-acid supplementation during pregnancy (see our blog on MTHFR). Tongue and lip-ties were traditionally clipped by the midwife or doctor shortly after birth or during the first week. During the early and mid-1900s, due to marketing from formula and brassiere companies, breastfeeding took a backseat to formula feeding. Tongue and lip-ties don’t impede formula feeding the way they do breastfeeding, so the conversation surrounding revisions (the clipping of tongue and/or lip-ties) died down. In more recent decades, breastfeeding has been coming back into practice, due to efforts of La Leche League, other breastfeeding support groups, and increased knowledge and education on infant nutrition.

What are the signs of a tongue and/or lip-tie?

When a baby has a tongue and/or lip-tie, signs and symptoms manifest for both the mother and the baby. For the mother, she may experience thrush (yeast infection) of the nipple, clogged milk duct(s), mastitis (painful breast inflammation caused by infection), a lipstick (beveled) shape to one or both nipples, pain, cracking, and/or bleeding of one or both nipples, and low milk supply. For the baby, there may be a clicking sound while breastfeeding, s/he may come off the breast frequently, experience general fussiness at the breast, slow growth, weight loss, wakefulness, gassiness, colic, musculoskeletal issues, torticollis (top of the head and chin tilted to opposite sides), tight shoulder(s), a lip blister, and spitting up and acid reflux (often being prescribed Nexium). Parents usually have an easier time noticing a lip-tie, and while lip-ties are typically less problematic, whenever there’s a lip-tie there’s often a tongue-tie as well. At Hopewell Family Care (when suspecting a tongue or lip-tie), we’re primarily checking to see if 1) the mom is having any pain, 2) the baby is gaining well/poorly, and 3) if the baby is having any gastrointestinal issues.

What can be done for a tongue and/or lip-tie?

Lactation consultation. Referral to lactation for an additional assessment can be helpful. While symptoms can point to a tongue or lip-tie, and some general practitioners can suspect them, a lactation consultant (IBCLC) should be seen to determine if and exactly what kind of tie a baby has, and to determine a course of action. They often recommend trying new breastfeeding positions, such as laying reclined or on your back so the baby is on top of the breast, or on all fours so the baby is under the breast. They can also suggest tongue stretches for the baby. Sometimes they will recommend a referral to an ENT or dentist for further diagnosis or treatment, as IBCLCs can't give an official diagnosis.
Nipple shields. Though not a long-term solution, nipple shields can help temporarily relieve nipple pain while making adjustments to improve the breastfeeding relationship. Nipple shields create a barrier between the mother’s nipple and baby’s mouth, and help shape the nipple in a way the restricted tongue or lip doesn’t allow the baby to.
Craniosacral therapy and chiropractic care. Craniosacral massage therapy can help to loosen jaw muscles in order to open the jaw wider for a better latch. Find a massage therapist who is certified and experienced in this kind of therapy. Chiropractic care can address maladjustments made during birth, and also torticollis and limited head turning.
Revisions. Typically, I give babies up to two weeks using alternative therapies (those just mentioned) to see if it can become functional (adequate for proper breastfeeding). If after two weeks the symptoms of the dyad (mother and baby) aren’t improved, referral for a revision (clipping of the tongue and/or lip-tie) is our next discussion. Choosing whether to get a revision or not is a subjective decision for parents to decide. Revisions are done by a doctor (ENT specialist or a neonatologist) or dentist. We recommend our patients to Dr. Prather at P.S. Smiles in Franklin. A revision is a two-minute procedure done with either sterile scissors or laser. A small incision is made in the frenulum to release the tongue and/or lip. Local anesthesia can be used, but is not required. If used, the procedure won’t hurt, but the tongue will be uncoordinated initially, so the baby won’t be able to learn a good latch until it wears off. If not used, the procedure will hurt, but the baby can practice a good latch immediately. This would be an appropriate time to use Tylenol, though be sure to dose your child based on their weight. Exercises need to be done for up to five weeks after the procedure to ensure that no scar tissue forms, which could re-adhere the tongue or lip (this happens frequently when exercises aren’t done). A revision isn’t a magic fix-all. Babies have to relearn how to latch, and lactation consultation is recommended to achieve an efficient latch.

What about a tongue-tie in an older child?

There is no age limit for a child to have a revision done. Symptoms of a tongue-tie in an older child include several cavities, the need for orthodontics (bottle feeding changes the shape of the palate, often requiring such), sleep apnea (bottle feeding also contributes to the narrowing of the maxillary sinuses, occasionally causing such, and is sometimes misdiagnosed as ADHD), being a picky eater (called ‘goldfish babies,’ preferring soft foods as the tongue is little help in eating), and headaches and migraines (even into adulthood). Knowing the cause, if it is a tongue-tie or not, can help in addressing and treating these symptoms.

If your breastfeeding relationship is challenging, these are some considerations to make. Receiving education in breastfeeding can help you determine if your baby is latching correctly, and foresee potential issues that may point to a structural issue like a tongue or lip-tie. If you are concerned about this issue when your baby is born, consider seeing a lactation consultant early on (even in the hospital), or asking your care provider at their newborn exam to look for this. Being aware of potential issues, and knowing they can often be fixed, is a great first step.

Jaimeé Arroyo Novak, FNP