This weeks guest blog post is by Dr. Vanessa Stitt, a GP in Galway with a special interest in tongue tie. Here she tells us a little bit about tongue tie and answers some of your questions along the way.
Tongue tie is a hot topic at the moment among mothers and healthcare professionals alike. With so much on the Internet about ties and division, navigating the whole area can be tricky. Tongue tie occurs when the string of tissue under the tongue is especially short, thick or tight and as a result causes restricted movement of the tongue. MOST babies have a lingual frenulum (a string of tissue that attaches the tongue to the floor of the mouth) but not all of these babies have a tongue tie!
There MUST be restriction that causes a problem with tongue function. Incidence figures vary, but is likely that 3-5 babies in every 100 are affected, and males are more affected. What causes this is still unknown, but genes may be a factor, and there can often be other members of the family with tongue tie. Tongue mobility is the critical factor that affects breastfeeding, and so it may lead to difficulties for the breastfeeding baby. Bottle fed infants are less likely to have any problems with a tongue tie but certainly can have symptoms.
Tongue tie can be described as being anterior or posterior. With anterior tongue ties, the tongue is held down close to or at the tongue tip. These are usually very noticeable, as in the picture above. Whereas an anterior frenulum is normally quite visible and frenotomy (the procedure to divide the frenulum) has been done for a long time, the concept of the posterior tie is more recent. Posterior tongue-ties are situated nearer to the base of the tongue, and are not as visible. A health professional MUST examine a child's mouth with a gloved finger to exclude posterior tongue ties.
Sometimes tension on the floor of the mouth can masquerade as a posterior tongue tie and having body work, by a craniosacral therapist or a cranial osteopath trained to work with babies can have great results. For this reason, it is often recommended that babies who show signs of fascial strain or tension have sessions of bodywork to see do things improve first, before considering surgical intervention. It can also help optimise timing and outcome of tongue tie release. This can be discussed at the assessment.
Another term you may have heard is lip tie which is an upper lip frenulum that causes a problem with function. Every day pictures of babies upper lip frenula are posted by mums on facebook support groups asking "is this a lip tie?" (and the answers given from other mums is invariably yes). A lip frenulum is not a tie unless restricted and causing issues with function. The misinformation starts with the classification most doctors use when describing this tissue. This classification system just describes anatomy. A class 2 upper lip frenula is actually normal and what most babies have, and a Class 3 upper lip frenula with no restriction is not a tie. Lip tie can occasionally cause problems with feeding (both breast and bottle), but it most often as a result of a co-existent tongue tie. Later on in life, it can cause dental decay of the two top front teeth - this is mainly the "hooded" type if tie- and a gap in between the two front teeth called a diastema. A diastema can happen without a lip tie.
The tongue-tie can be separated in a quick procedure called a frenotomy. An assessment of the oral cavity is done using a torch and gloved finger. A numbing gel is applied to the area. The procedure involves cutting through the fold of tissue using scissors. The baby should be able to feed straight after having the procedure. Sometimes there are a few drops of blood. The whole procedure only takes a few minutes. Frenotomy may help if you or your baby are experiencing some of the symptoms below.
Potential challenges for the breastfed baby with a tongue tie include
Difficulties in achieving and maintaining deep attachment to the breast
Weight loss or challenges to gain weight
Restless and unsettled feeds
Noisy or clicking sounds during the feed
Tiring easily and falling asleep on the breast
Colic or reflux symptoms as a result of swallowing air during feeds
Challenges for the mother breastfeeding a baby with a tongue tie include
Distorted nipple shape after a breastfeed
Bleeding, damaged or ulcerated nipples resulting in nipple pain
Incomplete milk transfer by the baby resulting in engorgement and /or mastitis
Potential challenges for the bottle-fed baby with a tongue tie include
Frequent small volume feeds
Slipping off the teat
Dribbling of milk during feeds
No improvement when the teat is changed for a different type
Difficulty keeping soother in mouth
Colic or reflux symptoms as a result of swallowing air during feeds
Potential challenges for a weaning baby with a tongue tie include
spitting food back out
difficulty moving on from very thin consistency foods
choking or gagging
There is growing evidence that tongue tie can causes issues with speech, especially articulation of some consonants like 'R' and 'L'. Tongue tie can limit the tongue's ability to remove food from the teeth, resulting in poorer dental hygiene and cavities, and can result in malocclusion (misalignment between the teeth of the two dental arches when they approach each other as the jaws close). There is also evidence that tongue ties can be related to sleep disorders, mouth breathing, poor maxillofacial development, poor posture and head and neck pain and strain in adulthood.
Skilled lactation support is very important prior to frenotomy. The ideal healthcare provider for lactation support is an International Board Certified Lactation Consultant (IBCLC). Your midwife or public health nurse also may be an IBCLC. Some IBCLCs are also craniosacral therapists. In the absence of a lactation consultant, midwives, clinical midwife specialists, public health nurses, GPs, neonatologists and paediatricians may be in a position to provide support if your baby has a tongue tie. Performing a frenotomy on a normal frenulum won't resolve any breastfeeding issues and no one wants an unnecessary procedure done to a baby, so checking other steps first makes sense.
Releasing a tongue tie can bring about huge benefits and save a breastfeeding relationship, but it is not a magic bullet, and the majority of babies slowly improve over time, up to 8 weeks to see the full effect. To quote Dr Bobby Ghaheri, "if i ask you to train for a marathon for three months, but during that 3 month period your shoe laces are tied together, you will develop a specific way of running the marathon. but if i untie your shoes the morning of race and ask you to run a marathon in a normal fashion, your training for three months won't help you much. You have developed a different skill set and muscle strength to compensate".
Dr Vanessa Stitt of Tongue Tie Galway graduated with an honours medical degree in 2010 from NUI Galway. She then completed four years of General Practice Training, also in Galway and has a special interest in family planning and women’s health, children’s health, diabetes care, genitourinary medicine and substance misuse. She is a member of IATP (International Affiliation of Tongue Tie Professionals), ICAP (International Consortium of Oral Ankylofrenula Professionals), and ALCI (Association of Lactation Consultants Ireland). Vanessa developed an interest in tongue-tie after my own son was diagnosed with a tongue-tie and i was having difficulty breastfeeding. He underwent a frenotomy procedure and there was a marked improvement in his latch when breastfeeding- they happily breastfed for another 8 months.