Tongue-Tie and Breastfeeding
Updated: May 13, 2020
To clip or not to clip? A 2015 article in Pediatrics, the journal of the American Academy of Pediatrics (AAP), investigated whether or not pediatricians should recommend treatment for tongue tie and upper lip tie in the face of breastfeeding difficulties. The authors concluded that the evidence is inconsistent and weak, but that frenotomy (the surgical revision of a tongue tie) may improve maternal pain with breastfeeding (though may not improve breastfeeding ability in baby).
The subject of tongue tie management is a tangled web of differing opinions and little research. It can also be an expense not covered by insurance, which parents may not know. And it may not really solve any of the breastfeeding problems a mom is having. With so much controversy, what can parents do?
What is tongue tie?
First, it’s important to get a correct assessment. Tongue tie, or ankyloglossia, happens when the membrane that connects the tongue to the floor of the mouth (the lingual frenulum) is unusually short, thick or tight. This typically decreases tongue mobility – something essential for milk transfer and maternal comfort when breastfeeding. Tongue tie is hereditary and occurs as the fetus is developing in utero. It arises in about 4% to 16% of babies, and is two to three times more common in boys.
Tongue tie could potentially affect your baby’s speech, jaw and dental development, and nutrition. Sometimes babies with tongue tie may have issues with digestion (including reflux) and eventually problems with eating solid foods. But solid research in all these areas is lacking.
When mom has sore nipples and the pain isn’t alleviated with changes in positioning and deeper latching, then tongue tie may be the culprit.
What are some of the signs and symptoms?
When mom has sore nipples and the pain isn’t alleviated with changes in positioning and deeper latching, then tongue tie may be the culprit. This is especially true if, after a feeding, mom’s nipples look compressed, creased, bruised or have a white strip across the tip. Sometimes her nipples might look like a tube of new lipstick. Mom may have vasospasm (due to constriction of the blood vessels in the nipple), low milk supply, recurrent plugged ducts or mastitis, or recurrent thrush.
Tongue tie might be suspected if baby has a poor latch and weak suck, difficulty establishing suction and staying attached to the breast (the breast may slide in and out of baby’s mouth while feeding), an unusually strong suck (which may be accompanied by a quivering jaw after or between feeds), or clicking noises while feeding. Babies with tongue tie may have poor weight gain or even weight loss, gas, irritability, colic, or reflux. These babies tend to swallow infrequently after mom’s milk first lets-down, refuse the breast, feed for short periods, become fatigued with feeding, or fall asleep before finishing a full feeding. They may clamp down on the nipple, or make chewing or biting motions at the breast.
What can be done?
Treatments fall into three main categories:
1. Surgical intervention: A frenotomy is the “snipping” of the tight connective tissue under the tongue to allow for greater tongue mobility. The procedure is performed in the physician’s office most often with surgical scissors. It can be done with laser, but this is more costly and often not covered by insurance. Babies seem to experience minimal pain or bleeding with the procedure, and can be put to the breast immediately afterwards.
2. Alternative treatments: Body work, such as chiropractic and cranio sacral therapy (CST), can be useful for babies with tight tongues. CST is light touch that is strategically used to release tight muscles which can help with positioning and latching. CST may need to be done more than once. Suck exercises may also be suggested as an interim treatment along with body work.
3. Wait and see: If the tongue tie is mild, baby’s growth is acceptable and mom isn’t having pain, then the healthcare provider may suggest patience and time. As your baby gets bigger, his tongue will grow too, making the tie less pronounced and the tongue more mobile. Working closely with a lactation consultant can help make feeding more comfortable and productive.
Function becomes a strong indicator of need for intervention, but tools to assess function have yet to be validated when using to assess tongue tie.
What does the research say?
The Academy of Breastfeeding Medicine recommends conservative treatment for tongue tie. In most cases, they suggest, education and support, as well as reassurance, as a good start. They go on to say that if frenotomy is warranted for tongue tie, it should be performed by an experienced healthcare provider.
Since there is little agreement on definitions and classifications of tongue tie, however, diagnosis is difficult. What one doctor may classify as a mild tie, another might call more severe. Function becomes a strong indicator of need for intervention, but tools to assess function have yet to be validated when using to assess tongue tie.
In a recent study, Emond and colleagues (2014) randomized mother-baby pairs with mild to moderate tongue tie to two groups: immediate frenotomy (intervention group) or standard care for 5 days (comparison group). At the end of day 5, mothers in the comparison group still having breastfeeding difficulties were offered frenotomy at that time. They found that twice as many moms in the comparison group were bottle-feeding at 5 days when compared to the early intervention group. Moms in the intervention group also reported they felt breastfeeding was going better after the frenotomy. While their research shows early frenotomy may be preferable, the authors conclude that better tools are needed to measure the impact of tongue tie on breastfeeding.
Berry, Griffith and Westcott (2012) designed a randomized controlled trial to determine if frenotomy improve maternal pain with breastfeeding. Infants were randomized to two groups – actual frenotomy, or a sham frenotomy procedure. Seventy-eight percent of the mothers in the frenotomy group reported improvement, while 47 percent of the mothers in the placebo group did. This significant difference led to their conclusion that “There is a real, immediate improvement in breastfeeding, detectable by the mother, which is sustained and does not appear to be due to a placebo effect.”
Literature reviews also add to the knowledge base about tongue tie treatment and breastfeeding success. Cawse-Lucas, Waterman and St. Anna (2015) suggest improvements in maternal pain are minimal, and frenotomy shouldn’t be done unless “a clear association exists” between tongue tie and lactation difficulties. They only looked at a few studies, however, and only looked at whether the frenotomy improved latching. Their conclusion may be based on the limitations of current tools to measure latching success. Reviewing four RCTs and 12 observational studies, Ito (2014) looked at whether frenotomy compared to lactation support alone would improve infant feeding. Areas of consideration included latch/suckling, milk supply, nipple pain, continuation of breastfeeding and infant weight gain. The conclusion? “Every outcome consistently showed the effectiveness of frenotomy for breast-feeding difficulties.”Brookes and Bowley (2014) found that revision of tongue tie improved breast milk production, infant weight gain, maternal pain, and duration of breastfeeding with minimal complications, if any.
Apart from breastfeeding problems, it has been suggested that tongue tie may impact speech, dentition and lifestyle as a child grows. Chinnadurai, et. al. (2015) completed a systematic review looking at two randomized controlled trials, two cohort studies, and 11 case series,and concluded that there’s insufficient evidence to perform a frenotomy for reasons other than breastfeeding difficulties. More study is needed to determine if there are, indeed, long term consequences of not treating tongue tie in the newborn period.
The diagnosis and treatment of tongue tie requires cooperation of the breastfeeding mother, the baby’s doctor, a lactation consultant, and a specialist. This may be a pediatric dentist or an otolaryngologist ( or ENT). Working as a team and basing decisions on evidence will support the best outcomes for both mom and baby.
This video sponsored by the American Academy of Pediatrics gives a great summary in this topic.
If you have more specific questions and would like expert advice from an IBCLC for your individual breastfeeding questions, check us out!
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Academy of Breastfeeding Medicine Clinical Protocol Committee. (2004). ABM clinical protocol# 11: guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Published online.
Berry J, Griffiths M, & Westcott C. (2012). A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeeding medicine, 7(3), 189-193.
Brookes A & Bowley DM. (2014). Tongue tie: The evidence for frenotomy. Early human development, 90(11), 765-768.
Cawse-Lucas J, Waterman S, & St Anna L. (2015). Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?.
Chinnadurai S, Francis DO, Epstein RA, Morad A, Kohanim S, & McPheeters M. (2015). Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review. Pediatrics, peds-2015.
Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, & Sutcliffe A. (2014). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-Fetal and Neonatal Edition, 99(3), F189-F195.
Francis, D. O., Krishnaswami, S., & McPheeters, M. (2015). Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics, 135(6), e1458-e1466.
Hazelbaker, A. (2015). Modern myths about tongue-tie: the unnecessary controversy continues. Accessed online at http://www.alisonhazelbaker.com/blog/2015/9/1/modern-myths-about-tongue-tie-the-unnecessary-controversy-continues.
Ito, Y. (2014). Does frenotomy improve breast‐feeding difficulties in infants with ankyloglossia?. Pediatrics International, 56(4), 497-505.
Shay, S., Mandelbaum, R., & Shapiro, N. (2016). Tongue Tie in Infancy. Current Treatment Options in Pediatrics, 2(3), 246-255.
Thomas J & McClay JE. (2015). Breastfeeding: what to do about ankyloglossia, lip-tie. AAP News, 36(6), 11-11.