What is Tongue-Tie?
What we know
The frenulum is the membrane which extends from the underside of the tongue, to the bottom of the inside of the mouth. The presence of a frenulum is normal anatomy. Tongue tie (ankyloglossia) occurs when the frenulum is abnormally short, or tight, restricting movement sufficiently to affect normal tongue function.
How common is it?
Estimates vary, it may be around 1 in 10-20. It is thought to be more common in boys and there may be other members of the family with a tongue tie.
What are the signs?
Tongue tie may be suspected in the presence of a number of signs which are present as a result of a baby having difficulty latching deeply, maintaining a deep latch or, in some cases, an inability to latch at all. These may include, but are not exclusive to:
For the mother/person breast or chest feeding:
Painful, pinched, blistered/cracked/bleeding nipples when optimising positioning has been addressed
Nipples which look misshapen, pinched or blanched after feeds, as above re positioning
Mastitis or blocked ducts
An impacted low milk supply due to poor milk removal
Feeds where the baby is not effectively removing milk and so taking longer than they would otherwise, thus impacting mum by way of exhaustion.
For baby:
Restricted tongue movement where baby may not be able to extend their tongue, lick their lips, during crying their tongue may remain in the floor of their mouth, or just the edges may curl up forming a ‘dish’ shape.
A tongue that appears ‘forked’ in shape when elevated or extended.
An inability to open their mouth wide when attaching to the breast even when in an optimum position.
Unsettled/fussy behaviour when latching and during feeds when positioning and attachment has been addressed.
Behaviours that suggest they are unable to control the milk flow
Difficulty maintaining an optimal latch
Falling asleep at the breast due to tiring during a feed
Excessively frequent feeds
Early weight loss or poor weight gain where no other causes are present
Clicking noises &/or dribbling during feeds
Swallowing air excessively during a feed causing wind, hiccoughs, or ‘colic’
Reflux in excess of what is considered normal posseting
Any of the above issues may present for other reasons and so in order to make an accurate diagnosis it is important to be seen by someone who is suitably qualified to explore all that is going on and carry out a full assessment.
How is it diagnosed?
While a number of Health Care Practitioners may be able to suspect there is some involvement of tongue tie, in order to make a definitive diagnosis you will need to be seen by someone who is qualified to assess for tongue tie as this is not routinely part of Midwives, Paediatricians, Health Visitors, Neonatal Nurses, Lactation Consultants or breastfeeding supporters training as it requires further study and an extended role.
Diagnosis involves taking a full history and assessment of breastfeeding, including pregnancy and birth as this can impact breastfeeding. Most tongue tie practitioners use some form of assessment tool in order to determine how function might be impaired and the many use the Assessment Tool for Lingual Frenulum Function (ATLFF) developed by Alison Hazelbaker (1993) which looks at areas of function and, as a secondary factor, the tongue’s appearance, in order to determine a score. Scores of 10 and below for function & 8 or below for appearance indicate that frenulotomy may be beneficial.
How is it managed?
If a tongue tie is diagnosed a frenulotomy (tongue tie division) can be carried out if it is felt by the parents that, on the balance of risks and benefits, they wish to go ahead with this surgical procedure. This is a very individual decision so there needs to be time for all factors to be considered and a full discussion of options to be explored and these may include various feeding strategies.
The most commonly used method for dividing a tongue-tie in the UK involves cutting the frenulum with a pair of sterile scissors. This procedure is known as a frenulotomy. The baby is wrapped securely in a towel or blanket so they cannot wriggle or put their hands to their mouth. Their head is then held still by a parent, nurse or other helper. The practitioner performing the procedure lifts the tongue using the finger or fingers of one hand. (Some practitioners prefer to use a Brodie Director, a small metal spade shaped instrument with a central slit to isolate the frenulum and lift the tongue). With the scissors in the other hand the practitioner slides the blades under the tongue so they are on either side of the frenulum and snips. Some tongue-ties divide well with just one snip, others will require 2 or 3 snips depending on how tight, thick and far forward the frenulum is.
Do you need me to go into more detail about parents’ common concerns, risks etc?
Where can people go for help?
If you are experiencing breastfeeding difficulties where you are suspicious that tongue tie may be involved you should ask your Midwife, Health Visitor of GP for a referral to your NHS specialist clinic. These clinics are run by various disciplines nationally so there may be breastfeeding support alongside the treatment but not always.
You can choose to see a private tongue tie practitioner who may have Nursing or Midwifery qualifications and may also be a certified Lactation Consultant also. Some surgeons offer private treatment too. A search on the Association of Tongue-tie Practitioners website will enable you to find your closest service: https://www.tongue-tie.org.uk/find-a-practitioner/
Carole Goddard (RM, BSc, IBCLC)
August 2020
