Introduction.

The impact of a significant tongue tie on the ability of a baby to be breastfed is very often severe. As a consequence, many mothers who plan to breastfeed their babies are compelled to wean them to the bottle much earlier than expected.

It is not always possible to predict which tongue ties will inhibit breastfeeding, as characteristics of the mother’s breasts also have an effect on such factors as milk transfer. The length of the frenum (or the apparent severity of the tongue tie) has no bearing on whether the baby will be able to breastfeed efficiently.

Mr Mervyn Griffiths found that: “…the thickness, shape and percentage length of the tongue tie were not predictors of success or failure. …This suggested that the function of the tongue (i.e. the symptoms themselves) produced by a combination of tongue, mouth and tongue tie is more important than simply the appearance of the tie.”

This has been frequently confirmed in my clinical practice, where a baby referred with a provisional diagnosis of ‘a mild tie – can breastfeed’  has been found to have severely abnormal appearance and restriction of mobility while another baby has a less obvious tie but cannot be breastfed.

The Process of Breastfeeding

Milk develops in the mother’s breast after the birth of her baby, but the supply is replenished and increased only by the vigorous sucking that empties the breast. If the baby cannot suck correctly, the milk supply is not renewed and it is very likely that it will eventually fail.

The infant needs to open the mouth widely enough (gaping) to allow the tongue to protrude forward, past the gum ridge, and then it must take a big mouthful of the breast. This ensures that:

  • The milk sinuses are massaged by movements of the baby’s tongue and by pressure from the lower alveolar ridge causing the release of milk which is ejected through the nipple.
  • The tongue protruding over the gum ridge protects the nipple from being squashed painfully and even damaged by being caught repeatedly between the upper and lower gums.
  • Peristaltic movement of the tongue, (rippling, from the front of the tongue to the back), strokes the breast, draws out and maintains the flow of milk.
  • These movements of the tongue also stimulate the nipple to elongate, so that it is pointing down the baby’s throat, and directing milk towards the aesophagus. Most babies can empty a breast in 10 to 15 minutes with efficient sucking.

When there is a surge in the production of milk which flows more strongly for a while, it is called ‘let-down’.

The Tongue Tied Baby

When a tongue tie is causing problems with breastfeeding, the baby often does not open his mouth widely, thus not latching on to the breast at the correct angle. Instead he may latch onto the nipple, and ‘gum’ or chew it, causing severe pain and eventually, nipple damage. There can be cracking, distortion, blanching or bleeding from the nipple, sometimes followed by infection or mastitis.

The tongue tied baby also will be unable to protrude the tongue horizontally past the gum ridge or lips, because of tension on the short or tight frenum in this posture. The mother’s nipple therefore is not protected from injury.

Peristaltic movement may not occur, or it may occur only on one side of the tongue; or irregularly, in some cases it may even change to a reverse peristalsis, the ripple going from the back of the tongue to the front.

The nipple does not elongate, and milk may not be directed correctly for swallowing, making the baby prone to aspiration of fluids, infections, coughing, gagging, choking, or vomiting.

Since the latch is not correctly positioned, the sinuses where milk is stored are not stimulated to release milk.

The tongue-tied baby may be found to be unable to make a good seal around the breast with his lips so that milk is seen to dribble from the mouth while sucking. This is sometimes due to the presence of a maxillary frenum – a prolonged or tight frenum between the upper lip and the upper gum which limits the flexibility or mobility of the upper lip – which can be present together with a tongue tie.

Noisy sucking or noisy snap-back sucking is often reported, where the frenum stretches as far as it can go to compress the nipple, and then snaps back like a stretched rubber band being released. This can occur with both breast and bottle feeding.

Since latch is often not correctly positioned, the mother suffers intense pain when the baby seizes the nipple or chews on it, or even when he slides off the nipple, being unable to maintain a hold on the breast. In some cases the pain is severe enough to make mothers dread breastfeeding.

Maternal nipple pain is reported to preclude an adequate milk ejection reflex, and the presence of all or even some of the above problems can interfere with the acquisition of milk. The unsatisfied infant, tired out with sucking, but comfortable in his mother’s arms will often fall asleep on the breast, only to waken still hungry and needing further feeding.

Some mothers have reported feeding their baby 2 hourly, day and night, others describe a feed that might last 2 hours. Pain from such continuous feeding can be so severe that mothers reported hoping their babies would continue sleeping.

These problems can persist in spite of help and support from professionals. Doctors are often unable to help these mothers, who are told that the nipples will toughen up, or even to take pain killers prior to feeding. Unfortunately the pain will only abate if the structural problem is removed.

The infant can experience as much discomfort as the mother: hunger, malnourishment, swallowing of wind, sleep disturbances, vomiting, and reflux can be present, and cause incessant crying and inability to settle.

Breastfeeding in these circumstances will be anything but pleasurable or satisfying and will cause disappointment, sadness and guilt for the mother. Poor weight gain or failure to thrive may prompt termination of breastfeeding and early weaning to the bottle.

Some infants will continue to have problems on the bottle, such as dribbling, swallowing of air and vomiting. Many will also have difficulty coping with purees and solids when these are introduced.

Conclusion

It is still possible to find items in the literature on Ankyloglossia which state that tongue tie does not inhibit breastfeeding or cause other significant problems. However, there is also a growing body of evidence – both anecdotal and scientific – from studies and trials which indicates that tongue tie does affect breastfeeding strongly enough to interrupt it.