Ask Dr. Doug: Tongue Tie
Q: I am having so much trouble with breastfeeding. She’s our second, and feeding is painful and very different from our first. We’ve seen two lactation consultants, and both were concerned that she might have a tongue tie. Our pediatrician isn’t so sure. I’m not sure what to do. Any advice?
A: You’re not alone in feeling confused about this. Most of the recent debate around tongue tie comes from a good place – a desire to help moms meet their breastfeeding goals, but without performing unnecessary procedures. Both concerns are important, so let’s think through this.
First, what is a tongue tie? We all have a band of tissue under our tongue that connects to the floor of our mouth, called the frenulum. When that tissue is too short, too tight, or too far forward, it impacts tongue movement, and can be called restrictive. Tongue tie can lead to pain with breastfeeding, feeds that take a long time due to poor milk transfer, reflux symptoms from swallowing air, or poor weight gain for your baby.
Ultrasound data shows us that the middle of the tongue moving up and down is the most important part of getting milk when nursing at the breast. That means the old idea of, “If your baby can stick out his tongue, he’s fine” isn’t true. And you can’t diagnose tongue tie from a photo. It’s a functional diagnosis, taking into account how the tongue moves and how it fits with the breast.
Why the recent uptick in diagnosing tongue tie? When you know better, you do better. There are many reasons breastfeeding may not be going well, but in the past when someone might have said, “It hurt too much so I stopped” or “I’m pumping plenty, but he never seems to get enough from the breast,” tongue tie may have been playing a role – it’s just that no one looked for it.
You may have heard the terms anterior and posterior ties. This has to do with where the shortened tissue attaches to the tongue. Anterior ties are visible when babies cry, and they’re hard to miss. Posterior ties are not mysterious or made up – you just have to know how to properly examine a baby’s oral function and anatomy to diagnose them. Posterior ties are farther back under the tongue, and can result in a poor latch or uncoordinated suck. There may or may not be much pain. Usually feeds take a long time, as milk transfer from the breast may be inefficient. Some babies may have issues with bottle feeding as well.
There are many other reasons breastfeeding may not be going well (the list is long!), and that’s why it’s so important to take a team-based approach with an International Board Certified Lactation Consultant before deciding how to proceed. If after skilled lactation help, we feel a release is warranted, I will perform a quick procedure in the office called a frenotomy, where I snip the frenulum. This releases the tension on the tongue, improving mobility and resulting in less pain for mom and better transfer of milk.
I hope you have a supportive team as you navigate these decisions. And please remember, there are lots of ways to feed a baby, and no mom should feel shamed for her feeding choices. Parenthood is challenging enough without adding more judgement!