Tuesday 3 September 2019

Tongue Tie - Assessment and Treatment. Louise David IBCLC

This post is dedicated to all the mums who are seeking answers for the difficult breastfeeding journey they have unexpectedly found themselves on. 

Keep following your gut, don't give up. That feeling... it's never wrong.

The Basics...

Tongue tie (TT)– When the piece of skin (lingual frenulum) attached from the underside of the tongue to the floor of the mouth or gum ridge restricts the mobility and functionality of the tongue due to its length, thickness or inelasticity.
This frenulum may be attached anywhere along the underside of the tongue from the back (posterior) to the tip (anterior). Likewise it can be connected to the floor of the mouth at the back or all the way up to the gum line.

Posterior TT- Commonly health professionals who might diagnose a TT don’t look beyond the obvious foremost TT most people are familiar with. When the frenulum isn't attached at the tip of the tongue it is not very easily seen, therefore, missing or dismissing a PTT is an easy mistake to make. 

I think too much focus is put on the terms anterior and posterior, these terms only refer to where the conection is in the mouth, in simple terms, in the back halk or front half.

Most studies indicate that between 3 and 10 % of babies have tongue tie. The rate may be more due to ties being misdiagnosed because of practitioners lack of experience in examining the mouth correctly and a poor understanding of the relationship between breastfeeding problems and ties (kotlow 2017).

  Upper Lip Tie (ULT) – When the piece of skin (labial frenulum) connecting the underside of the top lip and the upper gum is too tight or too low down the gum affecting the ability for the lip to flange out.

Frenotomy – The procedure of releasing TT and or ULT. The frenulum is cut with scissors to allow free unrestricted movement of the tongue and upper lip.

Minutes old the lingual frenulum is captured in this photo.
Photo property of Louise David IBCLC

Ties and Breastfeeding...

There is great conflict amongst medical professionals in regards to their views on TT and how TT affects breastfeeding. The most common conflict is between pediatricians who believe TT in no way impacts breastfeeding and lactation specialists who believe undoubtedly their role in causing breastfeeding difficulties cannot be denied.

When one understands the mechanics of breastfeeding and the oral function of the baby and how milk is removed the role a TT plays in interfering is understood. This purely comes from experience. Recent practice has seen the role of ultrasound technology to view the inside of the mouth while the baby is breastfeeding. This is absolutely not necessary when the experienced lactation specialist assesses a breastfeed.

For parents it can be a rough road to finding answers when they’re dealing with practitioners whose practice is not supportive of bf. Its hard for any practitioners practice to be evidence based in the area of breastfeeding and TT as research in this area whilst its emerging its still lacking. Anecdotal evidence is insurmountable and common sense prevails. 

A tongue and lip tie cannot be diagnosed without a thorough oral assessment and its impact on breastfeeding cannot be assessed with out a feed being watched. All too often I hear mothers saying the doctor said “she doesn’t have a tie” and "the doctor didn’t even look" under the babies tongue. 
Whilst some TT are so glaringly obvious others, further into the underside of the tongue, takes correct technique to expose the frenulum. 
It is not a difficult difficult technique and it is very easy to learn. With practice any practitioner can become experienced in TT diagnosis and should be able to assess the restricted tongue. 
The correct and most reliable way to assess the mouth, the baby should be placed with her head in the assessors lap with her bottom and feet supported by mum or dad. The tongue can then be elevated and the level of restriction noted (Kotlow 2017). 
Then, and even more importantly i believe, a full breastfeeding obeservaion by a practitioner who knows what they are looking for can complete the tie assessment, putting together how what the finding in the mouth is affecting the action at the breast .

The breastfeeding relationship can be highly successful, that is comfortable, pain free with a thriving content baby, when the right practitioner is employed for support and intervention if necessary. The language the practitioner uses and the answers to your questions are a dead give away about how much your practitioner knows not only about TT but also more importantly about breastfeeding.
Furthermore, there is skill in a practitioner acknowledging their limitations and referring to another practitioner when they are not confident in assessing TT, rather then denying a TT or dismissing the parents concerns.

The same baby as above. Nipple feeding. Her latch did not
improve until the tongue tie was corrected.
Photo property of Louise David IBCLC

 Signs and Symptoms of Tongue and Lip Tie...

  • Pain during feeding
  • Squashed or ridged nipple
  • Cracked/bleeding/blistered nipples
  • Nipple vasospasm
  • Mastitis
  • Low milk supply
  • Oversupply

  • Difficulty latching or staying latched
  • Clicking sound
  • Milk spilling/leaking when feeding
  • Poor weight gain (from birth)
  • Poor weight gain following good weight gain (delayed)
  • Tongue “snap back” or “biting” action when feeding
  • Long and frequent nursing sessions
  • Fast nursing sessions with extreme fussiness
  • Falling asleep quickly as if tiring out, then waking soon after wanting to feed again.

Common Misconceptions...

The following misconceptions are comments parents often hear from inexperienced practitioners. I go on to explain why they are wrong and why the belief of them by practitioners revealed their lack of understanding about breastfeeding.

Misconceptions number 1: He can stick his tongue out past his lip so it’s not too bad.

The extension of the tongue is only one factor in its functionality. Other factors to be considered are the elevation of the tongue, the way the tongue moves side to side (lateralization), the way the tongue spreads out, the way the tongue can cup the nipple/finger/teat, the peristaltic movement (this can be different on a dry finger to a flowing breast) and if there is any ‘snapback’ noted with sucking.
The claim is made, and i agree with, by Coryllos et al. (2004) that elevation appears to be the most important of the tongue functions for breastfeeding and should be highly considered in the assessment. 
This comprehensive list is evidence enough that the simple rule that, “its ok if the tongue goes past the lower lip” is highly presumptive and inaccurate. Furthermore if a practitioner is assessing and dismissing tongue tie on this factor alone it can be said that a thorough examination has not taken place. To see a video clip of how to thoroughly examine a baby for tongue tie see this link.

Misconception number 2: the frenulum is not all the way to the tip of the tongue so its ok.

The classical appearance of TT is the common anterior type where the frenulum is seen to attach at the anterior tip of the tongue. This type is common for about 75% of ties (CORYLLOS et al). It’s easy for the unfamiliar practitioner to then miss or dismiss the other types of ties that do not present in this manor.

See types of ties.

Common language used to describe ties is anterior TT (type I and type II) and posterior TT (or type III and type IV). I believe we need to move away from the thinking of anterior and posterior TT, because if a tongue is tied, and it is restricted with poor functionality then it doesn’t matter where it’s attached its still tied. 
Consider this, all TTs have a posterior component. The frenulum runs from the base (posterior) of the tongue to some point along the tongue up to and in a type I including the tip. If a type I tie is only partially revised it would remain somewhere between a 2 and 4. The breastfeeding may improve going from a 1 to a 2-4, but if fully revised to the base of the tongue removing all restriction the imporvemt has the potential to be more dramatic with breastfeeding more effective and pain free.

Types of Tongue Tie by Dr L Kotlow

Class of Upper Lip Ties by Dr L Kotlow

Misconception number 3: The frenulum will stretch, grow.

There is no evidence that supports this claim. Many adults suffer TT and its effects. As a baby grows, they may be able to breastfeed better (less pain and more efficiently) if the mother is able to persevere the weeks and months of pain and difficulty. 
The very thin frenulum may break on its own, when mild trauma (first bike stack or sharp little teeth emerge) but this shouldn't be relied upon as a "treatment".

The emerging evidence shows amazing results, that frenectomy is a safe and effective treatment for TT that maintains breastfeeding. A randomized controlled trial of the effect of frenotomy on breastfeeding by Hogan, Westcott & Griffiths 2005, found that 28 out of 29 babies in a control group where no treatment was given showed no improvement in breastfeeding. In the treatment group were frenotomy was performed at 48hours of age 27 out of 28 improved and fed normally (the remaining one fed on a nipple shield). The results are undeniable and show that frenotomy is not only safe and effective but imperative to the continuation of breastfeeding when ties pose a problem. I can confirm that in my practice the result of improved breastfeeding and pain reduction is so very consistent. 

Misconception number 4: wait until baby is talking to see if it affects speech and then consider release

With the most common reasons for cessation of breastfeeding being nipple pain and damage, the wait and see approach just doesn't cut it in my opinion. 
If we have a diagnosis of TT and an option for revision there is no evidence in favor of waiting. Waiting will only see nipple pain unimproved and the likely hood of breastfeeding continuing is poor at best.

Misconception number 5: The procedure can only be done before a certain age.

Age limits on the frenotomy procedure are often arbitrary and practitioner preference. For example i work in two different clinics, one age limit is 6mths and the other is 12mths. 
In my experience most babies cope very well with the procedure no matter their age. Newborns less than around 4 weeks settle the fastest, not much beyond a brief cry out. The older baby can be a little more upset with a cry lasting a couple of minutes. There is then some babies where other than the usual breastfeed these babies required more active settling including rocking, pacifier, walking in mums arms.

Anecdotal evidence and also in my experience the earlier the baby is seen to, assessed and TT released the more immediate the improvement. Coryllos et al. (2005) explains that the babies tongue adapts to normal movement and function faster the earlier the frenotomy is performed. They also explain the benefit of having the services of an IBCLC employed for breastfeeding and emotional support stating that the later the tie is corrected the longer time (days to weeks) it can be until breastfeeding becomes fully effective.

Misconception number 6: Post frenectomy you must do a vigorous stretching regime to prevent reattachment.

This is a very controversial topic, hotly debated on parenting and breastfeeding forums. Once again there is no evidence to suggest the effectiveness of stretches in preventing reattachment. The truth is we do not know which babies will reattach and if they do, why.
The advice you are given post release will depend on your practitioners opinion and experience with stretches. 

I believe given the lack of evidence vigorous and aggressive stretches are not warranted. They cause undue stress and likely pain to baby. In my practice I teach the parents to visualize the diamond shape under the tongue, this may require physically lifting the tongue. If the diamond cannot be seen firm pressure into the site and pressing upwards can separate the regrowth and permanent reattachment may be prevented.

Photo examples and Case studies...

Louise david IBCLC tongue tie wollongong
Typical presentation of the classic anterior tongue tie (Type I in the Kotlow chart).

If the Tongue tie doesn't present all the way to tip like this, and the frenulum is not visible in
this "Sail" like state, the less experienced practitioner is likely to dismiss it as no tie being present.

Note the "Sucking blister" present around the lips, due to the increased intraoral vacuum compensating for the poor latch.

Photo property of Louise David IBCLC

lactation consultant wollongong
This tongue presents as a Type II on the Kotlow Diagnostic chart (see above). The Frenulum is visible, however, not all the way to the tip of the tongue. 

With this presentation it is common for parents to be told things like "She might have a tongue tie, but its only mild", "Its not too bad, it'll probably stretch", "the tongue isn't heart shaped so its not too bad". These misconceptions have been addressed above.
Photo property of Louise David IBCLC

Case 1:

7 day old male.

Mother breastfeeding with great difficulty. Using nipple shield 80% of feeds due to pain and cracked nipples. Baby having very long feeds and falling asleep at the breast. Mother concerned about small weight gain (50g over 3days). 

Word of mouth referral. Baby presents with type II tongue tie. Baby latches very shallow and is nipple feeding only with minimal milk transfer. Pain score with out shield is 8/10.

Frenotomy performed. Baby settled at breast within 2 minutes. After initial fussiness baby latched well and deeply. Mother states it "feels different". Pain score is 2/10.  

Case 1 - Before
Photo property of Louise David IBCLC.

Case 2:

4 day old male.

Mother breastfeeding independently with the aid of a nipple shield for sore nipples. 
Discharged home from hospital on day 3. The community midwife visiting the home on day 4 identified the baby has a tongue tie and home visit by myself was arranged for later that day.

Baby presented with a type I tongue tie. Latching was difficult (slipping on and off) without the shield and feeding with a shield was given a pain score of 4/10.

Frenotomy was performed. The baby settled in less than one minute by feeding at the breast. The baby took the breast without the shield. The latch was deep and the pain score now was 1/10.  

Case 2 - Before: note the obvious "notching" of the tongue.
The anterior of the tongue is anchored to the floor of the mouth by a short frenulum but the sides want to elevate creating that typical butterfly shape.
Photo property of Louise David IBCLC

After: With the anchor point release the tongue has a much more normal contour. The notch in the tip whilst still present, is markedly reduced.
Photo property of Louise David IBCLC

 Case 3: 

2 day old baby girl.

3rd child of mother, previous son had tongue tie revision at 6 months of age.
Painful cracked and bleeding nipples. Discharged home from hospital day 2 and home visit by myself on referral from hospital midwife.

Baby presented with type II tongue tie. The tip of the tongue was smooth and rounded. There was an obvious frenulum and a central trough along the tongue. The pain score for the feed prior to frenotomy was 8/10.

Frenotomy was performed on the tongue tie. The baby settled prior to returning to the breast. Mother was assisted with latching the baby and reported the feed post frenotomy as "pain free" (0/10)
Case - 3 Before: Frenulum visible when tongue lifted with finger, thus demonstrating that just looking usually isn't enough to find a tie.
Photo property of Louise David IBCLC
After: (Poor quality photo) Tongue elevation that was only able to be achieved prior with lifting the tongue with finger and stretching the frenulum.
Photo property of Louise David IBCLC 

Case 4:

5 month old girl.

Mother questioned the presence of tongue tie since birth due to family history, difficult and painful feeds and poor weight gain.

Numerous health professionals denied the presence of tongue tie and encouraged persistence with breastfeeding.

A google search lead the mother to contacting me.

On examination a very obvious tongue tie was present. The mobility of the tongue was clearly restricted, mainly extension and elevation.

Frenotomy was performed, baby settled after about 3-5 minutes and fed to sleep. Mum described the feed as "it feels different... Deeper"

Due to poor management of this dyad by other health professionals the couple ceased their breastfeeding relationship shortly after the frenotomy was carried out. Rightly so, the mother was happy with her achievement in spite of all the difficulties she faced.

Photo property of Louise David IBCLC
Before: Very restricted extension. Deep central groove or "trough".
Photo property of Louise David IBCLC
Before: The frenulum of this posterior tongue tie is submucosal (under the skin) and needs to be "exposed" to be seen. 
Photo property of Louise David IBCLC
After: Post frenotomy, the contour of the tongue is almost "normal". A small notch is just visible centrally. 

The before and after tongues are a prime example of how the frenulum, when it is too tight or short, dramatically impacts the appearance and function of the tongue.
Photo property of Louise David IBCLC

Finding a practitioner to help…

Many mothers have to travel far and wide to find a practitioner willing to perform frenotomy on their baby. Some hospitals offer the procedure to their inpatients, some GP's do the procedure and some pediatric dentists carry out the procedure with laser. Who ever the practitioner it is important they are experienced and trained. 
A practitioner who works along side an IBCLC is a good sign that they are respectful to the breastfeeding and really have the babies best interest at heart.

Tips to help baby with the frenotomy procedure:

I believe the practitioner’s methods has a lot to do with how babies manage. These important steps can help baby cope and cause mum the least amount of stress.

·      Keeping the baby with mum, preferably at the breast so she is calm until the practitioner is ready for the procedure. I.e. space prepared, scissors, gauze ready, hands washed and gloves on. 
·      Baby is firmly swaddled and  held firm by the practitioner and a support person.
·      With the snip done (the actual procedure rarely takes more than a few seconds) gentle firm pressure with a finger and gauze on the site baby is carried to mum and brought directly to the breast.
·      If baby has been feeding on a shield, this feed is probably not the feed to try to eliminate its use.
·      If baby wont take the breast, soothe with a pacifier or other method and once calm bring baby back to the breast.

I find the majority of babies have stopped crying by <1min, the majority of babies will take the breast to settle, many babies settle with out the breast however it is still offered as this is the optimal time to have the latch and feed observed by the IBCLC where she can advise on positioning and latch, she can identify the improvement of the efficacy of the feed and maternal comfort/pain levels.

In my opinion a practitioner who removes baby from mum for any extended period of time and does not have the ability to assist with breastfeeding directly after the procedure increases the stress to mother and baby and is limiting the potential for mother to get the most out of having had the procedure done.

I hope this has been a valuable tool in helping you on your breastfeeding journey, if you haven't found the right answers here, don't give up on your search. The right help is out there and the end result is worth it.

Please share this post with anyone you think may benefit, raising awareness is key to beating this breastfeeding boobie trap.

If you are in the Wollongong/Illawarra area and need help with your breastfeeding or you think your baby may have a tongue tie, don't hesitate to see me in my clinic or you can find me on Facebook.

Thank you and until next time,

Louise xxx

This post is based mostly on my experience as a private practice midwife and IBCLC. I have referred to a few written pieces on the following list:

Coryllos E, Watson Genna C and Salloum A, “Congenital Tongue-Tie and Its Ipact on Breastfeeding”, American Academy of Paediatrics, August 2004 pp. 1- 9.

Hall D and Renfrew M, “Tongue Tie”, Archives of Diseases in Childhood, Dec 2005 Vol 90 no 12 pp. 1211-1215

Hogan M, Westcott C & Griffiths M, ‘Randomized, controlled trial of division of tongue-tie in infants with feeding problems.’ Journal of Peadiatrics and Child Health 2005 vol. 41 no. 5-6 pp. 246-250

Kotlow L, ‘Breastfeeding should be fun and enjoyable: Why does it hurt when I breastfeed’ 2017 https://www.kiddsteeth.com/assets/pdfs/bf2017.pdf

Li R, Fein S, Chen J & Grummer-Strawn L.’Why mothers stop breastfeeding: Mothers self-reported reasons for stopping during the first year.’Pediatrics, 2008 vol. 122 no. supplement 2 pp. 569-576

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