How Does Ankyloglossia Affect Breastfeeding?
By Ann Calandro, RNC, IBCLC
About four out of every 1,000 babies born are affected with a condition called ankyloglossia or tongue-tie. Tongue-tie is when the small piece of skin under the tongue is tight and holds the tongue fastened to the bottom of the baby’s mouth. The tongue is restricted from upward motion. The small piece of skin, called the lingual frenulum, may in some cases reach all the way to the tip of the baby’s tongue. The condition tends to run in families. It may persist into adulthood, causing additional problems.
The tongue-tie may cause breastfeeding problems.
The Lost “Art”
In years past, it was understood that tongue-tie may affect a baby’s ability to breastfeed. It is said that midwives used to keep one fingernail sharp for the purpose of cutting the frenulum loose to aid breastfeeding. Physicians routinely clipped the small piece of skin if the frenulum looked tight at birth. When bottle-feeding became the norm in our country, physicians were taught that clipping the frenulum was an unnecessary procedure, and physicians were no longer taught this procedure during medical training.
Now the tides have turned back, with more than 60 percent of all babies beginning life breastfeeding. However, there are still many physicians who do not feel that the tight lingual frenulum could cause problems with breastfeeding, and they discourage mothers from having the frenulum clipped.
In some cases, it does seem that breastfeeding can be successful even if the baby has a tongue-tie. In other cases, the tongue-tie may cause breastfeeding problems. In an attempt to draw the breast into the mouth and “milk” the breast with the tongue, the baby becomes frustrated and may “bite” at the breast or may not be able to fully compress the milk sinuses to remove milk. Baby’s tongue normally cushions the breast from the bony lower jaw while breastfeeding, and when it cannot, breastfeeding is painful.
The Importance of the Tongue to Breastfeeding
It is important to consider the role of the tongue in breastfeeding. When a baby attaches to the breast, his tongue extends and grooves to cup the breast, removing milk with a rolling motion while lifting up to compress the breast.
A tongue-tied baby may have difficulty extending his tongue over the lower gum line. When Baby’s tongue is too tightly bound to the bottom of his mouth, forming a seal and creating a positive pressure can be a difficult maneuver. Mothers may find that their babies do not remove milk well enough to gain weight normally. They may find that the tongue action of the baby causes extremely sore nipples, because the baby cannot correctly attach to the breast.
Dr. Ruth Lawrence, in her book Breastfeeding: A Guide for the Medical Profession, says that there are many causes for sore nipples such as improper latch, improperly removing the baby from the breast or baby sucking in the bottom lip. She feels that if these are ruled out as cause for nipple pain, the baby should be checked for tongue-tie. She lists six steps for identification of tongue-tie, medically known as ankyloglossia:
- When tongue protrudes, tip is anchored behind alveolar ridge
- When infant cries, tongue remains anchored
- Tongue is notched or heart shaped when protruded
- Tongue cannot be manually extended by examiner
- Frenulum is short (less than 1 centimeter or 1/2 inch) and inelastic
- Tongue is attached close to the alveolar ridge
Angelia Thompson, a registered nurse who successfully nursed her first two babies, had trouble nursing her third baby. Thompson asked her lactation consultant for some assistance with latch-on. Despite careful positioning and latching, she noticed that breastfeeding did not feel the same as it had with her first two babies. When her son went in for his first weight check, he was not gaining weight well.
“Breastfeeding my third child was more painful than with the first two,” Thompson says. “The latch-on was particularly more painful. I had to reposition the baby often, and sometimes I had to hold my breast throughout the entire feeding to decrease the pain. Also, my milk did not come in as much in the beginning. I had to nurse and then pump after each nursing during the day to increase my milk supply. At a week of age, I took my baby to a pediatric dentist, who clipped my baby’s tongue. I put him to the breast immediately following the clipping. There were no adverse effects. It bled only slightly after the clipping, but nursing stopped the bleeding completely. I immediately felt a difference with nursing—no pain. I couldn’t believe it. I’m glad I had it done. I would recommend it to other nursing moms anytime for their comfort and peace of mind.”
By the Book
Lactation consultants have long been frustrated because physicians rarely encourage parents to seek help for tongue-tie, even if it becomes apparent that things are not going well with breastfeeding. Lactation consultants are very familiar with tongue-tie and the problems it may cause.
While our literature and resources frequently address this problem, medical literature rarely discusses tongue-tie. In the past, medical textbooks stated that clipping a tongue-tie is unnecessary. Indeed, it is not necessary for bottle-feeding success in most cases. When many of the textbooks were written, bottle-feeding was the norm in our culture. Times have changed.
Alison Kay Hazelbaker has written a guide to assessing tongue-tie for healthcare providers called The Assessment Tool for Lingual Frenulum Function. This easy-to-use guide assesses both function and appearance of the baby’s tongue. She believes that diagnosis must be made “firstly on function and secondly on appearance.”
Another tool intended to help the medical community in identifying tongue-tie comes from a family physician and lactation consultant in Calgary, Canada. Dr. Evelyn Jain has produced a video for physicians about tongue-tie with instructions on how to properly perform the frenotomy procedure.
Facts on Frenotomy
Physicians who perform the frenotomy procedure report that it is simple, usually bloodless, and the baby can nurse immediately afterward. Often, the mother notices an improvement right away and reports that her baby can now nurse comfortably. The majority notice a definite improvement within a week.
Many pedodontists, pediatric ear, nose and throat physicians or specially-trained pediatricians can assess for tongue-tie and perform the procedure (frenotomy) if necessary. If the frenulum is thin and stretchy, the procedure may be done in the office without anesthetic. Many physicians believe that injecting the tongue with a local anesthetic is more invasive and painful than doing a quick clip and then allowing the baby to nurse. Numbing the frenulum with a topical gel would cause inability to nurse after the procedure, which is comforting to the baby while clamping down the site to decrease any bleeding that may occur. Sometimes the frenulum is very vascular and thick or anchored totally to the floor of the mouth, and in these cases, surgery (frenectomy) would be more extensive and require hospitalization and anesthesia.
Many authors believe that ignoring a tongue-tie often causes breastfeeding failure. Being unable to breastfeed places children at great risk for illness and allergy. Some believe that speech may be affected. It has also been noted that abnormal swallowing patterns may cause improper oral development and malocclusion of the teeth.
The tongue thrusting, swallowing pattern may cause many orthodontic problems. Most of us use our tongue in a variety of ways, one of which is to clean between our gums and teeth after eating. Oral hygiene is compromised. Children with a tongue-tie cannot lick an ice cream cone. While tongue-tie continues to be a source of controversy between health care providers, it is a very real phenomenon for which breastfeeding parents need a very real and a very quick solution in order to be successful.