Tongue-Tie and Your Baby

Co-written by Jamie Sakamoto, Occupational Therapist II, Children's Hospital Los Angeles and Kary Rappaport, OTR/L, SWC, IBCLC, Occupational Therapist III, Children's Hospital Los Angeles

If you recently had a baby and are having difficulty breastfeeding or bottle feeding, you may have been told that your little one has a short lingual frenulum or ankyloglossia. Also known as tongue-tie, ankyloglossia is when there is a tight band of tissue that connects the tongue to the floor of the mouth and limits full movement of the tongue. The tongue needs to be able to move freely up and down, in and out, as well as side to side in order for a child to be successful sucking, swallowing, and eventual chewing and talking.

Tongue-tie is present from birth and may be a benign presentation with little or no impact to early feeding skills. However, it can cause issues with bottle feeding and can be especially problematic when it comes to breastfeeding. A significantly short frenulum may limit the baby’s ability to achieve the deep latch necessary to express milk efficiently. Mothers may experience a great deal of pain and possibly skin damage on the nipples due to a shallow latch.

Early Warning Signs

Mom has:

• Painful/damaged nipples
• Frequent nipple infections or thrush
• A declining or poorly established milk supply

Baby:

• Fusses at some point during the feeding
• Makes a clicking noise frequently while eating
• Loses seal (“falls off”) on the breast or bottle frequently
• Is not gaining weight well
• Is very cranky/gassy/uncomfortable after feeds
• Spills a lot of milk from the mouth while eating
• Seems to cough a lot while breastfeeding or bottle feeding
• Takes a long time to complete a breast or bottle feed and never really seems satisfied

The act of early feeding is arguably the most important newborn and new caregiver task. In addition to nourishing a newborn, successful feeding facilitates bonding, early communication and self-regulation skills. Breastfeeding should not be a constant struggle for mother or baby. No one wins when a mother perseveres through a terribly painful or constantly frustrating breastfeeding situation. Many parents express how early feeding difficulties caused stress and feelings of guilt. Therefore, early intervention is vital in order to support the parent-child dyad. Early intervention is particularly vital for breastfeeding because milk supply is established very early on and delayed intervention can lead to difficulties with the mother's supply. A skilled lactation consultant should be able to identify tongue-tie for you, as should a skilled occupational therapist; a speech and language pathologist, ear, nose and throat doctor or a pediatric dentist who specializes in tongue-tie should also be able to make the diagnosis.

In some cases, a single consultation from a trained dysphagia therapist (speech and/or occupational therapy) or a lactation consultant can facilitate improved latch despite a short frenulum. A therapist can also provide oral exercises to improve the tongue range of motion or provide a referral, if necessary, to a trained physician or dentist for the tongue-tie to be corrected.

Whether it causes difficulties with early feeding or not, tongue-tie should not be overlooked or ignored. Newborns with feeding difficulties should be screened for short frenulum prior to their discharge to home to ensure the caregiver is able to feed without difficulty.

Tongue movement is important!

The structure of the tongue and how it moves within the mouth shapes our palate. When the tongue is restricted by a tight frenulum, it cannot rest in the ideal position to help with palatal shaping. The arch of the palate evolves as we grow and impacts the way the teeth come in and the way the face forms. A well-formed, nicely arched palate supports a well-rounded face with generally straight teeth.

The resting tongue position also impacts the ability of the airway to stay open, which impacts overall ability to remain alert and focused during the day, as well as to get deep, consistent sleep at night.

The tongue needs to have full movement in order for the child to chew efficiently and swallow safely, and to clear food from the teeth and lips.

If you suspect your baby has a tie and are seeking support, I suggest a team approach. The team should probably include a feeding/swallow therapist (occupational therapist or speech and language pathologist) with experience specifically in infant feeding, a lactation consultant or lactation educator if breastfeeding is a priority for the family, and a pediatric dentist/ENT/pediatrician who is well-versed in tongue-tie and “clipping,” or surgical correction of tongue-tie. I strongly recommendearly intervention and support for any type of infant feeding issue. Babies eat several times a day, every day, so even a few days of incorrect eating patterns can cause a big problem—for baby’s comfort and weight gain, and for parents’ stress levels, ability to bond, and feelings of success as a new parent.) The earlier you get support, the more likely the problem can be resolved quickly.

The occupational therapist’s role

• An occupational therapist can play an important role in addressing tongue-tie, including:
• Assessing oral motor patterns, swallow function, feeding function, developmental skills and sensory systems to determine what seems to be causing or contributing to the feeding issues
• Providing recommendations for developmentally supportive positioning or activities to avoid additional delays, potentially correct the feeding issue, and/or support the new tongue movements needed post-clipping, if clipping is indicated
• Assessing and intervention if there are other facial, neck, trunk or hip muscles that appear tight or are limiting the baby’s function
• Identifying tongue-tie and connecting families with the appropriate professional to help clip it if this appears needed
• Discussing findings with families and making a specific plan tailored to their needs, values, and priorities
• Discussing with the child’s pediatrician and whoever will be consulted to clip the tongue if needed
• Providing pre- and post-clipping tongue exercises to help build new patterns and maintain the range of motion gained by clipping
• Helping parents identify an appropriate bottle/nipple choice if bottle feeding is desired or if it is needed for a period of time to address weight gain issues
• Addressing the disrupted bonding between parent and baby or refering to the appropriate professional if more intensive therapy is needed

I know early feeding issues feel overwhelming and scary, and just the idea of your baby having a tongue-tie can seem devastating. It can and will get better and there is a team to support you. Your baby is amazingly adaptable and with the right support, you and your child will get through this.