Ankyloglossia (Tongue "Tie")

Everyone has a lingual frenulum, a fibrous attachment that holds the tongue to the base of the mouth and covers the muscle. About 1 in 10 babies will have some kind of tongue "tie," or ankyloglossia, which means that their frenulum is tighter or farther out on the tongue than other babies’. Only about 1/2 of these tongue ties will cause trouble with breastfeeding.

Please watch our Tongue Tie Parent Presentation to hear about our clinical approach to tongue tie for those with breastfeeding difficulties.

Signs of Tongue Tie Impact

Signs that a tongue tie is impacting breastfeeding include: 

1. Parental pain with nursing: We do not recommend that parents try to "get used" to this, or live through it. Pain with nursing indicates damage to the nipples, which can set up a parent for plugged ducts, mastitis, and even hospital admission, which isn’t good for lactating parents or breastfed babies. Look for:
   1. Nipple pain that lasts the whole feeding and isn’t getting better
   2. Cracked or bleeding nipples despite help with positioning from a lactation consultant
   3. A nipple that is flattened, has a line, or is "lipstick tube" shaped after nursing
   4. A "chompy" or "chewing" like suck in the baby, often with a dimpled cheek
   5. A sandpapery or "rubbing" feeling with nursing
2. Problems with "milk transfer": This means whether the baby can get the milk out of the breast. Look for:
   1. Overly frequent nursing, back and forth nursing, or "cluster feeding" that happens every day
   2. A baby who never feels full, or never sleeps for more than 30 minutes at a time
   3. A baby who never fully wakes up to feed and is often sleepy
   4. Poor weight gain or failure to thrive

Tongue Assessments

If these sound like you, get the tongue and latch checked soon by the baby’s provider, a breastfeeding specialist or a lactation consultant. A full tongue assessment should include checking out the:

1. Baby’s palate for a high arch
2. Baby’s upper lip for flexibility (low lying lip "tie" doesn’t tend to cause trouble on its own)
3. Whether baby’s tongue can lateralize (move side to side), lift up, extend out of the mouth, cup the finger and wave (peristalsis)
4. A comfortable latch
5. A before and after breastfeeding weight to see if the baby got a full feed

Considerations

Things to consider when you are thinking about clipping a tongue tie:

1. Are there other things going on? Neurodevelopmental issues, prematurity, torticollis and reflux are often found with infants with tongue tie. These may be the cause of the feeding trouble, or may be separate issues, but should be addressed by the baby’s provider.
2. Have you considered craniosacral therapy or feeding therapy with a speech pathologist or occupational therapist or La Leche League International websites.
3. Have you considered laser or "cold" technique (scissors). They have not been compared in studies, and we have seen good outcomes both ways. You may prefer laser if there is a bleeding disorder in the family. Please note: UR Medicine Breastfeeding & Lactation Medicine does not perform frenotomies on infants who have not received a Vitamin K injection at delivery.

Posterior Tongue Tie

Posterior tongue tie, also known as a "type 4" or "submucosal" tongue tie, tend to present slightly later and slightly differently than the "anterior" version. Most breastfeeding medicine specialists agree that these ties can be just as often problematic as the "anteriors," and sometimes more so. Posteriors tend to present:

• Later
• With growth delay, slow weight gain, or failure to thrive
• With "chomping" suck, or sandpapery feeling suck
• With difficulty with bottles
• With parents with chronically damaged nipples (vasospasm or mastitis)
• With low milk supply in parents

We have seen good outcomes with clipping these ties, and there is evidence to support this. However, these children often also need accompanying suck therapy or craniosacral therapy. See #2 under Considerations above.

Call (585) 276-MILK for an appointment for tongue tie evaluation!

Frenotomy

The frenotomy procedure is a low-risk, but not no-risk procedure in which the tongue-tie is cut. It may be recommended to treat certain kinds of tongue-tie that are impacting feeding. We do not generally recommend frenotomy to prevent future health concerns such as speech, as these outcomes are unpredictable. If you are considering frenotomy for your child, please watch the video above and consider:

• Benefits: Frenotomy has shown benefits in breastfed infants including: improved latch, decreased pain for breastfeeding parents/mothers. There is some, but less robust, evidence that it improves how much milk infants can remove from breastfeeding, and decreases reflux
  • There is very limited evidence for frenotomy for lip-tie and bottle feeding problems
  • There is no current research in using frenotomy for "buccal ties" or "cheek ties"
• Risks: Risks of frenotomy include bleeding, infection, cutting of surrounding structures such as muscle or salivary ducts. These are all rare outcomes.
  • The procedure is painful, your child will be given sucrose solution or cold breastmilk for pain, as there are no approved intra-oral anesthetics for infants. In addition, a numb mouth is not a great idea for infants who need to eat every 1-2 hours.
  • If you know that you your child will be receiving frenotomy, you can pre-medicate with acetaminophen (Tylenol) - check with your pediatrician for dosing, or use this resource from the AAP.
• At UR Medicine Breastfeeding & Lactation Medicine, we:
  • Perform frenotomy for tongue-tie only, you will be referred to another provider if your baby needs a frenotomy for lip-tie
  • Do not perform frenotomy on infants who have not received a Vitamin K injection at delivery. An Ear, Nose and Throat doctor or dentist has more capabilities to control excess bleeding in the case of hemorrhage due to Vitamin K deficiency
  • Use scissors or CO2 laser (LightScalpel©) to perform frenotomies. Read details on the CO₂ laser.

Frenotomy: Post-Operative Care and Follow-Up

• Pain: Your child will typically not need any medicine for pain.
  • However, if you do wish to give something then use acetaminophen (Tylenol) at 15 mg/kg every 4-6 hours.
    NOTE: In babies under 2 months of age, a fever is a medical emergency.
  • Some people have used Oragel Naturals or Hyland’s Teething tablets (all can be bought in a typical pharmacy like CVS), or Teething Oils with clove (can be bought at Beautiful Birth Choices or online).
  • Consider making your own clove oil: 2 tablespoons olive or coconut oil 2-3 drops clove bud essential oil.
• Keeping the frenotomy area open and scar-free: Some practitioners advise exercises to prevent the cut edges of the frenulum from re-attaching and forming a scar that makes an even worse "tongue tie." This is more common with practitioners who use laser, though there is no evidence for it working. So, we recommend doing the following 3-4 times per day with diaper changes for 1-2 weeks, IF your baby is not unhappy or in pain:
  • Gently tap your baby's lips to get them to stick out their tongue.
  • Rub the lower and upper gums side to side to see your baby’s tongue move with you – "follow."
  • Play "suck tug of war" with your finger or a pacifier.
  • While your child is sucking on your finger, push down on the back of the tongue and hold it for 3 seconds.
• Bleeding: You may see blood in the baby's spit up, or notice a small black streak in the otherwise yellow bowel movement. That is some swallowed blood that turned black from the stomach acid. If you notice any bleeding or oozing later this first day or when you do the exercises, you may:
  • Use a cloth or gauze dipped in ice water and put some pressure on that area for 1-2 minutes.
  • Put your child to breast (or bottle): The feeding stops bleeding.
• Breastfeeding: We encourage you to try and slowly normalize breastfeeding over the next 1-2 weeks, transitioning as you see fit from the things you might have been using, like a nipple shield or bottles with expressed breast milk or formula. But don’t feel rushed.
  • Teach your infant to open wider, take more of the breast in, and splay the upper lip.
  • Work with your Lactation Consultant.
  • Consider craniosacral therapy or feeding therapy.
• Office follow-up: Please schedule a follow up within 10 days. Please call if you have concerns earlier.