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Saturday, October 6, 2012

Tongue tie and the breastfed baby

Breastfeeding can be a wonderful thing. It can also be difficult, especially if things aren't going especially well. There can often be bumps in the road that make you want to totally give up and call it quits forever.

When it comes to those difficulties and feeding issues, perhaps one of the most under-explored problems is tongue tie. The difficulties a tongue-tied baby often has at the breast can be quite profound, and yet if you - or your doctor - don't fully understand what they are, it can either make or break the breastfeeding experience.

The tongue obviously has a major role to play in breastfeeding. Tongue tie, or anklyoglossia, is when the frenulum - the tissue that connects the tongue to the floor of the mouth - is tight, making it hard for the baby to feed properly. Some can be mild, some quite pronounced, and can affect different babies in different ways, or not at all. While some tongue-tied babies have no problems, for others it can be extremely difficult.

An example of tongue tie in an infant.
Janelle Aby, MD
Sometimes it can be difficult to tell if your baby has tongue-tie; sometimes it's quite obvious. There are signs to look for, according to the La Leche League, that might be important identifiers in determining whether or not this is really the problem:
The tongue tip should be able to extend to lick the lips, lift the front half of the tongue to the roof of the mouth, and sweep along the gums. If a tongue-tied baby tries to extend the tongue, it may not be able to extend past the lower lip, or the tongue tip might be forced downward over the lower lip. If the tongue is particularly tight, the back of the tongue will lift while the front remains tied down to the floor of the mouth, which is sometimes called “tongue humping.” If the baby attempts to lift a tied tongue, it often leaves a dent in the tip of the tongue, reminiscent of the top of a heart. The sides of the tongue will lift more than the center if the baby is tongue-tied. When the tongue tip attempts to reach either side of the mouth, the baby will twist the tongue and will not be able to bring the tongue tip to the back of the gums. A severe tongue-tie will prevent the baby from getting the tongue tip over the lower gum ridge.
Both the connective tissue under the tongue and connecting the top lip to the gums can be tight as well, such as here:
Maxillary labial frenum.
Problems that tongue tie can create include a bad latch, which can cause nipple pain and soreness in the mother. Without proper latch and the full ability to suck, the baby may spend more time on the breast to get enough milk to satisfy him. He also may have weight gain issues, gassiness and fussiness. Mother's milk supply often goes down, leaving both mom and baby frustrated, and mom is left thinking something is wrong with her milk.

Unfortunately, doctors are often not entirely educated on the subject of tongue tie and what to do about it. My friend Amy, a mom of four, said that although her oldest two both had it, because they were gaining weight the doctor wasn't concerned. "My doctor said that their tongue tie was not a problem, even though it was causing problems, just not weight gain issues," she said. When her third son was born, she sought a second opinion when the initial physician found nothing wrong. "Within a few days" of getting the frenulum clipped, she said, "he was such a different baby, with nursing and just his disposition in general."

This is the problem: even if mom does suspect something is wrong, the doctor may not always act on your suspicions. I actually read a question from someone whose doctor told her tongue tie was over-diagnosed, which I find hard to believe. Based on the differences between each type of tie and the individual anatomy of the mother's breast, experiences may vary: some may give up nursing early because of painful, cracked nipples and low milk supply, and some may have no problems at all, which some speculate might cause doctors to not recognize it properly.

Third-time mom Christina is in the throes of trying to get her baby accurately diagnosed. She explains that her baby doesn't seem to be able to get a "deep latch," milk will dribble out of her mouth while nursing, and she makes "clicking sounds" when she eats. She also projectile vomits regularly and gags whenever a bottle or pacifier are used. The ENT specialist that saw her daughter pronounced her "fine," but Christina knows that isn't true. Upon getting a second opinion from a pediatric dentist, the dentist confirmed that no, she wasn't "crazy," and that she's 'heard her story hundreds of times' from other mothers, whose intuition "is rarely wrong."

Christina emailed photos to the dentist, who wrote back and said that her baby has the most severe form of tongue tie there is, upper and lower, and said that "signs and symptoms indicate that she requires tongue-tie and lip-tie frenectomies." (Does this sound like a baby that's "fine" to you?)

Although every baby occasionally spits up and has fussiness or gas, it seems like this leaves a wide door for the formula industry to step in. There are all kinds of formulas marketed for babies with "colic," gas and spitting up, and many think that tongue ties are going undiagnosed because of this. "This makes me seriously wonder how many breastfeeding relationships are destroyed by doctors telling women that everything is fine when it isn't," Christina says. That something is wrong with you and your milk, so why don't you just switch to formula instead?

Before the widespread use of infant formula, the birth attendant usually clipped a tight frenulum immediately after birth. Since the cultural shift to using formula, however, it's largely fallen out of practice.

When a Florida doctor's child was born with tongue-tie, she had her son evaluated by an ENT who agreed to do the procedure. I'm guessing it's because she was a fellow doctor, not because he thought she was just a mom with good instinct. A lactation consultant, she pointed out, noted how lucky she was to find a doctor who would take her concerns seriously. When her child was born, she asked the postpartum nurse about the telltale heart-shaped tongue, and the nurse replied, "That's a tight frenulum. But no one does anything about them anymore." If no one does anything, the mother may go weeks, even months, struggling to breastfeed, even giving up because it seems unsuccessful. Because infant formula use has become so engrained in our medical culture it seems to be the first suggestion for solving any problem, even when there are other solutions.

Amy's doctor made an interesting observation: that more second- and third-time mothers come in for this problem, because first-time mothers often don't realize what it is and may stop nursing altogether because of milk supply issues, etc. "Perhaps they just give up nursing or trudge through even though they are having a horrible time," she thinks. "I didn't ask for help because I wouldn't even have known what to ask about." With no other children to compare it to, it can be confusing and frustrating to figure out what's going on. Then you might get an uninformed doctor who mistakenly says nothing is wrong.

If you suspect your baby has tongue-tie, especially when it's not glaringly obvious, here's a partial list of possibilities that might help:

• In mom, persistent very sore, damaged or blistered nipples (because of a bad latch)
• excessive weight loss in baby
• slow or no weight gain in baby
• cannot maintain a seal at the breast or bottle, often has gaps at corners of mouth that milk may spill out from
• baby only swallows infrequently
• very frequent feeds; I've also read that babies who spend a long time on the breast before being satisfied (if they are at all) is also a sign
• excessive gas, colic, green stools
• unable to protrude tongue (depending on the degree of the tie)
• clicking sound when feeding, may pop on or off
• low milk supply in mother
• gagging

For the article and entire list, click here.

It's important to trust your gut - if something doesn't seem right, check with your doctor. Realize that doctors aren't perfect, and do not be afraid to seek a second (or even a third!) opinion. It's not unheard of - and quite sad, really - for parents to travel miles, across states, even, to find someone who will listen to their concerns and do the procedure. But once it's done, it can often make all the difference in the world.

More reading:
Tongue Tie: From Confusion to Clarity
Tongue-tied breastfeeding 
Information on Tongue-Tied Babies: Breastfeeding Basics
Tempest Beauty: Maxillary Labial Frenum and Tongue Tie
Booby Traps: Docs who won't snip tongue-tie, thousands of breastfeeding moms and babies suffer - Best for Babes Foundation


Diana Chastain said...

I am fairly certain my daughter has/had the second. Her latch was painful. We fought through it. I was lead to believe that I had a low supply by my MIL. But looking back and knowing what I know now, my daughter had it. And I was hard to fight through but we breastfed for 14 months. She self weaned then. And she was always on the 25% curve but my doctor was never worried. She is now 21 months and just very petite. With my next I will know what to look for.

sara r. said...

My second has a tongue tie that was diagnosed by my midwife right after birth. I already had heard about them, so knew that clipping it immediately was a good idea, but even now his tongue is visibly short and he can't stick it far out of his mouth. He leaked milk and his latch is not great, but it hasn't affected his nursing otherwise, so we are fortunate. I mention the possibility of tongue tie to any mom that i hear is having pain nursing or supply issues.

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