Brisbane Tongue Tie Clinic - Dr Helen Fung
P.  07 3398 5886
412 Old Cleveland Rd,
Coorparoo QLD 4151
info@brisbanetonguetie.com.au
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Tongue Tie Explained - Causes, Symptoms, and Treatment
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My Personal Journey to
Motherhood and Breastfeeding
 
1st September, 2015
By Dr. Helen Fung
Dr Helen Fung
10th September, 2015
  
What is a tongue tie?
 
The medical name for tongue tie is ankyloglossia. It is caused by a short membrane, or frenulum, that restricts tongue movement. It is fairly common, affecting roughly one of every ten babies. The prevalence in different studies varies widely (incidence ranging from 4% to 16%). This is partially because there is no clinical agreement on identifying a tongue tie, and different studies may have used different criteria.
 
The presence of a frenulum is normal. Its appearance can vary significantly between babies, ranging from a thin web to a thick and wide belt. The length can also vary, and may extend from the edge of the tongue to the lower front teeth, or may be so short it tethers the tongue tightly to the floor of the mouth. Diagnosing the presence of a tongue tie requires experience, but generally speaking, where the frenulum is restricting the normal range of motions required for adequate function, a tongue tie may exist.
 
Many babies with tongue tie can be breast and bottle fed successfully, but some tongue ties can cause pain for the breastfeeding mother, or interfere with a baby's ability to breast and bottle feed. In these cases, tongue tie release, or frenotomy, can provide a significant help for both mother and the baby.

 
How tongue tie develops?
 
During embryonic development, the frenulum guides the growth of oral structures. The tongue begins to form at about fourth week of pregnancy, and the frenulum guides the forward growth of the tongue. As the embryo continues developing, the frenulum retracts or dissolves away from the tip of the tongue to increase the tongue's mobility. After birth, the tip of the tongue continues to elongate forward, giving the impression that the frenulum continues retracting. Sometimes, the frenulum does not dissolve enough, which restricts the tongue movement, and a tongue tie results.

 
What are the signs and symptoms of a tongue tie?
 
  • For the baby, symptoms may include:
  • Difficulty latching or maintaining attachment to the breast
  • Gumming or chomping at the breast, rather than sucking
  • Increased swallowing of air
  • Prolonged feeding, including continuous snacking
  • Clicking on feeding
 
The maternal experience of breastfeeding a tongue tied baby may include:
  • Pain, damage, bleeding, blanching or distortion of the nipples
  • Mastitis, nipple thrush or blocked ducts
  • Severe pain with latch or losing latch
  • Sleep deprivation caused by the baby being unsettled
  • Reduction or loss of milk supply

 
What are the consequences of a tongue tie?
 
Breastfeeding problems
 
Breastfeeding requires a baby to be able to protrude the tongue beyond the lower gumline and elevate the tongue towards the palate to be able to transfer the milk from the breast effectively. If there is inadequate movement, or difficulty keeping the tongue in the correct position, the baby may chew instead of suck on the nipple, resulting in nipple pain and inefficient feeding.
 
Inability to breastfeed successfully in the presence of a tongue tie can cause a variety of challenges for the infant, the mother and the family. A strong bond is built between the mother and baby when a calm and satisfied baby can interact with the mother. Repeated difficulties during breastfeeding can interrupt or delay this bonding. Sleep deprivation affects both mother and baby; unsuccessful suckling will tire the baby, who will fall asleep on the breast and wake unsatisfied, which prolongs the feeding time without fully satisfying the hunger.
 
Ultimately, sleep deprivation and inadequate nutrition may lead to poor weight gain, or even failure to thrive.
 
Speech difficulties
 
The tongue has the ability to elevate, retract, protrude, and move to the sides. The presence of a tongue tie can mean that the tongue might be unable to move into the correct position to produce certain sounds, such as “D”, “T”, “L”, “TH”, etc. This may also result in delayed development of speech.
 
There are several case reports reporting improved articulation following frenotomies, however there are currently no clinical studies with good quality evidence that assess the effects of frenotomy on non-breastfeeding outcomes. It is important to note that when a frenotomy or frenectomy is performed in older children with speech disorders, it may only result in limited improvement, as the child has already developed incorrect ways to use tongue to produce certain sounds.
 
Oral hygiene
 
The tongue functions to clear the teeth of food debris and spread saliva. The presence of a tongue tie can contribute to dental decay and inflammation of the gums, or gingivitis. Restricted ability to lick the lips may also result in messy eating, gagging, or even choking and vomiting due to the inability to tidy up inside and outside of the mouth whilst having a meal.
 
Challenges with other oral activities
 
A tongue tie can interfere with many oral activities such as licking ice cream, playing wind instruments, or participating in plays and games involving tongue movements and gestures. It may also contribute to persistence of dribbling.

 
What are the management options for tongue tie?
 
If a baby or mother is experiencing symptoms such as breastfeeding problems, is unable to suck properly, fails to put on weight, or the mother is experiencing pain, some form of intervention may be required to save the breastfeeding relationship. Not all breastfeeding problems are caused by the presence of a tongue tie, so an examination by a professional is required. If a tongue tie is present, a lingual frenotomy or a lingual frenectomy are two different management options.
 
Frenotomy
 
Frenotomy, often referred as tongue tie release, is performed on newborns and neonates with a tongue tie to enable them to latch and suckle during breastfeeding and bottle feeding. Frenotomy is a relatively painless, in-office procedure, where the tongue tie is clipped with sterile blunt ended scissors to free the tongue to allow full range of motion. It takes less than a second, and as the frenulum contains almost no blood, very little bleeding results. The mother is able to stay in the same room, and breastfeeding can commence immediately after the procedure. Anaesthesia or stitches are not required. According to the NICE (National Institute for Health and Care Excellence) and the NHS (National Health Service), one fifth of the babies actually sleep through the frenotomy when performed with scissors, whilst others may cry for a few seconds. In small babies, feeding and cuddling straight away are more effective than the use of painkillers.
 
Frenotomy can also be performed using a laser, where the tongue tie is burned with a laser beam. This is a relatively new method in the market. Little clinical evidence is available, but typically laser takes significantly longer, around 30 seconds, with separation from the parent due laser safety guidelines, and prolonged restraint required.
 
Regardless of the method, the earlier the problem is identified and the frenotomy is performed, the less time it will take for the baby to breastfeed effectively and comfortably after the procedure. Therefore looking for help as early as possible is strongly recommended.
 
Frenectomy
 
Frenectomy is more extensive procedure, which involves tissue removal under general anaesthesia. This is the preferred procedure for infants over 12 months of age and is not recommended unless there is a good (speech, dental or other) justification for doing it.

 
Is it safe to treat a tongue tie?
 
There is some controversy surrounding the management of tongue ties. Some doctors believe that the risk of infection and tongue damage means babies with tongue ties should be watched, not automatically cut. Where there are no symptoms, this makes sense. However, the risk of infection and any tongue damage is extremely low. The problem with watch and wait attitude is that the mum and baby can’t keep breastfeeding, and the relationship may be lost. Research has shown that a delay of more than four weeks is more likely to be associated with breastfeeding abandonment. A tongue tie is a physical feature of the tongue, and waiting only worsens the problems, not improve them.
 
Prominent Australian paediatric surgeon Dr Martin Glasson has described as “an operation which is simple, brief and virtually devoid of complications”. Similarly, the National Institute for Health and Care Excellence (NICE) guidelines advises that “current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue tie)”.
 
 
If you feel that your baby is experiencing breastfeeding difficulties due to a tongue tie, contact us right away! We can usually offer you an appointment within just a couple of days.
 
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References:

Ballard JL1, Auer CE, Khoury JC. Pediatrics. 2002 Nov;110(5):e63. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.

Brookes A, Bowley DM. Early Hum Dev. 2014 Nov;90(11):765-8. Epub 2014 Sep 23. Tongue tie: the evidence for frenotomy.

Chinnadurai S, Francis DO, Epstein RA, Morad A, Kohanim S, McPheeters M. Pediatrics. 2015 Jun;135(6):e1467-74. Epub 2015 May 4. Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review.

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http://www.nhs.uk/Conditions/tongue-tie/Pages/Introduction.aspx

http://www.nice.org.uk/guidance/ipg149

Riskin A1, Mansovsky M, Coler-Botzer T, Kugelman A, Shaoul R, Hemo M, Wolff L, Harpaz S, Olchov Z, Bader D. Breastfeed Med. 2014 Nov;9(9):430-7. doi: 10.1089/bfm.2014.0072. Epub 2014 Oct 7. Tongue-tie and breastfeeding in newborns-mothers' perspective.

Power RF, Murphy JF. Arch Dis Child. 2015 May;100(5):489-94. Epub 2014 Nov 7. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance.

Rowan-Legg A1. Paediatr Child Health. 2015 May;20(4):209-18. Ankyloglossia and breastfeeding. [Article in English, French]

Sharma SD1, Jayaraj S1. J Laryngol Otol. 2015 Aug 28:1-4. [Epub ahead of print] Tongue-tie division to treat breastfeeding difficulties: our experience.

Todd DA, Hogan MJ. Breastfeed Rev. 2015 Mar;23(1):11-6.Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes.

Webb AN1, Hao W, Hong P. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):635-46. Epub 2013 Mar 26.The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review.