‘There are so many myths surrounding tongue-tie.
Tongue-tie seems to be one of the most talked-about, one of the most debated and controversial topics in infant feeding. Infant feeding is an emotive and controversial topic to be fair, but tongue-tie certainly seems to cause a stir and heated debate at times!
Why all the misinformation, mixed messages, myths and debate around tongue-tie?
Firstly, some of this relates to how we get our information. Research and the ‘best’ type of research to inform practice can be hard to come by, in all things relating to breastfeeding. Some of this relates to funding for such research to take place, I’m not going to debate this here as that’s a different controversial can of worms to the one I’m opening today, but also sometimes is down to the efficacy of the type of research that is needed to demonstrate this.
For example, this kind of research would mean randomly allocating subjects, aka babies, so already ethically complicated, to one method or treatment and other babies to another, without them knowing which they were assigned to. This is to compare and gain the evidence to say, ‘this is what works best’. You can’t really perform a tongue-tie division on a baby without the parents knowing and when the subjects in one group get good results you can’t really deny that treatment to the subjects on the other path, so therefore the research cannot really continue.
Gaining this type of research is challenging.
A lot of our information surrounding tongue-tie comes from the United States and their health care system is very different to ours. You pay health insurance and practitioners are paid for procedures. This can result in the potential for bias to the collected data. That individual would have something to gain financially for showing babies benefit from a tongue-tie division! That means biased information and not really the quality evidence base that should be used to inform practice.
So, lots of difficulty with the quality and type of evidence we have surrounding tongue-tie. Hence some of the myths and controversy!!!
There are so many things I hear people say regarding tongue-ties that are just NOT TRUE!!! So, I thought lets’ blow a few of these myths wide open! The more people that can say, ‘nope I know that’s not true’, the better. Then maybe that air of mixed messages and confusion about tongue-tie can flutter off somewhere else!!!
My baby can stick their tongue out, so they can't have a tongue-tie.
False!!! False!!! False!!!!!
Tongue extension or poking out your tongue is important when it comes to feeding! But it’s not the only factor needed to feed.
To latch to the breast, babies need to be able to open their mouth wide and bring the tongue down and forward, over their bottom lip. This creates a groove in the tongue that allows them to scoop the breast up. The nipple and areolar (the darker area around the nipple) are then drawn into the baby’s mouth by negative pressure. Negative pressure is created by the front part of the tongue moving up and down. This compresses the nipple against the palate and the rear part of the tongue then drops, creating a wave like motion of the tongue. Tongue movement is directed by the forward and backwards motion of the lower jaw to create this negative pressure which is essential for milk being removed from the breast.
It's not all about extension
Yes, your baby needs to be able to extend their tongue, but here are two other important factors to consider.
They need to be able to maintain that extension.
This means the tongue staying out over the bottom lip, to act as a protective cushion to the nipple. This prevents the hardness of the gum from damaging the nipple during feeding. This ability to leave the tongue over the bottom lip also enables the baby to sustain the latch, cup the tongue, to hold the breast in place.
Some babies can extend their tongue, but struggle to maintain this position. This could be due to tension on the tongue from the lingual frenulum, (the piece of stringy skin that stretches from the floor of your mouth to the underside of our tongue.) Most of us have a lingual frenulum. It is when it is too short, tight or too far forward on the tongue and restricts tongue movement, that the frenulum is then classed as a tongue-tie.
This tension creates a snap-back action of the tongue, pulling it back behind the gum. ‘Clicking’ can often be heard as the suction is lost and some mums report a rubbing, flicking, and often painful feeling when this happens!
Loss of suction as the tongue snaps back can cause the baby to lose the latch, resulting in a baby frequently releasing the breast, or slipping off and needing to be re-latched. These babies are often described as just never staying on for a whole feed, or constantly slipping back to a much shallower latch, despite efforts to get a good deep attachment when feeding.
Some babies though, use other measures to try and stay on the breast, so they don’t keep slipping off. This can lead to the sucking blisters that can sometimes be seen on babies’ lips, caused by them hanging on with their lips, compensating for the tongue not effectively holding the breast in place, or they may clamp down with their jaw to stay on, which is painful and uncomfortable for mum!!! Your baby may be on and feeding but it’s certainly not optimal or effective.
Your tongue moves in mysterious ways!
Tongue extension is not the only action needed for feeding.
The tongue needs to move from side to side, make a good cup to hold the tongue in place and the tongue tip needs to elevate to the roof of the mouth. Tongue elevation or the lifting of the tongue is possibly one of the most important elements required for effective feeding.
Tongue-ties can result in your baby not being able to elevate their tongue. The up and down movement of the tongue is required to create negative pressure, so creating a space or vacuum in the mouth that leads to milk being removed from the breast. Poor or ineffective elevation can lead to issues with milk transfer. This can result in poor weight gain for your baby and a drop in milk supply for you, as the demand and supply foundation of feeding isn’t working effectively.
Babies do need to stick their tongues out, but if they can do this, can they maintain this extension? And what about elevation?
My baby is gaining weight so can't have a tongue-tie
False!!! False!!! False!!!
As discussed, sometimes when the tongue isn’t working optimally, then compensatory mechanisms are employed!! Your baby may be gaining weight because:
You are feeding them non-stop. It can be hard work for babies to use other methods to try and transfer milk when the tongue isn’t moving effectively. Therefore, they get tired, often before they have really finished the feed. They then need to go back on the breast. The constant putting back to the breast, this baby who never has that milk drunk or sated look after a feed, may be enough to keep their weight up, but this is not optimal for them or sustainable for many mums. Exhaustion, pain, and that feeling that your milk supply must not be good enough will grind you down and potentially derail your breastfeeding journey.
Your baby may be getting milk, but the process by which they are doing this is causing you pain and nipple damage. It may be working to a degree but how sustainable is this?
The other factor here is just how amazing the human body is. Sometimes the breast does an incredible job of compensating by upping supply and/or having a forceful let down response. This sort of forces milk into the baby, who is not really creating the correct pressure needed to draw the milk from the breast. This provides that weight gain, but often also provides a windy or refluxy baby, due to them not being able to transfer or manage milk flow effectively. This isn’t always the case either, some mums bodies’ create a good or even oversupply in response and some mums will just lose their supply quickly if breastfeeding isn’t effective.
In the early days of breastfeeding, milk supply is hormonally driven. To sustain milk supply it becomes driven by the demand and supply system. So frequent removal of milk, drives production. A baby that is not effectively removing the milk, may result in milk supply dropping as the body responds to milk being left in the breast or not adequately removed. Where there is ineffective milk removal, this can cause a down regulation of milk supply. In the early days it may seem all is ok, but then as time goes on, and milk supply relies on your baby creating the demand, mum’s supply drops and a baby who was gaining well, suddenly slows down!
Weight gain is not the only indicator of an issue and shouldn’t be the only factor in if a tongue-tie division is required or not. How the mum is feeling and how their breastfeeding experience is, are also crucial factors!!!
You can't see a tongue-tie, so there isn't one!
False!!!! False!!! False!!!
Most of us have a lingual frenulum. It’s how this affects the function or movement of the tongue that is crucial.
When the frenulum is very far forward, this is classified as anterior, meaning close to the tip of the tongue. This is the classic ‘heart shaped’ tongue you see described as tongue-tie.
Sometimes the frenulum is further back or even slightly hidden underneath the tongue so cannot been so easily seen. You can often feel these, and the tension/tightness, rather than see them.
Posterior tongue-tie vs anterior
The terms anterior and posterior just refer to the position of the lingual frenulum. Anterior meaning closer to the front or tip of the tongue, posterior meaning away from the tip or further back under the surface of the tongue. This just considers the appearance of the lingual frenulum, not the function!!
You can have an obvious frenulum right at the tip, but it is elastic in nature and doesn’t impact feeding. So, this isn’t a tongue-tie, it’s just a lingual frenulum!!!
Posterior tongue-tie- you may not see it, but it can still cause an issue!
The lingual frenulum can be less obvious, sometimes right back underneath the tongue. You may only see this by lifting the tongue and pushing back to expose it. This
could be short and thick and restricting movement. So, although you can’t really see it, it is affecting feeding, so therefore is a restricted lingual frenulum otherwise known as tongue-tie. These more posterior locations of restriction can impact the ability to lift the tongue, importance of which was discussed above, but also the ability to make a good secure ‘cup’ position with the tongue and therefore impact feeding, in some cases just as significantly as those with anterior tongue-ties that restrict tongue movement.
Anyone who is only looking in the mouth isn’t assessing the function of the tongue, and
this is a crucial element to identifying if your baby has a restricted lingual frenulum, or just has a visible lingual frenulum.
It is function, not appearance that determines if the frenulum is restricted and impacting feeding.
Tongue-tie assessment, is more than just a quick look!
There are many other myths and false information that surround tongue-tie that I haven’t explored here. Partly as it would just go on and on!! The key pieces to take away from this article are:
What does breastfeeding feel like? It’s not just about how it looks; it is about how it feels!
Pain when breastfeeding is not normal, pain is a signal something is wrong! Whilst it may take some time to learn how to breastfeed, this should not be weeks and weeks. If you are finding it a struggle, you need more support.
What is the breastfeeding experience like for you and your baby? Is each feed taking a long time? Is your baby never ‘full’ or ‘finished’ after a feed? Pain, very frequent feeding, an unsettled, windy, or colicky baby, are all indications that something isn’t right and needs addressing!! Trust your instincts and reach out for more support.
It’s all about the function! A quick look tells you nothing! If the person telling you it is (or isn’t) a tongue-tie, didn’t complete a full infant feeding assessment, including observing a feed, and didn’t feel in your baby’s mouth, then we don’t know if it’s just a lingual frenulum or if there is restriction that is impacting feeding.
And just as a last little myth to try and shine some light on.
Restrictions to lingual frenula or tongue-ties can and do impact babies that are bottle feeding.
Yes, it may impact to a lesser extent, and they may be more able to bottle-feed, but many common issues such as reflux, wind, or even suggested allergies are not as they seem. They are in fact caused by ineffective feeding. Ineffective bottle-feeding can just as likely lead to an unsettled, unhappy baby!
So regardless of how your baby is feeding, is it optimal?