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Tongue Tie & Oral Restriction

What is a tongue tie?

Firstly, it’s important to understand that a lingual frenulum - the fold in the membrane and connective tissue under the tongue - is a normal part of our anatomy, but there are differences between individuals in how long it is, how stretchy it is and its exact placement. Having a visible frenulum does not automatically equal a tongue tie.

If the frenulum is very short or inflexible it can restrict how the tongue moves and functions this is what we call a tongue tie. In babies, a restrictive frenulum can cause difficulties with feeding - either at the breast or the bottle - and this is a common reason for families seeking support.

We estimate that about 10% of babies may have some restriction but not all of them will have difficulties with feeding.

 

Signs & symptoms that may be associated with tongue tie

For the baby:

Unable to open mouth wide

Notch or dent at the tip of the tongue

Difficulty latching or staying on the breast or bottle

Clicking noises during feeds

Dribbling while feeding

Not managing fast milk flow easily - coughing, choking, gagging

Very frequent or very long feeds - never satisfied

Unsettled

Reflux symptoms / colic / painful wind

For a breastfeeding / chestfeeding parent:

Nipple pain and damage

Compressed / squashed nipples after feeding (sometime blanched or white)

Low milk supply or an abundant supply with fast flow

Emotional distress

Exhaustion

Mastitis or blocked ducts

 

You may not experience all of these and there can be other causes.

 

 

What else could be the cause?

The foundation for all infant feeding, but particularly for breastfeeding, is a good latch - and a shallow latch (for whatever reason) can cause all of the things listed above. That’s why it’s really important to have a full feeding assessment before considering whether tongue tie is the problem. Sometimes, where tongue tie is not an issue, all of the above can be resolved with changes to position and attachment - although you will both need some time to build skill and confidence in the new techniques. If tongue tie is causing the shallow latch then working to improve the latch is important as preparation for division and afterwards when babies are relearning how to use their tongue.

Some babies seem to hold a lot of muscle tension in their bodies, their necks and their mouths. This may be because of their position in the womb, a difficult birth or because they’ve been working hard to compensate for a shallow latch. Releasing this tension can sometimes resolve or improve a lot of the things listed above. Often muscle tension and tongue tie go hand in hand - releasing tension before division is part of the preparation. I may suggest accessing bodywork with another practitioner such as osteo, chiro or craniosacral therapist.

Often there are multiple factors involved and taking a holistic approach - improving feeding, releasing tension and, after preparation, dividing the tongue tie (frenulotomy) will get the best results.

 

 

A note on lip ties

It’s normal to see a piece of connective tissue in the centre of the upper gum stretching to the centre of the upper lip in babies. It will become less obvious as the baby grows. Most importantly, babies do not need to flange their top lip out in order to feed well at the breast some do, possibly as a compensatory mechanism if there’s a shallow latch, but if the tongue is working well and the latch is deep the top lip can be in a relaxed, neutral position

Although many US and Canadian practitioners divide lip ties it is not recommended for feeding issues in the UK and I do not offer that service.

 

 

How I can help

I’ve trained as a Tongue Tie Practitioner after years of providing specialist infant feeding support as both a midwife and IBCLC - this means we can explore all aspects of the challenges you are facing and work out whether tongue tie really is the issue for you and your baby.. I undertook Tongue Tie Practitioner training with Carmelle Gentle because her course takes a holistic approach to dealing with tongue tie or other oral restrictions and is aligned with how I work with families.

I offer a range of services that can be tailored to your circumstances, whether you just need feeding support or whether frenulotomy (division) is indicated.

 

 

What to expect

During the first consultation we will discuss your history and review infant feeding. If you are breastfeeding expect to put the baby to the breast several times during the session - this allows plenty of time to practise adjustments and changes of position. Sometimes this session is all that’s required and the challenges you’ve been dealing with will improve as you and baby get better at latching and feeding.

During the first consultation I will also offer to assess baby’s oral function - this will include using gloved fingers to feel inside their mouth and how they use their tongue. I use the Hazlebaker assessment tool which is well recognised and used internationally as the basis for my assessment. If there is tension to be released, or exercises that I think will help, then I will do those as part of the assessment process between feeds. I will also demonstrate how you can continue the work at home.

If there appears to be a tongue tie or other oral restriction we will then discuss a plan of care and follow up. Usually division of tongue tie, if needed, will take place at the next appointment - this is to allow time for baby to be ready for the division (frenulotomy) and get better at using their tongue before the division takes place. Between appointments support is available via email / text or WhatsApp.

At the second appointment, often 1-2 weeks later, we will review the feeding and baby’s oral function again before going ahead with the division if it’s needed and baby is ready. Baby will be wrapped securely and I will ask you to hold their head while I complete the division with sterile round-ended scissors and wearing sterile gloves. Sterile gauze is used to check the wound and apply pressure if bleeding.

Babies sometimes get upset by being held and having fingers in their mouths. The division itself is usually very quick. There is usually a small blood loss which is easily staunched as baby feeds so we aim to get baby feeding immediately after the procedure. The blood loss is usually much less than the amount taken for the neonatal bloodspot test on Day 5. Most babies are easily soothed after the procedure.

The TT / Oral Restriction package includes a third appointment to check on healing and progress. At this point we can plan any further follow up if needed.

 

 

Safety

Frenulotomy (tongue tie division) is generally considered very safe when completed by appropriately trained healthcare professionals. Complications are rare but include the risk of increased bleeding, the risk of infection, risk if damage to the tongue or salivary ducts. There is also a risk of scar tissue forming that is as restrictive as the original tongue tie (often described as ‘reattaching’).

Aftercare

There is little definitive evidence about specific exercises and stretches although during my training I have seen what a difference they can make to how well the wound heals and how well babies feed afterwards. I will ask you to continue any sucking exercises you’ve been doing as preparation and I usually suggest lifting the tongue a couple of times each day to ensure the wound heals without bulky scar tissue. I do not recommend disrupting or massaging the wound itself. I will provide you with checklists and reminders of any exercises.

Remember that a deep, effective latch while breastfeeding will provide therapeutic exercise several times each day as baby learns how to use their ‘new’ tongue and builds strength and skill.

 

 

Links and Resources

Association of Tongue-tie Practitioners information leaflet:

https://irp.cdn-website.com/f3c762d5/files/uploaded/ATP-Tongue-Tie-Infant-Feeding-A5-Marc h-19_2.pdf

Sarah Oakley’s article about lip-ties:

https://sarahoakleylactation.co.uk/wp-content/uploads/2022/06/lip-tie-article-revised-version.p df

Nice guidance: https://www.nice.org.uk/guidance/ipg149/chapter/2-The-procedure#safety

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