Why do tongue-ties and lip-ties cause problems with breastfeeding?
Lip-ties can make it difficult for the upper lip to flange or form a proper seal. They can result in a shallow latch, nipple pain and nipple trauma. In turn, a shallow latch can prevent the proper placement of the tongue, and efficient milk transfer. When a child has a lip-tie, they most commonly have a tongue-tie too (although the reverse is not as true).
Tongue-ties can also result in a poor latch when the tongue can’t extend forward under the nipple. In this situation, when the breast is introduced in the mouth the tongue is forced back into their airway, and the infant breaks the seal.
Many problems with tongue-ties can be related to the inability of the tongue to move upward. For milk to be released, the back of the tongue needs to be able to elevate firmly against the hard palate and create a vacuum as it lowers down. Efficient milk release depends on the successful creation of this vacuum. For this reason, it is important to assess for restrictions at the back part of the tongue.
The two most common reasons for early cessation of breastfeeding are pain and the perception of low milk supply. Since tongue-and lip-ties can contribute to shallow painful latches, and poor milk transfer they must be ruled out when these problems occur.
If your infant has symptoms of reflux in addition to breastfeeding challenges, you may wish to review our page on links between tongue and lip ties and infant reflux.
What are the common symptoms to take into consideration?
These lists are duplicated from the slides of Dr Larry Kotlow
Shallow latch, no latch or unsustained latch (slides off nipple), clamping
Breaks latch seal, clicking or smacking sounds, gassy, colic, reflux, vomiting
Prolonged non-nutritional feeding episodes
Unsatisfied nursing episodes, leaks milk, fights latching
Falls asleep on the breast
Gumming or chewing whilst latching
Poor weight gain or failure to thrive
Unable to hold pacifier
Signs of congestion, sleep apnoea, abnormal breathing
Can only fall asleep whilst upright
Chronic crying episodes
Creased or blanched nipples after feeding, flattened
Cracked, bruised or blistered nipples
Severe pain upon infant latching
Engorged or unemptied breasts
Premature weaning, changing the infant-mother relationship
You can check your infant by running your index finger under your infant’s tongue from one side of the floor of the mouth to the other side. If you can feel a bump, rather than a smooth passage then this could be an indication the tongue attachment is a problem in the presence of symptoms.
You can also feel for a good latch using your finger in their mouth. If you extend the finger to the junction of the hard and soft palate, and the part furthest in the mouth has little compression, it is a sign of poor attachment. When a baby is tongue-tied, compression will be felt in the part of the finger closest to the lip. In this situation, the baby is latching onto the nipple rather than the breast, causing nipple compression and pain.
If you are sufficiently concerned, the next step is to book in for an assessment and consultation. You also have the option to have this released on the day of consultation if it is confirmed this procedure will be beneficial.
It is best to not feed your child in the 90 minutes prior to your appointment to encourage them to feed more readily after the procedure.
Surgery to release your child’s tethered tissues is carried out with a Waterlase iPlus 2.0 laser, known for minimal heating and thermal damage of the tissues. The procedure is quick, minimally invasive with low risk of complications.
To protect and control your infants movements during surgical release, we gently place your baby in a swaddle and place appropriate safety glasses on them.
We typically do not use any drugs or injections prior to surgery, including anaesthetic. Some research has shown that use increases crying time, most likely due to their discomfort with the taste and feeling of being numb. Taking into account our desire to minimise their time under stress, the short duration of the procedure and the need for the baby to return to function well for feeding immediately after, anaesthetic will not be used.
As adults we can understand how disorientating it can be to be numb even without working out how to use new freedom of the tongue. Returning to the breast to immediately after the procedure is an important source of comfort for your infant and by eliminating use of anaesthetic, our intention is to preserve this for your baby.
It is not uncommon for your child to be crying during the procedure. This is most usually related to the discomfort of having someone work inside their mouth, rather than cries of distress from the pain. Please be assured that we will handle your baby with the utmost care, respect and sensitivity. Your baby will settle quickly after the procedure.
We understand that the prospect of your child having this procedure may leave you feeling distressed or helpless. Similar to most other surgical procedures, you will be asked not to be present in the room. We want to focus our full attention on your infant and completing this procedure as quickly with minimal variation as possible. Our aim is to return your baby to you as soon as possible. Your job will be to stay as calm and relaxed as possible during this time, in preparation to feed and soothe your baby immediately after surgery.
Whilst you may be separated from your infant for up to 10 minutes, the actual procedure will not usually take more than a couple of minutes.
When your infant is returned to you, you will be welcome to stay and take your time to feed them.
Whilst there is often a noticeable improvement in feeding after the procedure, release of lip and tongue ties should only be considered the first step and just one piece of the puzzle of achieving optimal tongue function and breastfeeding.
Releasing these restrictions can be compared to removing a cast that has been present on the arm for a prolonged period. It does not automatically mean that the muscles will work optimally immediately.
There are compensations that have been present since 18 weeks gestational age when sucking and swallowing training first began. When the tongue has had limited range of movement, we can expect there may not be enough strength to achieve the full elevation required for maximal efficiency of milk transfer during breastfeeding. It may take practice and training for muscles to work together properly.
Every baby will transition differently after a release, and require varying degrees of support. In some cases, there may be a period of going backwards before moving forwards.
Your lactation consultant will be an important source of support to optimise latch and positioning, offer tongue strengthening exercises and work on suck training.
A body worker will be important to reduce tension in other muscles that have been overworking to compensate for poor tongue function or any other strains that developed during the birth process. Reduced tension is important to help the tongue move more freely. We also perceive benefit in reducing the rate of contraction of the wound, which reduces the potential mobility of the tongue post release.
It is essential you follow instructions for post-surgery stretches. It is normal for wound edges to tend to join back together or reattach. When this occurs, the tissues may become restricted again. Performing stretches to actively manage the wound will help prevent this otherwise normal process of reattachment from occurring.
We also encourage avoidance or very minimal use of dummies if they are necessary. They interfere with elevation of the tongue which is important during normal oral rest posture and function. This also tends to promote reattachment.
There is also now growing awareness that Tummy Time has an important role in optimising tongue function. http://www.tummytimemethod.com/oral-restrictions.html
Although research is lacking, many leaders involved in tongue tie release agree in their perception that better outcomes can be achieved with body work before and after the release procedure. The tongue is intimately connected to many other body tissues in the neck and orofacial region. When the tongue has been restricted, there are often areas of tightness in adjacent muscles that have been overactive to compensate even before a child is born.
The aim of body work prior to the release is to reduce these tight areas, and remove any restrictions in the area that are unrelated to the tongue-tie. This may include any neck asymmetries, head tilts or other strains resulting from the birth process or interventions including caesarean sections, vacuum and forceps deliveries. This allows greater movement of the tongue and access to provide the most thorough release to restore optimal function.
There are also perceived benefits in terms of regulating the nervous system and helping babies to feel more relaxed. This can also be of benefit as the impact of stress in wound healing and recovery from the procedure should not be underestimated.
The best place to find out more about the concept of body work is the following website . http://www.ankyloglossiabodyworkers.com/benefits-of-bodywork.html
Complementary body work is considered “best practice”by members of the International Affiliation of Tongue-Tie Professionals (IATP), the leading body for the advancement of tongue-tie management.
It is also the approach endorsed by the only 3 Day university based program on Infant and Lip Tie Management offered by Tufts University in Boston which Dr Lim has attended.
It is our experience that it enhances outcomes for patients and most parents perceive benefit and value. Ultimately it is up to you to make an informed decision about proceeding. Ideally we recommend at least one appointment prior, and one after within 48 hours of the procedure, however many parents perceive enough benefit to return for further visits.
If you wish to proceed with this option, our office can provide a list of practitioners experienced in the team approach of managing oral restrictions.
It is normal for your baby to be unsettled on the first evening after their release. Most babies bounce back quickly. A few children will be more fussy and have peak irritability at days 4-5. Every baby has a different capacity to manage stress. In the worst case, be prepared that things may go backwards before they move forwards.
Try to manage your stress as best as possible, as your baby will be highly in tune to this. Offer lots of skin-to-skin as necessary.
Babies over 1 month may be given the age appropriate dosage of Panadol if there are no known medical contra-indications.
Alternative options for managing discomfort include
- breaking off wafer-thin pieces of frozen expressed breast milk or formula and holding them over the wound (prepare these by freezing in thin layers in ziplock bags)
- using homeopathic drops
- dipping your finger in a cup of water with a teaspoon of dissolved sugar, and letting them suck on this (the sucrose has analgesic properties)
It is important to interfere with the normal process of wound healing to prevent the edges from joining back together. You will be prescribed stretches to perform three times a day for three weeks to actively manage the wound.
These will be demonstrated to you following the release. In addition you will receive a copy of a book by Dr Larry Kotlow called “SOS for TOTS” that provides a good overview of Tethered Oral Tissues. It offers step-by-step illustrations and photos on oral massages and these stretches for your reference.
Avoid the use of dummies where possible as the interfere with proper tongue elevation. Prolonged use will promote reattachment of the wound.
Working with a lactation consultant or bodyworker early after release to optimise function is also an important part of preventing reattachment.
It is not uncommon for mothers to question the necessity of this procedure for their infant if they can just put up with the pain.
Pain beyond the initial period of breastfeeding is not normal. It interferes with bonding during feeding, and is a sign of abnormal oral function.
Optimal breastfeeding is the best way to develop the muscles that are involved with chewing solids, speech, healthy jaw development and closed mouth/nasal breathing.
The leading researchers involved in understanding how obstructive sleep apnoea develops are connecting the dots to suggest that proper orofacial function including optimal breastfeeding are key to minimising the development of these problems.
At the same time, it is important to understand that release does not automatically lead to normal function. As a result, avoidance of future problems cannot be guaranteed. Release of oral restrictions does offer the possibility of more normal function. The options can be weighed up with you during consultation.
The online book Breastfeeding Should Be Fun and Enjoyable. Why does it hurt when I breastfeed? by paediatric dentist Dr Larry Kotlow offers further information for consideration.