Tongue tie baby feeding challenges

by Anya Dunham, PhD

Summary of research and our experience with tongue tie baby feeding challenges, to help you compile a list of questions for your baby’s health care practitioner.

You’re probably wondering – and worrying – whether your baby has a tongue tie, whether you need to do anything about it, and how to overcome tongue tie baby feeding challenges. These questions are close to my heart because my three babies were born with tongue ties.

I must begin by saying that I have a PhD in Biology (my training and background), but I am not a medical professional. I wrote this article to summarize research on tongue tie in babies that I have found and to share some of my family’s experiences. I hope this helps you come up with a list of questions to ask your baby’s healthcare practitioners – and to continue looking for answers if you don’t get them right away or receive confusing or conflicting advice.

What are tongue ties?

A tongue tie, or ankyloglossia, means that the baby’s frenulum — the membrane under his tongue — is unusually thick, tight, or short, restricting the tongue’s movement.¹ Tongue ties are reported in 3 to 16% of babies, but the true percentage may be higher because not all cases are documented.^1,2.

Tongue ties are not a new phenomenon - but the prevalence of tongue tie feeding challenges may be

At present, there is much less research on tongue ties than there is on other infant feeding topics. Does this mean tongue ties are new, a fad or an old wives’ tale?

It appears to be neither. Some babies have historically been born with tongue ties and feeding challenges. My niece’s pediatrician mentioned casually that in the past, midwives used to keep one nail long and sharp to snip ties in newborns. I have found at least one record to corroborate this. In A Young Wife’s Guide in the Management of her Children written way back in 1764, John Theobald noted: “it may be necessary to cut the bridle of the tongue and this is usually done by nurses and midwives with their nail.”³

As time went on, hygiene and medical standards went up, which is undeniably a good thing. But also, bottle-feeding became the norm in many western countries due to promotion of formula-feeding in the 19th century. And so ties were no longer clipped with a nail, but seemingly became less of an issue, as most, though not all, babies with ties could still bottle-feed effectively.

Then in the 1990s breastfeeding rates went up – and tongue tie feeding challenges became a more prominent and better recognized issue.

Advice on tongue ties is often conflicting

Although most lactation consultants agree that tongue ties tend to cause breastfeeding difficulties, not all pediatricians do. Many medical guidelines don’t specify whether tongue ties need to be treated. Because of this, families often receive conflicting advice on whether their baby has a tongue tie and whether frenotomy is recommended.^1,4

It can be challenging to reconcile conflicting advice.

Tongue tie baby feeding challenges

Babies with tongue ties may experience a variety of feeding challenges.

To breastfeed, a baby needs to be able to open his mouth wide and bring his tongue down and out over the bottom lip to draw in the nipple and areola to latch, creating vacuum-like pressure. Many babies with tongue ties cannot create a vacuum as they latch onto the breast. Some babies cannot latch at all; others can but are not very efficient at extracting milk because of decreased tongue mobility. Breastfeeding mothers often experience nipple pain and damage, breast pain, and mastitis.¹

Sometimes, tongue tie feeding challenges are not apparent at birth. When a breastfeeding mother has ample milk and a strong milk ejection reflex, a baby might get sufficient milk in the early weeks passively, by milk sort of ‘fire hosing’ into baby's mouth. But this mode of feeding relies on milk flow rather than on active transfer by the baby. Once milk supply naturally regulates and the flow slows down  around 4-8 weeks, babies may begin to struggle with feeding and weight gain.

It appears that there may be a connection between tongue ties and reflux symptoms, at least in some babies. Siegel (2016)⁶ describes a phenomenon called ‘aerophagia induced reflux’ (AIR). A retrospective analysis of questionnaire/intake surveys of 1,000 babies over 5 years in a private surgical practice showed a correlation between aerophagia in babies with ties and reflux. After a surgical revision of tongue and lip ties, 520 (52%) babies showed improvement or complete reversal of symptoms of reflux, 283 (28.3%) had no change in reflux, and 191 (19.1%) showed improvement in post-feed irritability and less reflux symptoms but were not successfully weaned off reflux medications. Slagter et al (2021)⁷ also report an improvement in reflux symptoms in babies 1 and 6 months after tongue tie revision.

So, as I mentioned, tongue ties are not a new phenomenon, but the recognition of a problem is, and research does not appear to have caught up quite yet. There are still unanswered questions and uncertainties. Existing research mostly concentrates on the safety and effectiveness of frenotomy.

Research suggests tongue tie revision (frenotomy) is generally safe and effective

Frenotomy (also called ‘frenulotomy’ and tongue tie ‘division’, ‘release’, and ‘revision’) is a small surgical procedure in which the frenulum is cut.

How safe is frenotomy? Hale et al (2020)⁸ reported an average annual incidence of 13.9 cases of complications per 100,000 frenotomies in New Zealand, with a peak of 85.6 complications per 100,000 frenotomies in one region. (In total, the authors recorded 16 complications, most of which required hospital admission, over 2 years of surveillance. Complications included poor feeding (7 cases), respiratory events (4 cases), pain and bleeding (3 cases each) and weight loss (3 cases).) A Cochrane review of 5 small studies reported no adverse outcomes of frenotomy.⁹

How effective is frenotomy? Hogan (2005)¹⁰ reported that in babies with tongue ties, frenotomy was more effective in resolving improper latch than improving feeding position or adjusting feeding frequency. Several other studies stated that frenotomy made breastfeeding more comfortable, improved milk production, and led to more efficient feedings.^1,11,12 However, in most of these studies the assessments were qualitative, because somethings like comfort level is, of course, subjective and challenging to measure.

A Cochrane review I mentioned above⁹ that included 5 randomized trials (with 302 babies in total) reported a reduction in breastfeeding mothers’ nipple pain in the short term and “an inconsistent positive effect on infant breastfeeding” (generally positive effects but no definitively proven benefit). The review highlighted methodological shortcoming of the five trials: small sample sizes in all studies; in only two studies^12,13 both mothers and assessors were unaware of whether the revision was performed or not (i.e. ‘blinded’); and no study was able to report whether frenotomy led to long‐term successful breastfeeding. This is at least in part due to the fact that babies in the control group (those who didn’t initially get the frenotomy) were offered the procedure shortly after it became apparent that frenotomy had positive effects in the treatment group – and so long-term comparisons became impossible. The review concluded with the need for more research on this topic.

Getting the best possible answers for your baby

Figuring out whether your baby has a tie requires a close examination by an experienced professional – someone (or several people) who can see the whole picture.

Checking for ties is not always done at birth or during well-baby visits; there may or may not be routine screening where you live. In some countries lactation consultants can refer you to a specialist for assessment and surgical intervention; in others you’ll need a referral from your family doctor or pediatrician.

Remember that every baby has a frenulum, and that frenulum shape and size varies from one baby to another. Breastfeeding success depends not only on baby’s tongue mobility but also other aspects of baby’s oral anatomy as well as breastfeeding mother’s anatomy.¹⁴

It’s important to assess not only baby tongue’s appearance, but also its function.^5,15 A pediatric dentist we saw said that function – assessed through an account of parents’ experience and an observation of baby’s tongue movement and feeding – is the most important factor he considers.

I hope this information and our experience have given you some food for thought.

Don’t stop if the initial advice you receive is conflicting; continue looking for help until you feel fully heard and supported. Your baby’s health, comfort, and mastery in feeding – and your comfort and peace of mind – are valid and important.

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Warmly,

Anya

Hi! My name is Dr. Anya Dunham. I'm a scientist with a PhD in Biology, an award-winning author, and a mom to three young kids. Here and in my book, Baby Ecology, I analyze the research on baby's first year to find the optimal nurturing environment — the (usually wide) range of good options — to help you choose what works best for your baby and your family. Let's find the answers to new parent questions that are too complex to google. 

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