Mother&Baby's resident parenting expert Rachel Fitz-Desorgher is here to help with all your questions around pregnancy, babies and toddlers. This week she explains tongue-tie, how to tell if your baby has it and how to treat it.
It can’t have escaped your notice that at almost every postnatal coffee morning now there will be at least one mum who says her baby has been diagnosed with tongue-tie. Some groups I visit will have over half of the babies apparently afflicted. So, what is tongue-tie, how is it diagnosed and does it actually matter?
What is tongue-tie?
Let’s start by thinking about that term: tongue-tie. It conjures up someone who simply cannot get their words out because their tongue does not do what it’s supposed to do! In my own work, I try not to use the term because it suggests that a piece of membrane under the tongue is abnormal but, look in the mirror, lift up your own tongue and you’ll see that we all have a little web of skin under there.
People will tell you that its job is to stop your tongue falling back down your throat but that’s not true. It is actually a remnant from when you were an embryo and it’s job was to help your little embryonic tongue to grow correctly. I often think of it as one of those guide rails I need when I go bowling. I confess that I still can’t get the ball to roll forward in a straight line but you get the picture? The membrane (it’s proper name is a frenulum) attaches to the tip of the forming tongue and says “grow forwards and straight and end right here ...”.
Now the tongue is an incredibly strong muscle needed for suckling, eating and talking. It needs to be very finely tuned to the job in hand and work in a smooth, coordinated way so, as soon as the tongue has finished growing in the tiny embryo, it sets to work building up strength. Whilst your baby was developing inside you, every time they swallowed, their tongue moved powerfully up against the newly formed roof of the mouth building up tongue muscle and shaping the palate. Every time your little one sucked their thumb or fingers, the same thing happened, over and over and over again and, as the tongue moved more and more powerfully, that web of skin under the tongue tore back bit by bit until just the remnant was left.
Sometimes the membrane doesn’t tear right back, or it tears back but the remnant is thick enough or tight enough or fibrous enough that is tugs on the tongue as it moves and prevents that strong, coordinated action.
A frenulum which is thicker, tighter, shorter or more fibrous than ideal can, therefore, make the tongue action needed for suckling and eating and talking awkwardly. That is when people start talking about “tongue-tie” but as you now understand, just seeing a web of skin under a tongue does not mean there is a tongue-tie and this is probably at the heart of why you might seem to come across it so often - mums run into issues with painful feeding (or plenty of other issues such as evening crying, making clicking noises during feeds, “windy-ness”, poor weight gain), someone looks in the mouth, sees a bit of skin under the tongue and puts the blame for all the problems down to that.
In fact, even if the frenulum has not torn back at all and is still attached to the tongue tip, if it is thin enough and stretchy enough, then it really needn’t be a problem.
How can you tell if your baby is tongue-tied?
You can’t tell just by looking whether or not that frenulum is causing your or your baby’s problems so beware of people who do just that. You really need a frenulae (that’s the plural of frenulum), specialist, to feel inside the mouth, get your baby sucking on a clean thumb, and then assess whether or not the tongue can work in the strong, coordinated way that is needed to keep feeding a comfortable experience for you and effective for baby.
Even when the frenulum is overly tight or in-elastic 75% of affected babies are quite able to adapt around it. Frustratingly, the way that mums in the UK are shown to hold and “latch and attach” a baby on the boob makes it extremely tricky for a baby hampered by a tight frenulum to get on and suckle easily, whereas a simple cuddle hold to bring a baby right under the fall dropping weight of the breast, ensuring that their mouth is pressed right against the fleshy underside, triggers a touch reflex which makes the mouth open wide and allows the baby to use their innate urges to fiddle and faff around until they get on in a way that allows them to do what comes naturally.
Beware though - if you try and “look for the big mouth”, the mini gap you are forced to make between your boob and your baby’s mouth in order to get a good view, switches off that touch reflex, the mouth closes and getting on easily becomes impossible. There is a reason why the UK have one of the worst breastfeeding rates in the world ...
What treatments are there for tongue-tie?
So what happens if a baby does have an overly tight frenulum and no amount of support and clever tips and tricks have helped? Well, that is when a frenulotomy might be offered. This is a quick snip through the frenulum to remove the obstacle to the normal tongue action. Studies suggest, whilst that about 10% of babies have an overly tight frenulum affecting feeding, only about 2.5% of babies should actually need their frenulum snipped. You can see that it really is only a small minority of babies who need this doing and that a properly trained professional is the right person to assess that.
What's a frenulotomy?
A frenulotomy is done using a special type of scissors which can only snip the right bit of skin. The baby is securely wrapped in a blanket, the tongue is gently lifted up using either fingers or a small metal tongue-lifter designed for the purpose, and then the pesky bit of membrane is snipped right back to where it starts. It is essential that the very back of the membrane is snipped as this is where it is at its thickest and least elastic. Although this should only ever need to be done once, sometimes the very deepest part is difficult to reach and, if not quite divided, can continue to cause problems by tugging on the tongue. In that situation a second frenulotomy might be suggested.
As soon as the frenulum has been snipped, the frenulotomist presses on the tiny wound with a sterile gauze swab for a minute or two and then mum is usually asked to feed. Mum’s milk has lots of friendly bacteria in it and this can prevent infection in the wound. The high sugar content of mum’s milk also helps prevent infection AND stops bleeding.
A frenulotomy can be done on the NHS or privately; it can be done in a hospital, clinic or at home. It does, however, bring a few small but important risks which parents should be aware of:
Infection - whenever a cut is made in the skin, bugs can get in and cause an infection. The wound gets red and inflamed and might look oozy. The risk of infection is very small and, when it does happen, it is treated simply and effectively with an antibiotic syrup and it shouldn’t impact on feeding.
Blood loss - there are no major blood vessels under the baby tongue but there are tiny capillaries and these can bleed a bit like a paper cut - you press for a few seconds, the bleeding seems to stop and then, when you stop pressing, the blood oozes back again. The vast majority of babies only lose a couple of drops of blood (although in the mouth, mixed with saliva, it looks like a heck of a lot more!) On the unusual occasion when the oozing doesn’t stop, longer pressure or, very rarely, cauterisation might be needed.
Pain - it makes sense that a snip to a bit of skin, no matter how thin it is, will hurt and some babies really do let you know that they are upset. However, some babies sleep right through the quick procedure and some babies cry as soon as you wrap them up and lift their tongue and the crying doesn’t increase with the quick snip. So it is difficult to know how much pain a baby feels during a frenulotomy. It is kind, though, to be ready with some a baby-dose of paracetamol and a warm, cuddly feed.
Slow improvement - remember how the embryonic tongue needed free movement to work and gain muscle strength and coordination? Well, if it has been hampered right through development by a taut frenulum, the tongue does not build up that strength and so, even after a snip, it can take time (how long depends on how badly the developing tongue has been hampered) for the muscle to build up. People often say that a baby needs to “relearn” how to use their tongue but that’s not true - tongue action is innate, a reflex and requires no learning. But it does need lots of repetitive and correct action to build strength. Once the obstacle has gone, good exercise can start ...
Anxiety - no parent enjoys seeing their little one upset and you do need to take your own feelings into consideration when deciding whether or not to go down the route of frenulotomy. As you have seen, only a small number of babies really can’t adapt around their tight membrane so get good professional advice from a “tongue-tie” specialist before making your decision.
If you decide, or are advised against a frenulotomy then there is no need to worry about future speech issues. If a baby is able to adapt around their frenulum for suckling then there is a jolly good chance that they will be able to adapt around it to speak clearly. Most toddlers go through a phase of having odd speech patterns - lisps, stutters, inability to pronounce certain letters. This is normal and your health visitor will be able to reassure you or, if they think that there is a problem, refer you to a speech therapist for help and guidance. I see plenty of grown-ups who have entirely acceptable speech despite a tight frenulum and I often see grown-ups who don’t even know that they have a tight frenulum and slightly unusual speech production - they have adapted beautifully and it takes a frenulum geek like me to notice!
Why do some babies have a tight frenulum whilst others do not?
Finally, why do some babies have a tight frenulum whilst others do not? Well, there seems to be a genetic link. The frenulum is made of connective tissue and, just like loose ligaments (which are made of connective tissue) run in families as “double jointedness” some families have tight ligaments and they might be more likely to have a baby with a tight frenulum. There is, however, a group of genetic markers which, paradoxically, mix loose ligaments with tight frenuluae so, if in doubt, speak to someone who knows what they are talking about and can give you the right advice and support.
So have a good look under your baby’s tongue if you want to, feel that little web of skin if they will let you but don’t believe that every frenulum is a tongue tie. Your little one is more than likely to grow up to give even the very trickiest of tongue twisters a run for their money.
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