It’s a tiny strip of tissue, but it can have big ramifications. Babies whose tongues aren’t able to move freely can have trouble swallowing and be nearly unable to nurse. What is tongue-tie and how is it treated?

It’s a tiny strip of tissue, but it can have big ramifications. Babies whose tongues aren’t able to move freely can have trouble swallowing and be nearly unable to nurse. What is tongue-tie and how is it treated?

“I saw at a glance that something was very wrong at the Ginsbergs,” says Chava, a postpartum doula. “Usually, by the time a baby is a month old, he’s more or less on a schedule, mom is getting used to him, and people are waving goodbye to their postnatal doula — not calling one in. But the Ginsberg house was a wreck, baby Shimi wouldn’t stop screaming, and his mother Ayala looked completely exhausted.

“I watched Shimi nurse for a while. He was squirming and wouldn’t settle down. Then Ayala gave him a bottle of milk she’d pumped. The milk dripping from the corners of his mouth showed me that he wasn’t able to coordinate normal swallowing. A quick look was enough to see the heart-shaped tongue — one of the most obvious signs of a tongue-tie.”

Take a moment to pay attention to your tongue. Now swallow. Feel that wave-like motion? It touches the roof of your mouth at the front and then rolls backwards, while the sides flatten and then curve up again. The tongue should be anchored to the floor of the mouth by a thin strip of tissue called the frenulum. But in 5 to 10 percent of newborns, the frenulum is either too wide or too short, keeping the tongue from being able to move freely — a condition called tongue-tie. The normal swallowing you just experienced would be impossible with a tongue-tie.

The effects of tongue-tie on a nursing baby can be serious. “The tiny tongues of babies who are nursing have to be able to perform a complex type of sucking,” explains dentist Dr. Ari Greenspan (half of the Ari & Ari Mishpacha duo). “A tongue-tie can hinder baby’s efforts to move his tongue up, down, and out, which is what he needs to do in order to nurse.”

Some babies also have an upper lip-tie, which means that the strip of skin under the upper lip is too short or too thick, pinning the lip to the upper gum. The baby can’t open his lip enough to create a good seal while nursing. Up to 80 percent of infants with untreated tongue- or lip-tie can’t gain enough weight by nursing.

“Because Shimi can’t stimulate enough milk production, Ayala’s milk supply falters,” Chava says. “Shimi is starving and constantly crying. Ayala is emotionally and physically drained, but she doesn’t want to feed him formula. Mother’s milk will give him immunities at a time when he’s vulnerable, being small, with an undeveloped immune system, and not having had many vaccinations.”

The misalignment caused by tongue-tie can lead to severe pain for the nursing mother as well. Elisheva Friedman, a nursing counselor for the Monsey office of New York’s Women, Infants and Children (WIC) program, explains, “When nursing is going well, the baby’s mouth is like a suction cup. The tongue and the jaw do the work. But if the lips and tongue can’t do their jobs, body parts that should be staying in one place are moving around, causing constant friction, and, since the milk isn’t coming out well, the milk ducts get blocked and infected.”

“Ayala was suffering,” remembers Chava. “Tears were seeping from her eyes as she told me, ‘I’ve always thought that a crying baby was a sign of a bad mother. But he feeds all day, and cries, and never stops, and it hurts so much I cringe when it’s time to nurse him! I love him so much. All I want is to give him what he needs and make him happy, but I don’t know what to do! I hate nursing him, and I feel so guilty about it.…’ ”

The pain is so overwhelming that mothers of tongue-tied babies are three times more likely to give up nursing in the first week than mothers of babies with free tongues. Yet some mothers will persevere despite the agony and distress.

Recognizing the Signs

Some tongue-ties are easy to spot. The tongue may be welded to the floor of the mouth, or the tongue may be heart-shaped because the frenulum extends all the way to the front of the mouth. But sometimes, the problem lies too far back to be seen.

In diagnosing tongue-tie, function is more important than appearance. Dentist Ari Greenspan recommends: “Look at your baby and stick out your tongue. Even tiny babies will imitate you. If the baby is unable to extend the tongue fully, or if it has a heart-shaped appearance on the tip, you should have him evaluated. You can also try putting your finger in his mouth — pad-side up — until he starts sucking. See if his tongue extends over his gum line to cup the bottom of your finger. If not, you may want to have him checked.”

Some practitioners believe tongue-ties are being overly diagnosed, and that this is just a passing fad, yet there are no reputable studies to show that. According to Virginia dentist Dr. Rod Rogge, “a frenum ultimately serves no purpose and removing one will cause no loss of function or any type of speech impediment.”

Dr. Bobak Ghaheri is an ear, nose, and throat doctor (ENT) who has treated over 1,000 babies with tongue-tie. “The reason there’s ‘controversy’ over tongue-tie and its effects,” he explains, “is because of miseducation and misunderstanding.” Some doctors assume that parents who blame their baby’s feeding problems on tongue-tie are either neurotic or fooling themselves.

“Parents today are very savvy, but if you bulldoze your way into a professional’s office with the preconceived notion that your child has problem x, y, or z, it can be very threatening and off-putting. You have to realize — medical schools teach almost nothing even about normal breastfeeding. Most health-care providers, especially ENTs, are not particularly passionate about breastfeeding. It’s not part of why they became an ENT.… From the pediatricians’ standpoint, I think it’s just about information. Once they [learn more about it, they are] more accepting.”

Dr. Ghaheri has some advice for both concerned parents — and practitioners. “Be calm and respectful and open a dialogue with your practitioner. You have to be an advocate for your family. A worried mom can do better research than the FBI. The message for doctors is: Be open to the thought that the mom in front of you may know ten times more about this than you do, and remember that when a mom hasn’t slept for a long time, she might be a little more emotional than usual.”

A Little Snip

There is nothing to be lost and everything to be gained in treating an infant’s tongue-tie and enabling him to nurse. Swallowing during nursing creates a strong vacuum in the mouth. This pulls down the palate and molds it into a gentle curve, which will keep the teeth, when they come in, cleaner and better positioned. Teeth and palate, face, neck and postural muscles, and breathing are affected.

“The snip [that releases the tied tongue] is called a frenectomy,” says Dr. Greenspan, “It takes longer to fill out the consent form for the procedure than to do the actual procedure itself. The baby is swaddled, and its head is immobilized by a nurse. The surgeon uses a depressor to force the tongue to the roof of the mouth, and the tongue-tie is snipped, using sterile surgical scissors.”

Some babies sleep through the procedure. There may be little or no blood loss, or the small clipped area may ooze blood for a short time, similar to the bleeding after the loss of a baby tooth. The baby usually nurses straight after the procedure. This stops the bleeding and distracts the baby from any discomfort.

The improvement in nursing is usually immediate; in 95 percent of cases there’s a marked improvement within 24 hours. Dr. Donna Geddes, senior research fellow at the School of Chemistry and Biochemistry at the University of Western Australia, used ultrasound to watch 24 pairs of mothers and infants nursing before and after a tongue-tie procedure; her results showed that the babies were getting more milk after the snip.

A frenectomy can also provide pain relief to the nursing mom. The Journal of Pediatrics reported on a study of 58 infants, averaging six days old, whose mothers were experiencing pain from nursing; half of the babies received a frenectomy and half had a sham surgery. The mothers of the infants who’d had a frenectomy reported half as much pain as the mothers whose infants had only had a sham procedure.

“Nursing was uncomfortable and not quite what I’d expected,” says Raizel B. of Melbourne, whose son was born with tongue-tie. “I had seen my sister and friends feed before but not really taken much notice. My baby was taking over an hour to feed and I was sore. After leaving the hospital it went from bad to worse.

“Then a Child and Family Health Service midwife told me that my baby was tongue-tied and booked him in the next day to have it fixed. As scary as it was to see my three-week-old have a procedure, I was grateful that there was a solution. The very next feed after his ‘snip’ was like heaven. It confirmed that I was doing it right. We have now gone on to have a fantastic feeding relationship. Nursing is the most rewarding experience, and, nine months later, I don’t want to stop.”

Another option for treating tongue-tie is laser surgery. While the procedure may take a little longer with laser, it is bloodless and bactericidal and avoids the swelling that might occur after a snipping.

The Journal of Pediatric and Neonatal Individualized Medicine mentions a third treatment option, stretching exercises overseen by a speech therapist, but says, “frenectomy… is much more effective than intensive specialist support by a professional.”

Gentle manipulation of the bones of the skull and spine is another possibility for newborns who can’t nurse well due to tongue-tie. “The tongue is anchored to the 4th and 5th vertebrae,” Dr. Chana Bracha Kornfeld, a certified craniosacral therapist, explains. “If bones of the neck were pulled low because the cord was wrapped around it, they may pull the tongue out of position. Sometimes the tongue is not the cause of nursing problems, but the hyoid bone, above the palate and below the nasal passages. If it’s not in place, there’s no way to draw in air while nursing.

“Sometimes a baby’s head is jammed up against her mother’s hip bone for a long time before birth, so the muscles on one side of the neck are more bunched up than the muscles on the other side. A craniosacral therapist can manipulate baby’s neck until the muscles open up so the baby’s head can be made to nod yes or shake no. Without that freedom, he’ll be too uncomfortable to nurse well, especially on one side. You can literally see their necks get longer when you release the muscles; when they come in, they look like little Mafiosos, with no necks. It’s hard to nurse when your neck won’t move.”

Back when just about everyone nursed, treating tongue-tie was so routine that midwives would take care of it with their fingernails. Between 1940 and 1960, doctors became convinced that bottles were better, so if nursing wasn’t going well, no effort was made to help. By the time nursing came back into vogue, the old ways were forgotten, although there are reports that some lactation consultants, in a pinch, have used a sterilized fingernail to slice the frenulum.

Currently, tongue-ties are treated by dentists, ENTs, oral surgeons, or maxillofacial surgeons, although in some parts of England, lactation consultants and midwives are being trained to diagnose tongue-tie and snip when necessary. And necessary it is.

It can take over three weeks to get an appointment for a tongue-tie procedure in England, and the wait in New York is around three months. While a next-day appointment can be made in South Africa, the cost is close to US $1,000. In Israel and Australia, same or next day appointments at little cost are thankfully the norm.

With an eye toward encouraging nursing, the American Academy of Pediatrics is developing screening tools that will allow nurses to quickly check for a tongue-tie while assessing a baby after birth. “Whether or not there is an epidemic or whether we ignored tongue-ties and are looking for them now,” says neonatologist Dr. Sandra Sullivan from the University of Florida, “this is something that is coming up more often in nurseries.”

Not Just for Babies

Though many associate tongue-tie with infants, in reality, toddlers, teens, and even old-timers may be affected as well. Dr. Bobak Ghaheri, an ENT who treats about 30 tongue-tie cases a week, sees patients from the entire age spectrum, with a host of associated symptoms. “Tongue-tie has pretty much taken over my practice,” he says. “A number of my patients are toddlers who had trouble manipulating food inside their mouths, so they had some digestive problems as a result.

“Adults with tongue-tie complain of vocal fatigue  — it’s a strain for them to speak — along with jaw tension, grinding; a fair number of people say it’s a migraine trigger, because of the tension they carry in their jaw.”

Because of the range of potential symptoms, the individual affected by tongue-tie may be under a great deal of stress. Since swallowing is subpar, splashing of saliva is a frequent and embarrassing problem. Untreated tongue-tie may result in an openmouthed posture associated with an unbalanced skeletal structure, writes Carmen Fernando in Tongue Tie — from Confusion to Clarity (1998). Another side effect, per pediatric dentist Lawrence Kotlow, author of the Kotlow Ankyloglossia Assessment Chart, is “sleep apnea, which reduces blood flow to the brain.”

The affected individual may also be more prone to cavities, since “food debris is not being removed by the tongue action of sweeping the teeth and spreading saliva,” says speech-language therapist Dr. Caroline Bowen. Lip-tie may keep central adult teeth from coming in, warns the Mayo Clinic, or may cause tooth gap and inflammation of gums.

For older adults, tongue-tie makes it difficult to control a lower denture. Orthodontia may be necessary because of the way the tied tongue pressures the front teeth while swallowing, or the side teeth when it can’t curl up, or the way it keeps the top and bottom teeth from aligning with each other.

Fifty percent of people with uncorrected tongue-tie suffer from speech problems — typically, “an inability to speak clearly when talking fast or loud or soft,” according to dentist Dr. Ari Greenspan. This is because they try to speak with their mouths mostly closed, so their tongue can touch the teeth and palate as necessary to make the sounds “t,” “d,” “z,” “s,” “th,” and “l,” or to roll an “r.”

Fortunately, treatment for adult tongue-tie is the same as infants, with the same, extremely low risk of infection or prolonged discomfort — and almost immediate relief.

“While I was learning how to counsel nursing mothers, I realized that my mother had a posterior tongue-tie that had never been diagnosed,” Elisheva Friedman, a Monsey nursing counselor says. “Because of it, she used to choke on her food. It always embarrassed her; she thought she didn’t know how to eat right. She also had a little speech impediment, which also embarrassed her — she’d cover her mouth when she spoke. I cry whenever I think about Mom living in embarrassment her whole life. If only she’d found out earlier what was causing her problems, she could have had it taken care of in five minutes.”

(Originally featured in Family First, Issue 472)