The most common reason for breastfeeding difficulties, poor weight gain and sore nipples is a shallow latch. If you are having trouble breastfeeding see Positioning and Latching for more information. Consider contacting your local La Leche League Leader or an International Board Certified Lactation Consultant (IBCLC) for help.
Your baby’s oral anatomy includes the tongue, lips, jaws, cheeks and palate (roof of the mouth). All are involved in breastfeeding. A variation of any of these can affect how your baby latches and feeds. Perhaps you have corrected the latch and your baby is still struggling to breastfeed or gain weight. Or perhaps your nipples are still sore even with good positioning. It is possible that the cause is something in your baby’s oral anatomy.
The importance of the tongue for breastfeeding
In order for your baby to breastfeed, your baby needs to be able to:
- lift the front of his tongue about halfway or more to the roof of his mouth.
- reach his tongue past his lower gum.
- lower the back of his tongue during feedings.
- cup or shape his tongue around the nipple.
- move his tongue with a wave-like motion from front to back.
If your baby is able to make all of these motions with his tongue, then he likely does not have a tongue-tie.
Everyone has a thin membrane of tissue (lingual frenulum) that holds the bottom of the tongue to the floor of the mouth. In some people it is visible, and in others it is not. A visible lingual frenulum is not always a sign of a tongue-tie. A tongue-tie is present when the lingual frenulum is tight and/or thick enough to restrict normal tongue movement. However, there is no clear, agreed-upon definition of what a normal lingual frenulum should look like. Because of this, it is difficult to know exactly how common tongue-tie is.
It is estimated that between 3% and 13% or more of babies are born with a tongue-tie. There has been a significant increase in the number of diagnoses of tongue-tie in recent years. Some lactation specialists believe that this is because tongue-tie is now more recognized by healthcare professionals. Others believe that this is because tongue-tie is now being overdiagnosed and overtreated.
If your baby appears to have a tongue-tie but breastfeeds comfortably and effectively, no treatment is needed. However, some babies with a possible tongue tie are doing fine and then after a few weeks experience slow weight gain. If your baby appears to have a tongue-tie and is having difficulty breastfeeding or gaining weight and/or your nipples are sore, even after seeing an IBCLC, then it may need to be treated.
Before seeking treatment for a tongue-tie it is important to consider other possible causes of breastfeeding difficulties. The tongue-tie may not be the main problem.
- Improving positioning and latching is the first place to start.
- Using the laid-back breastfeeding position can make latching easier for your baby.
- Helping your baby get a good deep latch can help your baby stay on the breast and remove milk effectively. If your baby’s chin is tucked into his chest he will not be able to hold onto the breast. Your baby’s chin should be pressed deeply into your breast. Your baby’s nose should be tipping away and the head should be tipped back. This is the same position you take when you drink something.
- Shaping your breast into a ‘sandwich’ can help your baby get a deep latch. Squeeze your breast between your thumb on top of your breast and your fingers below. The ‘sandwich’ needs to be horizontal to your baby’s mouth, like your baby is eating a sandwich. This can help your baby’s lower jaw to get a bigger mouthful of breast.
- Seeing a healthcare professional who specializes in infant body work may resolve the problem. Tightness in the tissues around the head and mouth can affect normal tongue movement.
Some symptoms of tongue-tie in babies:
- difficulty latching and/or staying latched during feedings
- clicking sounds during feedings
- poor milk intake which may result in long feedings
- poor milk intake which results in short feedings
- long pauses to rest during feedings
- baby not content after feedings
- baby tired after feedings
- coughing during feedings
Symptoms of tongue-tied babies in mothers:
- nipple pain and/or nipple damage
- low milk production after adequate production with a previous child
If you think tongue-tie is the problem, you’ll want to see a healthcare provider who specializes in diagnosing and treating tongue ties.
Diagnosing and Treating a Tongue-Tie
In order to determine whether or not your baby has a tongue-tie that needs treatment, your healthcare provider should use an assessment guide. Not all healthcare providers believe that nursing is affected by tongue-ties. They may not be knowledgeable about how to diagnose or treat them. If your healthcare provider is not helpful, consider getting a second opinion. This may be a family doctor, nurse practitioner, pediatrician, pediatric dentist, oral surgeon, ear-nose-and-throat (ENT) doctor, or a breastfeeding clinic with a team of professionals. Some practitioners charge a fee. Ask about the cost before agreeing to the consultation.
Your healthcare provider may recommend treatment.
- Frenotomy is a simple surgical procedure performed in the provider’s office using scissors. The lingual frenulum is clipped to improve tongue movement.
- Frenectomy is a procedure using a laser to revise the frenulum by removing tissue.
- In most cases, neither procedure requires stitches and is usually done without anesthetic. There are few nerves and blood vessels in the frenulum and therefore there is usually very little pain or bleeding. However, in some rare cases, a surgeon and stitches may be required to realign tissues in the mouth.
There is little research on the effectiveness of a lingual frenotomy on breastfeeding outcomes. Some mothers find immediate improvement after the procedure. Others find that nursing improves over days or weeks. It takes some babies time to learn to use their more mobile tongue. It is unclear if the improvement is due to the procedure or due to improved positioning and latching.
Treatment After a Frenotomy
Some healthcare providers suggest specific care practices after a frenotomy; others do not. Many feel that nursing alone provides enough movement to strengthen the tongue and encourage proper healing of the wound site. There is very little research on the effectiveness of tongue exercises after frenotomy.
Everyone has a membrane that connects the upper lip and the upper gum line. This ‘upper lip frenulum’ is called the superior or maxillary labial frenulum (or frenum). There are no definitions of either a normal or tight labial frenulum (or lip-tie). There is also no research that clipping a lip tie improves breastfeeding. Research does indicate that the labial frenulum becomes much less obvious as children get older.
In a good, deep latch your baby’s lower lip will be flanged outward, lightly flanged or not flanged at all. Your baby’s upper lip is either not flanged at all or lightly flanged. Some nursing parents attempt to flange the baby’s upper and lower lips after latching. This is unnecessary and often causes a good latch to become shallower. When your baby is latched deeply, it is usually difficult to see your baby’s lower lip because it is hidden by your breast tissue.
Treatment is often not necessary.
- As long as your baby’s latch is comfortable and your baby is drinking well, there is no need to adjust your baby’s lips.
- As long as the upper lip is able to form a complete seal, without clicking or slipping off the breast, then there is no reason to clip the potential lip-tie.
- Even with occasionally clicking or slipping, as long as your nipples are comfortable and your baby is drinking well, there is no problem.
If your healthcare provider feels that your baby’s upper lip-tie is tight enough that it is negatively affecting breastfeeding, your healthcare provider may suggest that it be clipped.
Some practitioners have begun to discuss ties between a baby’s cheeks and gums. These have been called ‘buccal ties’. There is no research on how to diagnose or treat these possible ties or the outcomes of treatment.
Contact a La Leche League Leader or International Board Certified Lactation Consultant (IBCLC) for information and support if:
- your baby is having difficulty latching or staying latched, and/or
- your nipples are sore, and/or
- your baby is not gaining weight adequately.
Mohrbacher, Nancy. (2020). Breastfeeding Answers: A Guide for Helping Families, Second Edition. Nancy Mohrbacher Solutions, Inc: p. 262-279.