Sarah was desperate. Her three-week-old baby Tom was unsettled and squirming at the breast, and because he wasn't sucking well, she had been topping him up with formula so her milk supply was rapidly diminishing. She had seen a paediatrician who told her Tom had behavioural problems and she was feeding him too often; her baby health nurse had told her she needed to learn 'tired signs' because her baby was over-stimulated.
But it turned out nobody had watched Sarah actually feed her baby. Tom had a very disorganised suck. He kept sliding off the nipple, and he was making clicking noises and gulping in air because he couldn't get a good seal. Milk dribbled out of the corners of his mouth whether Sarah was breastfeeding or topping him up with a bottle.
When she came to see me, I checked Tom's mouth to assess the mobility of his tongue. He couldn't poke his tongue beyond his bottom gum, and when I rubbed his gums at the side of his mouth, instead of his tongue following my finger, his tongue tipped sideways. When he cried, Tom's tongue formed a 'trough' anchored in the middle and curled up at the sides – he couldn't raise his tongue up to the roof of his mouth.
Tom had a posterior tongue tie that was restricting the movement of his tongue, making it almost impossible to latch and feed effectively.
In some babies, like Tom, the little membrane called the frenulum which joins the middle of the tongue to the floor of the mouth, is too tight. This 'ties' the tongue so the baby has difficulty moving his tongue effectively. It means the baby will be unable to bring his tongue forward far enough to latch onto the breast and to draw the nipple far enough back into his mouth to feed well. If the baby's tongue is restricted it won't create an effective peristaltic action, rippling from the front of the tongue to the back, efficiently drawing out milk and maintaining milk flow.
If a baby has a lip tie, the frenulum on his upper lip will restrict movement so he won't be able to flange his top lip as he feeds.
Feeding and tongue ties
Tongue and lip ties make feeding very tiring for babies. They can't form a tight seal on either a breast or bottle, so milk will often dribble from the side of the baby's mouth as he feeds. Sucking may be noisy with clicking or 'snapping' back on the nipple as he slides off and grasps again while feeding,
Babies with this, whether breast or bottle fed, can be hungry and have poor weight gains because feeding is so exhausting they may fall asleep while feeding. These babies often suck in air as they feed, leaving them very unsettled. They may be diagnosed with reflux that doesn't respond to medication because the underlying cause is air swallowing due to a poor latch.
They are also often referred for sleep training when the pain and crying is a symptom of the tongue tie that has not been addressed.
And although Sarah didn't experience painful feeds (most likely because Tom wasn't actually attaching) babies with tongue and lip ties can cause severe pain for their mothers as they breastfeed: the baby may latch onto the nipple, and 'gum' or chew it, causing severe pain, and, eventually, nipple damage such as blanching (white nipples), cracks and grazing that can sometimes be followed by infection or mastitis.
Elle, mother of two-week-old Mia, had severely damaged nipples but had been dismissed by health professionals because to them, her baby's latch 'looked fine'. "I was told my nipples would 'toughen up'," she says.
But this is not how breastfeeding is meant to feel. Even if the latch 'looks fine,' if your nipples hurt or look 'squashed' after a feed (Elle's nipples were cracked and bleeding, as well as squashed like the point of a lipstick after Mia fed), seek help. After treatment, Mia latched deeply and Elle was able to breastfeed pain-free within days.
Not all babies with tongue tie have immediate or obvious feeding problems, although there are often 'clues' that something isn't right. According to Mel, mother of Poppy, 14 months, "My daughter fed like a trooper from the start." Mel had no pain while breastfeeding – until Poppy cut her first two top teeth. As Poppy fed, Mel felt as though she was pinching, and her nipples were left with deep dents where Poppy's teeth rested.
As Poppy started eating family foods, she gagged on meat, and couldn't suck out of a straw or sippy cup. When the next two top teeth came through, feeds became even more painful. One day Mel thought perhaps Poppy had some food in her mouth and tried to check under her top lip, but couldn't flange Poppy's lip. That's when she noticed the frenulum between Poppy's top teeth, and called me to see me.
It turned out that Poppy had an upper lip tie and a posterior tongue tie. Since having these revised by a dentist who uses laser, Poppy can drink from a straw, she eats well, is starting to talk and, best of all, she started sleeping much better.
Looking back, Mel now sees signs that all wasn't well – although Poppy was thriving, she fed frequently day and night, she was prescribed reflux medication which didn't really help, and when offered a dummy, it always slipped out of her mouth.
Other symptoms - and the solution
Tongue-tie is often hereditary – if either you or your partner had a tongue tie (you may have had your frenulum snipped as a baby), there's a higher chance your child will also have this condition. Often I will find a baby with tongue tie and then discover that one of the parents' own mothers had difficulty breastfeeding and, on checking, it turns out the parent also has a tongue tie.
Often there will also be stories about speech therapy or intensive dental work when this parent was a child. It's not just breastfeeding that can be affected by tongue or lip ties; difficulties can happen when the child starts eating solid foods, and speech can be affected (think Jamie Oliver).
Tongue and lip ties can also affect dental development, from misaligned teeth due to improper palate and jaw development, to tooth decay due to not being able to use the tongue to remove food stuck on the teeth.
Children and adults with unrevised tongue ties can also develop sleep apnoea - and some of the delightful pleasures of life, like licking an ice cream and kissing, can be affected. Social interactions can include problems such as spitting or dribbling excessive saliva when talking.
A tongue tie can be easily fixed by seeing a doctor or dentist who will either snip the frenulum or use a laser to revise it (the younger the baby, the easier it is). You will be able to feed your baby straight away and you may be surprised how much more easily your baby feeds – and sleeps – after the procedure.
Pinky McKay is an internationally certified lactation consultant and best selling baby care author of Sleeping Like a Baby and Parenting by Heart. She is also the creator of Boobie Bikkies, all natural and organic cookies to boost breastfeeding mothers' energy and support a healthy milk supply. Download Pinky's free ebook Making More Mummy Milk, Naturally at boobiebikkies.com.au