It's just a "little" tongue tie...

Maybe you are struggling with breastfeeding and someone suggested that your baby might have a tongue tie.  You immediately go to your doctor or lactation consultant to find out if this is the cause of your problems and they tell you the tie is little and you don't really need to do anything about it.  But they don't have any answers for the problems you've been having.  What to do?  You go to a support group or get a second opinion and these providers then tell you it's a quite obvious tie.  How confusing is that?!?  What does all this mean? In order to answer this question we need to discuss what a tongue tie is and we need to understand what the tongue is supposed to do during normal infant feeding at the breast.

Our typical anatomy includes tissue that holds the tongue to the floor of the mouth.  This tissue is called a frenum or frenulum.  When that tissue is too short, inelastic or located in a position that interferes with normal, expected, and necessary range of motion then it is considered a tongue tie.  This means then that the mere existence of the frenum is not a problem.  Seeing one in a mouth does not mean it is tied.  To only look at a frenum and diagnose it one way or the other is to not take into consideration it's impact on the tongue's range of motion and function, or ability to do the things a tongue needs to do, like support talking, feeding, swallowing and airway development.

When the tongue has good range of motion it rests in the roof of the mouth any time we are not talking or eating. That pressure of the muscular tongue in the roof of the mouth encourages the infant's narrow palate to widen which over time allows the floor of the sinus to lower creating a patent or unobstructed sinus airway.  In addition, the jaw structure widens to allow for optimal room for teeth to come in without being cramped.  When the roof of the mouth or palate is high and arched it also can contribute to inefficient nursing due to the extra height in the infants mouth and the inability of the breast to be compressed appropriately and effectively between the tongue and the roof of the mouth.

During breastfeeding the infant has reflexes that allow for the tongue to extend out past their lips to "reach" for the breast.  The tongue then wraps its outside/lateral edges around the breast to grasp ahold and draw the breast tissue into baby's mouth.  The upper lip and tongue together  create the seal on the breast which contributes to comfortable and efficient milk removal.  When the tongue has grasped enough breast tissue the nipple placement is quite far in the back of the mouth gently touching the roof of the mouth. This then triggers another reflex that causes the baby to begin to suckle. During suckling,  the front, middle and back sections of the tongue all moving independently of one another in a smooth, coordinated wave-like motion.  This wave like motion "milks" the milk out from the ducts towards the nipple deep in the baby's mouth.  When the back part of the tongue elevates and then proceeds to move downward a vacuum is created that efficiently extracts the milk out.

When the tongue frenum is short, inelastic or located in a way that limits the tongue's range of motion, breastfeeding can become compromised.  Some frenums are very obvious; when baby cries or tries to stick their tongue out there is so much tension from the frenum underneath that it causes pulling on the tongue resulting in a divot, indentation, central groove in the tongue or even a heart shape in the front center.  Often times these babies cannot even latch on to a breast or if they can it hurts the parent.  Some frenum lengths or positions allow for some of the necessary range of motion and not others.  For instance a baby may be able to stick their tongue out far enough to grasp the breast and draw it into the breast to the right place but the back of the tongue is restricted in mobility and it cannot elevate to the roof of the mouth or when it does the frenum from the underside is pulling it back to the floor of the mouth with a force strong enough to break any suction that existed often causing a clicking noise.  When the suction breaks it can be very tricky for baby to feed efficiently.  Many babies then get tired at the breast long before they are full.   In addition to the above examples there are many other ways that tongue ties can present, numerous symptoms for both mother and baby and some are more subtle in how they show up so be sure the providers you trust with your care are knowledgable, experienced and qualified to assess for oral function.

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"Some tongue tied babies absolutely can feed at the breast with minimal symptoms."

Guess what?!?  Some tongue tied babies absolutely can feed at the breast with minimal symptoms.  And that can make properly diagnosing tongue ties tough for medical providers who don't have extensive training and experience in assessing and evaluating infant feeding at the breast.  The compensations that exist that allow a tongue tied baby to feed with minimal symptoms usually change over time.  So if your provider doesn't know to look for all the different compensations, they could miss how the non symptomatic tongue tie can become troublesome down the road. For instance, an abundant milk supply can more than make up for poor function in the early days.  But a few months later when milk production is down regulated and soley based on what baby gets out, it can become difficult for that baby to get enough to eat which further impacts milk supply.  

​Often when a worried parent shows up at a physicians office concerned about a tongue tie, if the provider sees a little frenum they tell parents, "Oh, it's just a little tie, nothing to worry about.  But they fail to assess how the frenum is impacting the tongue's complete range of motion.  A provider who is well versed in infant feeding at the breast and oral function will do a comprehensive assessment that includes a visual and physical exam of the baby's mouth and entire body looking at the intricate interplay of parts that allow full range of motion, function, comfortable and efficient and effective breastfeeding.  A frenum must be examined through the lens of what it can do not just what it looks like. ​
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How a provider refers to a tongue tie is everything.  So if someone tells you it's little, ask more questions.  

• Do they mean it is short? (which is actually a very restrictive tongue tie!) 
• Do they mean it is barely there?  
• Do they mean it is little enough to hardly impact breastfeeding? (Are they a breastfeeding professional with extensive training in the field?)  If so, do they have answers for why you are struggling?
  
• Or do they mean it is little enough to not worry about its implications on feeding, speech, dentition and airway development? (Are they a Speech Language Pathologist, a dentist, a functional orthodontist other airway provider?) 

Ask for them to provide you with resources and links and adjunctive providers.  And then seek second opinions from other providers. This is not to say you don't believe the first provider- this is simply how you arm yourself with info to make fully informed decisions about the care of your baby, their optimal development and protecting your breastfeeding experience.  And in the end, run all the info through your head, your heart and your gut.  Are your personal and family philosophies resonating with the professional information and guidance you are being provided?

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"A frenum must be examined through the lens of what it can do, not just what it looks like."

A "little" tongue tie causes restricted tongue movements and that can have a BIG impact on breastfeeding.  Think of it like this: a "little" ding in a car door does not impact the use of the vehicle.  But a "little" hole in a tire will absolutely make it trickier to drive the car.  ​​The word "little" means very little without enough context.  

​What is your story of tongue tie?  How has it impacted you, your baby or someone you know?