Pediatrics; Your Pregnancy Matters
Feeding support and options to fix tongue-tie in babies
April 27, 2021
Tongue-tie might sound like an old wives' tale, but it's a real medical condition that affects 5 to 25 percent of newborns each year – a large range due to the many factors that can complicate getting a diagnosis.
But just because a baby has tissue under their tongue does not mean they will have feeding or speech implications. The functional contribution of the tissue is more important than whether there is extra tissue present. So, not all babies with a prominent frenulum are actually tongue-tied – and not all of them need intervention.
Babies with tongue-tie, or ankyloglossia, have extra tissue connecting their tongue to their floor of mouth which restricts the tongue motion. This can make it difficult for the baby to coordinate feeding.
While there is no strong evidence that tongue-tie affects speech later in life, the condition can cause problems such as:
- Abnormal growth
- Frustration for parents and baby at feedings
- Reduced breastmilk supply
Most new parents can help their babies overcome feeding challenges with lactation support and non-invasive therapies. In some cases, an in-office procedure called frenotomy can help free the tongue to move more efficiently.
Since so many factors can complicate infant feeding, most babies need the combined expertise of specialists who are trained in different aspects of infant oral health.
UT Southwestern brings together pediatricians, lactation consultants, speech therapists, and otolaryngologists (ear, nose, and throat specialists) to help families overcome feeding challenges in the first few months after birth. All of these providers work together to make sure the baby gets the best, most appropriate, and most timely care.
Let's discuss how we diagnose tongue-tie, when a newborn might need a procedure right away, and what we can do to help your baby feed and grow better.
Ruling out other feeding issues
Learning to breast or bottle feed is expected to be a little challenging for babies and new parents. There are many areas where little adjustments can make a world of difference.
So, babies who struggle with feeding can receive support from several different providers. The progression often goes like this:
- Lactation consultant: All patients who deliver at UT Southwestern have access to lactation consultants in the weeks after delivery. These experts can troubleshoot positioning and latching issues that might be keeping the baby from effectively feeding.
- Pediatrician: Your baby's doctor is an excellent resource for investigating feeding and growth concerns. If they think your child may have tongue-tie, based on a physical exam, the pediatrician may treat your baby before you even leave the hospital or in an outpatient setting. Depending on their experience and your baby's need, the pediatrician may refer you to a speech therapist or an otolaryngologist.
- Speech therapists: These experts can recommend stretching exercises to help coordinate the tongue, jaw, and cheek muscles, essentially retraining the mouth to feed.
With tongue-tie and feeding issues, timing is everything. The earlier we detect feeding issues, the easier it will be to correct them. If the baby cannot latch, even with the support of a lactation consultant, and the baby has a severe tongue-tie, we may recommend frenotomy before the baby leaves the hospital.
Some babies simply have trouble latching right away, but with ongoing lactation support, they will improve. Your care team will work with you to determine the safest and most appropriate next steps for your newborn.
These windows of time are key to successful tongue-tie diagnosis and intervention:
1. Within two to four weeks after birth.
When the breast milk supply is first established, there can be a "grace period" in which the milk starts flowing with less stimulation from the baby, and the supply is not highly dependent on demand. Even if the new baby's mouth mechanics are not great at extracting milk right away, the baby can "lap it up" if there is an oversupply of milk or a very active letdown. However, this is not a substitute for good feeding mechanics.
It's normal for newborns to spend a few days learning to nurse or drink from a bottle, but if you're still struggling after visiting with a lactation consultant, the baby may need to visit a speech therapist. The therapist can recommend tongue and mouth stretches.
2. Don’t wait too long to see an ENT.
We generally do the office procedure until about 12 weeks old. It’s true that by 10-12 weeks the milk supply is much more supply and demand-based, but intervention earlier than this would still make things a lot easier on mom, and if mom and baby are still struggling at 10 weeks there have probably been some growth issues.
What to expect at the otolaryngology visit
We will put together all the other specialists' recommendations and, after examining the baby and talking with you, create an overview of what is causing your baby's feeding problems.
We'll start by reviewing your baby's health history and feeding patterns:
- Was the baby a preemie?
- Any risk factors during pregnancy or delivery that may affect the milk supply?
- Do they suck, swallow, and breathe during feedings? Or do they tend to suck a long time without breaks to swallow (a sign they're not getting much milk)?
- Are they at risk for a condition that might affect muscle strength or coordination?
- Do they seem satisfied after eating?
- How long is a typical feeding session?
The otolaryngologist will check the baby's weight and how well they can suck on the doctor's gloved finger. We'll also check whether their tongue makes a massaging movement, which helps coax milk out of the breast or bottle. If the baby can move its tongue without restriction but is still having trouble feeding, frenotomy may not help. In those cases, we will refer you for more advanced speech or physical therapy.
For new parents
If you are breastfeeding, we'll also discuss your health history. Certain conditions, such as hypothyroidism or gestational diabetes – can decrease milk supply. We'll also discuss your stress level, your own eating and hydration routine, and whether you feel pain or discomfort while nursing.
If the issue is related to your health, we may recommend diet or medication changes to increase your breastmilk supply. You may need to consider supplementing with formula if your health makes breastfeeding too difficult. This can be disappointing for some parents, but remember, a fed baby is a happy baby. Whether your child is breast or bottle fed is not a reflection on your parenting skills or love for your child.
If the baby does have tongue-tie and other therapies haven't solved the issue, we may recommend frenotomy. Also called "clipping," this outpatient procedure can potentially improve tongue mobility and feeding success.
How we perform frenotomy
There are two widely used techniques for performing frenotomy: cold steel and laser. UT Southwestern otolaryngologists use the cold steel technique because, despite its name, it is gentler, causes the infant less pain, and bears fewer risks of complications, such as cysts or scarring.
When possible, we do this procedure at 14 weeks or sooner. After that point, the baby will likely be stronger with greater head control, and the procedure carries more risks.
Frenotomy takes only a few minutes and starts with a sweet treat. We typically do not use oral numbing medications in infants younger than one. Oral numbing and pain medication can be overactive in babies and can cause complications such as decreased oxygen levels and cardiac toxicity.
To avoid that risk, we follow the American Academy of Otolaryngology–Head and Neck Surgery recommendations to feed the baby a sugary liquid mixture. The sweet taste stimulates the brain to release "feel-good" hormones that help curb the minimal pain of the procedure without increasing the risk of complications.
Then, we use a small retractor with a groove in it to gently elevate the tongue, exposing the frenulum. We make a small cut in the frenulum, taking care to avoid the salivary gland ducts on the floor of the mouth.
The incision will go from the front of the frenulum to the back of the tongue, and we will know we have released the tie by confirming a diamond-shaped release in the floor of the mouth.. Separating the tissue allows for maximum tongue mobility. However, we don't cut the tissue all the way back. Instead, the doctor will gently separate the tissue with their finger, avoiding the risk of cutting into the nerves on the floor of the mouth and bottom of the tongue.
Then, the doctor will apply pressure to the incision to stop any bleeding. Next, the baby gets another dose of sweet liquid before we return them to you to feed. The suckling action of feeding comforts the baby and puts additional pressure on the incision site.
We'll observe the baby in the office for at least 15 minutes to ensure bleeding does not resume. While we wait, we'll go over a few exercises to do with the baby to minimize the development of scar tissue. It's best not to do these stretches at feedings – we don't want the baby to associate discomfort with eating, which can lead to further feeding challenges.
Listen now: Treating Tongue-Tie (backtableENT)
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A few closing thoughts
Moms and dads often blame themselves when feeding doesn't take off right away. But feeding problems are multifactorial, and most concerns can be resolved with expert support – no procedure required.
Seeking help when you need it is the best way to prevent long-term growth problems and reduce your frustration. Your pediatrician, Ob/Gyn provider, and lactation consultants will work with you to identify and overcome feeding challenges in your baby's first few months of life.
Our infant feeding team has the expertise to determine what's causing your baby's feeding issues. And if your child needs lactation support, speech therapy, or surgery, we'll guide you through the process and answer your questions every step of the way.
To discuss infant feeding concerns, call 469-497-2500 or request an appointment online.
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