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Tongue-tie occurs when tongue movement is restricted by the presence of a short, tight membrane (known as the lingual frenulum) that stretches from the underside of the tongue to the floor of the mouth. This strand of tissue is visible when the tongue is lifted and is a normal part of the anatomy. However, when it is short, tight, and inelastic, extends along the underside of the tongue, or is attached close to the lower gum it will interfere with the normal movement and function of the tongue and is a tongue-tie. The baby has difficulties building up a good vacuum during the feed as well as emptying the breast efficiently due to the malfunction of the tongue. It is more common in boys and around 10-20% of babies will be born with a tongue-tie.

Recently the knowledge about tongue-tie has increased and luckily the number of midwives, doctors, Health Visitors, and nurses who are able to diagnose or at least suspect a tongue-tie is growing, although there is still a big room for improvement and it is not standard practice to check or treat them in the hospital after birth.

There are a few ways of classifying tongue-ties, we grade them into Grade I-IV or in percent, 25-100%, depending on the location of the frenulum attaching from the underside of the tongue to the gumline or floor of the mouth. Some forms of tongue-tie are very easy to diagnose and simple to spot, other variations require skilled assessment as they are often embedded and need to be diagnosed by a professional trained in diagnosing and treating tongue-ties.

Some signs of tongue-tie in mums are painful feeding, cracked nipples, misshapen, white nipples, painful latch and engorged breasts, recurrent blocked ducts, mastitis.

Baby's symptoms can be: a white membrane visible under the tongue when crying, a heart-shaped tongue, inability to open their mouths wide, tongue mobility is restricted, slow weight gain, clicking sound during feeds, sucking cheeks in, gulping and spluttering, very windy and colicky, screaming after feeds, fussy on the breast, sliding off during a feed, needs repositioning, dribbling down the side of the mouth and others, reflux, spitting up.

The criteria for treatment are feeding difficulties. If the mother has received breastfeeding support and correcting latch and positioning don't have enough effect then surgical treatment as soon as possible is advisable. This will help mothers to continue breastfeeding instead of switching to formula.

Some bottle-fed babies also require treatment. Restricted tongues have the inability to build up a vacuum. Those babies often dribble while feeding and are often very unsettled because they swallow a lot of air. Many babies cough, splutter, and choke on the bottle as the limited mobility of the tongue doesn’t allow for managing the milk flow. The milk flows unhindered towards the back of the throat, which leads to choking.

Tongue ties can have long-term consequences. It can lead to difficulties weaning onto chunky foods, as the tongue can’t move the food around the mouth. Many tongue-tied babies are being fed finely pureed food and struggle to drink from a cup. Speech problems can occur due to limited tongue movement. Orthodontic issues due to restricted jaw growth can lead to overcrowding and crooked teeth. Many adults with untreated tongue-ties will report problems with TMJ pain, clicky jaws, snoring, and mouth breathing.

The tongue-tie procedure is usually performed without anaesthetic up to 1 year of age, (varying between services and experience of the practitioner) and is usually very well tolerated. The baby is swaddled and head and shoulders need to be held to minimise movement. The frenulum is cut with sharp, blunt surgical scissors. There should be minimal bleeding and it is encouraged to breastfeed the baby straight after that for comfort but also so that the tongue can press down on the wound. Complications such as prolonged bleeding or infections are very rare (1:10000) and most babies recover and heal very well. If the baby is older than 2 months it is permissible to give paracetamol before and after the procedure, it may not be necessary.

Aftercare includes keeping the site very clean, do not let the baby suck fingers that haven't been washed thoroughly with soap, if the baby uses a dummy or bottle, make sure it is sterilised.

Massaging the wound several times a day to prevent the regrowth or reattachment of the frenulum can potentially help but there has not been any scientific proof for or against it yet. There are some exercises that will encourage tongue movement and need to be done 4-5 times a day for 3-4 weeks. Making sure a deep latch is practiced after the procedure is a good way to keep the tongue moving. Unfortunately, about 2-4% of the cases will reattach and will have to be re-revised if the symptoms return.

Dr Sharon Silberstein

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