This month, I would like to clarify our policy on tongue and lip ties, as it is a topic that causes a great deal of anxiety for our mothers. For those of you that don’t know, a tongue tie, also known as “ankyloglossia, is a condition present at birth that restricts the tongue's range of motion. With a tongue-tie, an unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue's tip to the floor of the mouth, so it may interfere with breast-feeding. Someone who has tongue-tie might have difficulty sticking out his or her tongue. Tongue-tie can also affect the way a child eats, speaks and swallows.” [1] A lip tie, which isn’t even mentioned on many reputable websites, “is an unusually tight labial frenulum, which keeps the upper lip tethered to the gum line. Tongue and lip ties often occur in tandem, are more common in boys than girls, and tend to run in families.”[2]
You can see pictures of both ties on many websites. Parents often search the web to compare their baby’s anatomy to what they see online. If Mom is having difficulty breastfeeding, the next step is usually to see a lactation consultant and get an opinion regarding whether a tie exists. This is where things get tricky for us, as we are nurses and lactation consultants. We are not physicians. We cannot diagnose. That is not part of our Standards of Practice, Code of Professional Conduct or Scope of Practice.[3] That being said, most of us have enough experience to notice a tie immediately. However, what is most important, is that a qualified doctor assesses the function and mobility of both the lip and tongue. RN/IBCLCs help with that process by assessing the breastfeeding relationship and providing doctors with the information they need to determine if further evaluation is necessary.
I’d like to explain my approach to breastfeeding support where this is concerned. I want to start by admitting that I do not routinely assess any of the babies I see for a lip or tongue tie. Other excellent LCs that I know do this at the start of every evaluation, with a gloved finger. They visually assess both the lip and tongue frenulum and then check the movement. I don’t, and I honestly don’t know which is the preferred course of action. Some parents want it checked out immediately with a thorough exam and are grateful for the information. Others find it invasive and feel we are looking for problems before even seeing the baby nurse. If you have an opinion one way or another, please let us know at the outset. Our goal is always to give you the information you need to breastfeed your baby in a way that is comfortable and works for you.
When I am working with a family, I am looking to see if I can help Mom nurse comfortably, have the baby transfer an appropriate amount of milk, and ultimately gain weight consistently. If these things are all happening, regardless of what the baby’s lip and tongue look like, I see no need for further evaluation. I have seen many babies with lip and tongue ties nurse beautifully, with no intervention needed, and I prefer a wait and see approach. However, if I can’t help Mom to nurse pain free, the baby appears to be nursing fine with a great latch, but isn’t transferring milk, or isn’t gaining week to week, an evaluation is in order. The evaluation needs to start with the baby’s pediatrician. I will let the doctor know what I am seeing in the office and why I think a tie might be the cause. Pediatrician’s then refer to an ENT doctor or a pediatric dentist for an evaluation and potential repair. ENT’s use scissors or scalpel for the repair. Pediatric dentists use a laser. There are also great speech and occupational therapists that assess babies’ lip and tongue movement and teach exercises to parents to help stretch and strengthen the lip and tongue both before/after/in place of the procedures. In addition, craniosacral and chiropractic therapy often help babies oral movement in a way that facilitates successful nursing. Regardless of what route families choose to go, we like to take a collaborative approach to work with the pediatrician to help families get the assistance they need.
Sometimes, I don’t see any issues with a tongue/lip tie until the baby is over a month old. The baby nurses pain free, transfers a good amount of milk, and is gaining well when I initially see them. However, sometime after 3 weeks, when the baby goes through a growth spurt and Mom’s breasts are no longer engorged, the baby stops gaining. Mom feels like the baby is nursing, but that the breast isn’t drained. At the one-month checkup, the pediatrician catches the slow or no gain, and hopefully assesses the baby’s oral anatomy. At that point they will refer to an LC to assess the breastfeeding or an ENT/pediatric dentist. Please keep this in mind if you have difficulties further down the road. We are happy to see you again and help you figure it out.
Lastly, I have had issues months after seeing a baby, when I receive a call from a very upset mother, stating that 5 months later, someone (rarely a doctor) has told her that her baby has a tongue tie. She is furious with me, for not diagnosing it when I saw her. Fortunately, I can look back at my charting, and remind the Mom that all was well when I saw her. She was nursing pain free and the baby was thriving. Have things changed, I will ask? Sometimes they have, dramatically, but Mom didn’t call me. Sometimes they haven’t, and everything is fine. Either way, it takes me back to my three steadfast pieces of advice. First, remember that the health care professional you are seeing is making an assessment based on what they are seeing and the information you are giving them at that moment in time. Especially in the beginning, this changes daily, and follow up is so important if you are having difficulties. This is why families are often given different information daily with their newborn, because both Mom’s body and baby’s abilities are changing. Second, if things aren’t going well, advocate for yourself and your baby. Keep seeking help until you get the assistance you need. And lastly, trust yourself. You know your baby better than anyone, and if you think something is off, it probably is. Conversely, if things are going well, and someone tells you there is a problem, look at the big picture. Are you nursing pain free? Is your baby pooping and peeing? Gaining weight? Having periods of sound sleep? And is this week better than last week? If you can say yes to all these questions, you are doing great! If not, give us a call. We can help you figure it out and assist you in getting the evaluations/support you need to solve any problem you encounter.
