Tongue-tie and upper lip-tie

 

What is tongue-tie?

Tongue-tie occurs when the thin piece of skin under the baby's tongue (the lingual frenulum) is very short and restricts the movement of the tongue. The tongue is not free or mobile enough for the baby to attach properly to the breast. Tongue-tie occurs in about 5% of people. It is three times more common in males than females and can run in families.

Some babies with tongue-tie are able to attach to the breast and suck well. However, many have breastfeeding problems, such as nipple damage, poor milk transfer and low weight gains in the baby, and recurrent blocked ducts or mastitis due to ineffective milk removal.

What is an upper lip-tie?

An upper lip-tie is where a piece of skin under the baby’s upper lip (the labial frenulum) is very short or thick and is pinned too tightly to the upper gum. This can restrict movement of the upper lip preventing it from being able to flange or ‘pull out’. This can make it difficult for babies to attach to the breast correctly as it is harder for them to maintain a good seal. In older children and adolescents, an upper lip-tie can be associated with a gap between the front teeth. Generally this is only a cosmetic issue. However, it can make it difficult for a baby to breastfeed.

Upper lip-ties are often associated with a tongue-tie.

Why is a tongue-tie a problem for breastfeeding?

A baby needs to be able to cup the breast with his tongue to be able to remove milk from the breast well. If the tongue is anchored to the floor of the mouth, the baby cannot do this as well. The baby may not be able to open his mouth wide enough to take in a full mouthful of breast tissue. This can result in ‘nipple-feeding’ because the nipple is not drawn far enough back in the baby’s mouth and constantly rubs against the baby’s hard palate as he feeds. As a result, the mother is likely to suffer nipple trauma.

There are many signs that a baby’s tongue-tie is causing problems with breastfeeding, but you don’t have to have all of them:

  • nipple pain and damage
  • the nipple looks flattened after breastfeeding
  • you can see a compression/stripe mark on the nipple at the end of a breastfeed
  • the baby keeps losing suction while feeding and sucks in air
  • the baby makes a clicking sound when feeding
  • the baby fails to gain weight
  • the baby cannot poke his tongue out beyond his gum or lips
  • his tongue cannot move sideways
  • the tip of his tongue may be notched or heart-shaped when he cries
  • he may readily gag
  • the tip may look flat or square instead of pointed.

Why is an upper lip-tie a problem for breastfeeding?

If a baby has an upper lip-tie, he is not able to flange his lips out over the breast to obtain a good seal. He may slip off the breast easily, as he gets tired. A good seal is important if he is to breastfeed as effectively.

Diagnosis of tongue-tie or upper-lip tie

Australian Breastfeeding Association counsellors are not medically trained and cannot assess whether or not a baby has a tongue-tie or upper lip-tie.

If you suspect your baby has a tongue-tie or upper lip-tie that is causing breastfeeding problems, you may wish to contact a lactation consultant or other experienced health professional. They will be able to assess your breastfeeding and check your baby’s mouth to see whether the tight frenulum needs to be released.

Treatment for tongue-tie or upper-lip tie

If it is deemed that a tongue-tie or upper-lip tie is interfering with breastfeeding, then release (snipping) of the tight frenulum can improve the baby's ability to breastfeed.

Snipping a tight frenulum in young babies is a simple procedure that takes only a second or two. No anaesthetic is needed. The baby usually breastfeeds straight after the procedure. The mother will often notice a difference in how the baby breastfeeds, but it can take up to 2–3 weeks for a complete improvement to be made. Breastfeeding straight away also helps to stop any slight bleeding, distracts the baby from any discomfort and acts as an analgesic.

Mothers’ stories

Breastfeeding was uncomfortable and not quite what I expected. I had seen my sister and friends feed before but not really taken much notice. My baby was taking over an hour to feed and I was sore. After leaving hospital it went from bad to worse, with my nipples eventually cracking and bleeding.

Then a child and family health service midwife told me that my baby was tongue-tied and booked her in the next day to have it fixed. As scary as it was to see my 3-week-old have this procedure, I was grateful that there was a solution.

The very next feed after her ‘snip’ was like heaven. It confirmed that I was doing it right. We have now gone on to have a fantastic feeding relationship. Breastfeeding is the most rewarding experience ever and, 9 months later, I don’t want to stop.

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For the first 3 ½ months of my second son’s life, I couldn't breastfeed him sitting down because as soon as he was on the breast he would wriggle around and cry arching his back, so I got used to breastfeeding standing up jiggling and rocking to try calm him and get as much as possible into him before he refused the breast. He would only ever sleep upright in the sling during the day and would wake every 1–2 hours at night and it took a lot of effort to get him to go back to sleep. Despite all this, he was growing well.

We just became resigned to the thought that he was our colicky baby and that was that. We managed by taking turns to settle him at night and we carried, carried, carried him upright all day.

One day I came across an article in the Australian Breastfeeding Association’s Essence on 'upper lip-tie' with photos of the condition. I had known about 'tongue-tie' and knew what difficulties it could present for breastfeeding, but hadn't heard of 'upper lip-tie' before. It was basically the same problem but with the top lip unable to 'flange' or turn out to get an effective seal or mouth full of breast.

I could see that my second son didn't have 'tongue-tie', but by seeing the photos of this 'upper lip-tie' something clicked. My second son had it! It was so obvious. I had thought that his gummy smile was funny looking right from birth but didn't think there was anything in it apart from the fact he was toothless.

I called my ABA counsellor and explained what had been going on the past 3 ½ months and with her help, within a week and a half of realising this 'upper lip-tie' could be causing or attributing to our breastfeeding woes, he had a laser procedure to fix it.

My second son recovered very quickly — no pain medication, or antibiotics, or stitches. And, within days his breastfeeding technique improved, he would feed to sleep and he also managed to sleep on his back.

References

  1. Brodribb W (ed), 2012, Breastfeeding Management in Australia. 4th edn. Australian Breastfeeding Association, Melbourne.
  2. The Royal Women’s Hospital 2008, Tongue-tie: information for families. The Royal Women’s Hospital, VictoriaAustralia.  
  3. Geddes DT, Langton DB, Gollow I, Jacobs LA, HartmannPE, Simmer K 2008, Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 122:e188–e194.
  4. Buryk M, Bloom D, Shope T 2011, Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics 128(2):280–288.

Websites

NHS National Institute for Health and Clinical Excellence – Division of ankyloglossia (tongue-tie) for breastfeeding

Tongue-tie – from confusion to clarity

Unicef UK– Tongue tie and breastfeeding 

American Academy of Pediatrics - Congenital Tongue-tie and its impact on breastfeeding

Academy of Breastfeeding Medicine protocols – Ankyloglossia (currently under revision) 

© Australian Breastfeeding Association Reviewed March 2013