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The Mild Tongue Tie

"Baby has a "mild" tongue tie but it's too small to cause any feeding problems."
"Baby has a "slight" tongue tie but it doesn't need treating".

I meet so many parents who have been told this, it seems to be popular at the moment.  Parents I meet because of feeding problems; problems that are of course not being caused by that "mild tongue tie". Except they are...

Babies who might have reflux, colic or wind because they are either unable to make or maintain a deep enough latch at the breast/bottle, spending their entire feed sucking in air.

The resulting symptoms can be wide and varied, complicating diagnosis further.  Some feed constantly, other sporadically; some reflux, vomit, spluttering or gulp, bobbing on and off when the milk ejection reflex (let down) is triggered or the bottle is tipped.  If baby can't organise co-ordinate their sucking and breathing fast enough, this is often misdiagnosed as "fast let down" or that baby needs a slower teat (even if you have a 4 month old still only able to cope with a newborn flow).

Some are told as their baby can protrude their tongue, it isn't restricted enough to cause problems; without considering that "pulling tongues" is really quite different to opening your mouth wide and brining your tongue forward to feed; or that you also need life and sideways function as well as extension.  Others are told the tie isn't impacting after barely a cursory look in baby's mouth, or a quick sweep under the tongue.

The other BIG problem with simply having a quick peek in a baby's mouth, is you can often confirm whether a frenulum is restrictive, but it's much harder to confirm insignificance the same way.  In order to do so you have to piece together the signs and symptoms, watch the baby at the breast/bottle, assess their suck and what the tongue is actually doing during the feed.  If there are significant indicators, a specialist who is competent lifting the tongue is needed to complete the picture.

Furthermore we need to understand the presence of a frenulum doesn't equal a tie, it's only if the frenulum is restrictive it's classed as tied.  Therefore a mild tie is a "mild restriction" - but we need to define what classification system is being used.

Why?
Because problems caused by tongue tie, aren't caused by how the tie looks, but about how it allows the tongue to function (or not), and looks can be deceptive.  A tie can be like a super thin wire, or slightly wider and diaphanous but still visually "tiny"; yet if it is tightly holding the tongue it doesn't matter if it's super thin or a more chunky number.  Furthermore a tie can look insignificant from the front, but when assessed properly, one can find the frenulum runs back down the tongue, getting thicker and causing significant restriction further back.

To feed effectively the tongue needs to not only be able to protrude, but also needs to be free to move laterally in a co-ordinated fashion, plus it needs to elevate and undulate in a wave like motion to pull milk across and swallow effectively.

How can you possible confirm if baby can do all those things with a glance?

Anther myth is people generally consider ties right on the tip of the tongue to be the "most severe", those nearer the back "insignificant".

Whilst cosmetically this may be the case, a tie anywhere down the tongue can significantly impede function, without causing any dramatic visual changes such as a heart shaped tongue.

Regardless of where the tie is, a baby will still compensate with an alternative tongue action, which may (or may not) lead to nipple trauma for mum and ineffective milk transfer for baby.  They may still fail to make a seal at the breast, pulling, slipping or gradually working their way back to a shallow latch - does that sound less significant to you?

10 comments:

  1. Oh boy, had you only written this post six months ago!

    My LO was checked by 2 midwives, a paed and a GP, none of whom picked up on her tongue tie. She had all of the 'symptoms' you describe - inability to cope with my letdown, awful wind and hence frequent feeds; I didn't know what was wrong as we'd been told she wasn't TTed. After 10 weeks I finally found a list of symptoms and decided it just had to be a tongue tie. Luckily my HV is amazing and got me to a consultant within 2 days who discovered that she HAD had a TT but it had somehow self released. There is still a residual tie but after another 3 weeks or so she re-learned how to feed effectively and is fine now.

    It was NOT an easy time. Honestly I thought I was going a bit mad as she seemed to have all the symptoms yet who was I, a mere mum, to go against four medical professionals?

    Cursory checks are all well and good but we needed examining in more depth I think. You make, as always, excellent points.

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  2. *sigh* My daughter had a "mild" tt, and no one would clip it. She had a weak suck and a shallow latch, but no one would clip it. She had a heart shaped tongue and still no one would clip it!! We had to do suck exercises, and manually stretch her frenulum, and it still took months before her suck was strong enough for her to start gaining well. She's 15mo now and thankfully we have overcome many of the difficulties from her tt, and she is still going strong with breastfeeding...but she STILL needs it clipped!!

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    1. Hi Christine, I've not had tt diagnosed but I'm suspicious. When my son feeds he is only swallowing for a few minutes after a letdown when the flow is fast then sucks lightly without swallowing until another letdown increases the flow. He has a very high palate. His weight gain has slowed from normal to below normal going from 75th to 25th centile in 5 months. Does this sound familiar? Who have you asked to clip it?

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  3. Excellent article. My LO had a so-called mild tongue tie but we were having problems with nursing. I insisted they do a frenulotomy and my momma instincts were right on. 2 hours after the procedure he latched on like a pro and we've never looked back.
    On another note: one thing many medical professionals seem to ignore is the possibility of speech development problems later when some of these mild ties are left untreated.

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  4. I got told by my health visitor that my little girl has a tongue tie when she was 5 months old. We have been breastfeeding for 6+ months now and she's been thriving on it. She's also weaned on some solids now and is good with purees, lumpy purees and fingerfoods.

    However I've noticed she has a 'heart-shaped' tongue. She can't stick her tongue out very far and never licks the corners of her mouth (which I've been told by the Health Visitor I should encourage by putting food in the corners of her mouth, but she doesn't do anything with that). Should I expect any problems in the future? Or does the fact that she's always been feeding well and now eats well, mean she is just fine?

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  5. Once again you hit the nail on the head. Mine couldn't maintain a deep latch, shredded my nipples and bottle feeding was a total disaster with most of the milk lost to dribbles out of the sides of her mouth. "No tongue tie" my foot.

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  6. Anon 1 - that would depend who you ask. If baby is feeding/eating well, you would struggle for a rationale for division. But if she has so little lateral movement she cannot clean the corners of her mouth, it also means she cannot use them to clean her bottom teeth (or lick lips after a doughnut - or anything else that requires good tongue protrusion/lateral movement). Some people believe with exercises a frenulum can be stretched, whilst others believe this isn't so.
    I believe with protrusion issues the main speech sounds to keep an eye is"th" (lots replace with "f" ie think = fink) because "th", often in the middle of a word when it is harder to co-ordinate the tongue quickly.
    AA

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  7. Thanks for your wise words! I will talk about it with the Health Visitor again and see how we go from there!

    Anon 1

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  8. my little man is 16 weeks. He makes lots of clicking and spluttering noises as he feeds, he latches on and off a lot, feeds a bit better when 1/2 asleep and lying down, pukes up entire feeds at times. The latch looks ok from the outside -lower lip turn out and cheeks look normal, movement of ears etc. It looks like he has quite good tongue mobility, he can stick it out and shake it all about. I don't nkow how much mobility is needed towards the back but there is no obvious lack of movement. Feeding doesn't hurt me as he feeds but I do ssem to get sore more often than with other babies -a few bouts of thrush and 2 nasty cracks so far. He's gaining weight very well. I'm tandem feeding with his older brother so I suppose there is quite a lot more milk than I would have for one baby. He copes better when the flow is slower than during let down. We've had a LC have a look and the PHN. Both thought TT was not an issue. We've been feeding comfortably for a few weeks now -just the clicking is a little odd! Should I be looking to have him examined further for TT? Who would do that? Would it even need to be resloved when the difficulties we are having are minor at this stage?

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  9. Really interesting to read this. My son had a 'mild tongue tie' and I had conflicting advice from various medical professionals. The MW at the breast-feeding support group I went to said that it needed cutting, so I went to my GP - who said that they 'don't do that here'. I had such a nightmare with feeding - can remember sobbing in agony trying to feed him. After about 10 weeks things finally settled down. I'm sure it was the tongue tie though. Especially after reading this article.

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