The lingual frenulum is a fibrous structure that joins the base of the mouth to the tongue. The tongue, in turn, is composed of 17 muscles that allow complex movements to perform these functions. It is a muscular organ involved in the functions of sucking, swallowing, chewing, breathing, and speaking. So what happens when the tongue’s movement is compromised? Today we talk about how the lingual frenulum, which is often referred to as a tongue-tie, affects breastfeeding.

The lingual frenulum has its origin in gestation. In the beginning, the tongue and the floor of the mouth are joined together, and during the embryonic stage, the tissues separate to form these separate structures. After birth, the lingual frenulum is the trace of this separation and is sometimes visible to observation.

For many years it was defined as a fold of tunica mucosa located on the underside of the tongue that connects the tongue to the floor of the mouth and allows the anterior part to move freely. This definition suggests that the lingual frenulum allows tongue protrusion (forward movement of the tongue, even pulling it out of the oral cavity). So the frenulum would be ruled out as a probable cause of breastfeeding problems affecting the mother-baby dyad when this movement is observed.

But following recent research contributed by Mills et al. in 2019, this frenulum is described as the “dynamic, layered structure formed by the oral mucosa and underlying fascia of the floor of the mouth, which mobilizes into a midline fold with tongue elevation and/or retraction.” It is an anatomical structure that can be visualized during tongue elevation and retraction.

This new definition suggests that the lingual frenulum allows not only the movement of protrusion, which is not physiological, because in none of the functions mentioned above is this movement necessary. It also allows the movements of elevation and retraction of the tongue. Thus, the observation and evaluation of the lingual frenulum should be performed with the tongue elevated and pulled towards the posterior part of the oral cavity.

The appearance of this frenulum can be varied since it can be thick, thin, short, or long, anchored to the floor of the mouth or in another area, and so on. But the main characteristic is that it should allow free movement of the tongue along its entire width. The lack of mobility due to the restriction exerted by the lingual frenulum is known as ankyloglossia (tongue-tie).

It is essential to be aware of the importance of reviewing the positioning, attachment, and latch in case of breastfeeding difficulties as one of the first things to be evaluated and to propose suitable modifications. If there is no improvement with these initial strategies, ankyloglossia may be suspected due to the presence of a limiting frenulum if other signs and symptoms are also present:

• Persistence of pain during breastfeeding
• Recurrent problems due to poor drainage of the breast (especially mastitis and obstructions)
• Infant presents low weight gain or weight stagnation
• Long breastfeeding sessions (beyond 60 minutes at each feed) or infant never lets go of the breast on their own
• Unusually frequently feeding
• Presence of hypogalactia or hypergalactia
• A sensation of gagging of the baby and/or clicking noises during breastfeeding

The detection of the sublingual frenulum is necessary to be able to make an overall assessment of breastfeeding. Too often, they are underdiagnosed. In the same way, a correct evaluation of breastfeeding technique, positioning, attachment, and latch should be carried out in case of any difficulty during the first months of breastfeeding.

References:

Mills N, Geddes DT, Amirapu S, Mirjalili SA. Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery. Int J Otolaryngol. 2020 Jun 28;2020:1820978. doi: 10.1155/2020/1820978. PMID: 32774383; PMCID: PMC7391099.

Campanha SMA, Martinelli RLC, Palhares DB. Association between ankyloglossia and breastfeeding. Codas. 2019 Feb 25;31(1):e20170264. doi: 10.1590/2317-1782/20182018264. PMID: 30810632.

Martinelli RLC, Queiroz I, Jordao R, Rodriguez AC, Berretin-Felix G. Histological Characteristics of Altered Human Lingual Frenulum. Int J Pediatrics and Child Health. 2013; 2 (1): 5-9. Available in: https://www.researchgate.net/