Tongue tie or ankyloglossia literally means tongue-tied or anchored. The tongue is anchored to the floor of the mouth, and the baby is unable to make the proper movements that should allow them to suckle effectively and without compromising the well-being of the mother.

Where is the short lingual frenulum (tongue-tie) located, and what is it used for?

The tongue tie should be inserted into the tongue. In the case of babies with a short tongue frenulum, we observe the frenulum further at the front, which means the tongue protrudes, and this can cause difficulties in sucking and swallowing for the baby.

Why does this happen?

Some theories point out that in the womb, during the separation of the hyoglossus and genioglossus muscles from the tongue, this occurs incorrectly (or is a genetic defect), leaving the frenulum outside the tongue and “tying” it to the floor of the mouth in an excessive way. This prevents protrusion movements, elevation, lateralization, and grooving.

All these movements are necessary so that babies can suckle pleasantly and effectively and so that, later, when starting complementary feeding and introducing solids, they can perform the movements necessary to salivate and swallow the food.

Recently, information has been circulating that the short lingual frenulum may be caused by excessive intake of folic acid during pregnancy. But there is as yet no scientific evidence to this effect, and it is also irresponsible to advise mothers against taking this supplement.

What happens these days, as there seem to be so many tongue-tied babies?

To begin with, we must not forget that breastfeeding is a matter of two, and on many occasions, a baby with a tongue-tie may not have difficulties in latching on, sucking, and swallowing the milk, nor may it cause pain or discomfort to her mother.

In recent years, more and more babies seem to have tongue-ties, but not all babies with breastfeeding difficulties have tongue-ties. It is true that many mothers who have difficulties in their breastfeeding journey end up discovering at some point that their baby was born with a tongue-tie.

Do all babies have tongue-ties?

Ankyloglossia is nothing new. What has happened is that, simply, this situation had been almost forgotten by healthcare professionals because of the appearance and generalization of artificial formula feeding as a way of infant feeding, the loss of breastfeeding culture, and low breastfeeding rates. In recent years, the implications of a tongue-tie have been scientifically resumed and studied. This has been possible thanks to several factors, such as greater research into sucking and the situations that compromise it, a return to breastfeeding culture, and an exponential increase in the number of mothers who breastfeed.

Is a type IV more serious than a type I?

When we talk about types of tongue-tie, we are not talking about their severity. This classification simply helps healthcare professionals to have a reference to agree on a common description and to understand what type of frenulum we are talking about.

• Anterior type I: insertion of the frenulum occurs at the tip of the tongue. When the baby cries, the tongue is heart-shaped or appears bifid as the frenulum pulls the tip of the tongue into the mouth.
• Anterior type II: insertion of the frenum occurs a few millimeters further back than type I. The tongue is not usually seen bifida, but when the baby cries, you can see that the tip of the tongue descends down.
• Posterior Type III: This type of frenulum, like type IV, has what we call a submucosal component. When the baby cries, visually, the tongue resembles a block, or the tongue rises from the sides and sinks from the center, creating a concavity.
• Type IV posterior: no frenulum visible. On the contrary, the tongue is completely anchored to the floor of the mouth. Like type III, a compact tongue is seen in the form of a block, and when the baby cries, the tongue is not raised.

What if our baby has one of these types of ankyloglossia?

It is important to point out that suffering from one type or another of ankyloglossia does not mean greater or lesser difficulty in breastfeeding. However, this classification allows us to understand what type of frenulum we are talking about. A short lingual frenulum can cause (or not) the following difficulties for the baby during lactation and in other areas of her life:

Ineffective latching, poor milk transfer, and compensated latch at the breast normally mean little weight gain and can cause the mother pain during breastfeeding, sore nipples, repetitive mastitis, and so on.
As the child grows, there may be poor dental occlusion and speech difficulties. These babies are usually mouth breathers, and this can cause inflammation of the airways: tonsillitis, pharyngitis, bronchitis, etc.

What to do?

A mother who has detected one of these types of tongue-tie wonders: should we always intervene? Valuing a short lingual frenulum as the only cause of difficulties is a biased vision; in the same way, checking only the baby’s latch and positioning alone is biased.

Thus, before intervening in the frenulum, it would be necessary to always review vital details for the proper course of lactation and assess the latch and the position of the mother to see if we can achieve significant improvements: mouth wide open with lips curled outwards, the nose and chin touching the breast, the mother and baby very close together, look for the alignment ear-shoulder-hip of the baby, try biological nurturing positions and keep a breast hold with the palm of the hand.

If, after all this, and with the help of an expert, IBCLC, or midwife, your difficulties do not improve, the next step would be to assess whether it is appropriate to intervene in ankyloglossia. As we have said, ankyloglossia can not only affect breastfeeding but can also have repercussions later on. With all the information in their hands, the parents should decide what they want to do: whether they prefer to intervene in the tongue-tie or not.

How are the tongue-tie interventions?

Types I and II are sectioned using a slight cut during day surgery. The surgeon protects the tongue with a grooved probe that leaves the frenum visible and makes a cut on it with blunt scissors. The cut barely bleeds, as the frenum is barely irrigated. Immediately after the cut, the mother breastfeeds the baby again.

Types III and IV require sedation, and for this reason, their interventions are performed in the operating room. The cut can be rhomboidal with scissors or an electric scalpel that cuts while cauterizing. In less than 10 minutes, everything is done, and the baby is returned to her mother to be breastfed. It should be noted that at the moment, in some areas, the type III and type IV tongue-tie begin to be operated on in consultation without the need to sedate the baby.

What happens after the operation?

Mothers may notice a different and less painful suction immediately after the operation. However, babies take some time to get used to and learn to breastfeed again, and sometimes, the improvement is not so evident. For this reason, it is vitally important in types III and IV to carry out post-operative exercises in order to avoid adhesions and the frenum reappearing.

Let’s remember

We could summarize that tongue-tie can cause difficulties in lactation and other disorders, so it is necessary for a specific evaluation of the baby’s tongue-tie in the mother/baby couple that presents obstacles to breastfeeding. When we observe a feed, we should go far beyond the simple verification of a good latch and a good posture since the tongue is one of the first motors of lactation and must function perfectly in order to achieve a pleasant and effective lactation for both the mother and the baby.

Do you have any other questions?

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