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 it 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 short tongue frenulum we observe the frenulum in an anterior position, i.e. the tongue protrudes, and this can cause difficulties in sucking and swallowing the baby.
Why does it happen?
Some theories point out that in embryonic stages and 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, which prevents protrusion movements, elevation, lateralization and grooving.
All these movements are necessary so that the baby can suckle pleasantly and effectively, and so that, later, when starting complementary feeding can perform the movements necessary to salivate and swallow the digestive bolus.
Recently, information has been disseminated that the short lingual frenulum may be caused by excessive intake of folic acid during pregnancy. There is as yet no scientific evidence to this effect, and it is also reckless to advise mothers against taking it.
What’s with the short braces these days?
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 have no difficulty latching on, sucking and swallowing the milk, nor may it cause pain or discomfort to his mother.
However, in recent years, apparently all babies have tongue-tie and is the devil. In reality, not all babies have to experience this difficulty, although it is true that many mothers who have difficulties in their breastfeeding end up discovering that their baby was born with tongue-tie.
Do all babies have tongue-tie?
Ankyloglossia is nothing new. What has happened is that, simply, this situation had been almost forgotten because of the appearance and generalization of formula as a way of infant feeding, the loss of the culture of breastfeeding and the low rates of breastfeeding. In recent years, the implications of a tongue-tie have been scientifically resumed and studied, and this has been possible thanks to several factors, such as greater research into sucking and the situations that compromise it, a return to the culture of breastfeeding 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 we are not talking about severity, types help us to have a reference and to have 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 millimetres 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 centre, 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, a priori, 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 to the baby during lactation and in other areas of his life:
Ineffective latching, poor milk transfer, compensated grips at the breast which normally mean little weight gain and can cause the mother pain during breastfeeding, cracks, repetitive mastitis…
As the child grows, there may be poor dental occlusion, 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 biased vision, in the same way that it is to evaluate only the baby’s grasp and latching.
Thus, before intervening in the frenulum, it would be necessary to always review vital details for the proper course of lactation, assess the grip and the position of the mother to see if we can achieve significant improvements: mouth wide open with lips evertidos, 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 grasp postures, keep the breast grasped with the palm of the hand…
If after all this, and with the help of an expert, IBCLC or midwife, the difficulties do not improve, the next step would be to assess whether it is appropriate to intervene 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, it should be the parents who decide what they want to do: whether they prefer to intervene the tongue-tie or not.
How are the tongue-tie interventions?
Types I and II are sectioned using a light ambulatory cut. 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.
The types III and IV some require sedation and, for this reason, their interventions are performed in the operating room. The cut can be rhomboidal with scissors or with an electric scalpel that cuts while cauterizing. In less than 10 minutes everything is finished and the baby is returned to his mother to be breastfed. It should be noted that at the moment, in Barcelona, the type III and type IV braces 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.
We could summarize that tongue-tie can cause difficulties in lactation and, a posteriori, other disorders, so it is necessary a specific evaluation of the baby’s tongue-tie in the mother/baby couple that presents obstacles in lactation. When we observe a feeding, 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.