Families struggling on their lactation & infant feeding journey often ask, “does my baby have a tongue and/or lip tie?”
Sometimes, this question is prompted by a health care professional and in other cases, dedicated parents researching the cause of their concerns. While this is an important diagnosis to consider in the differential of abnormal feeding, it is only one small piece of the puzzle. Unfortunately, many families do not have access to a skilled health care provider with the appropriate training to review, summarize and discuss their individual clinical picture and the most up-to-date evidence. Further, there is a shortage of medically trained providers in Edmonton who can complete a comprehensive assessment and perform the procedure (frenectomy), if indicated, without cost to the patient.
It is my hope that the below short summary will provide some clarity as families navigate this complex area of care in our community.
Doesn’t everyone have tissue under the tongue?
If you lift up your tongue, you are likely to find a small band of tissue connecting it to the floor of the mouth. However, for some, it is tight or restricted by the type or length of collagen fibers present, causing discomfort, limitation in elevation or inability to stick the tongue out. It is hypothesized this occurs due to a failure of soft tissue division or apoptosis during fetal development. In infants, if these tissues are restrictive, it can impact the infant’s ability to latch to the feeding. In a similar way, a baby’s lips can be attached to its gums in a tethered fashion. Together, these restrictions make it difficult for an infant’s mouth to grasp a nipple, create and/or maintain suction while nursing and can limit the transfer of milk or prevent the use of a bottle or a pacifier.
Tongues and lips are only considered “tied” if their movement and function is restricted. It is important to note that many people have very prominent frenulums which do not cause problems for themselves or the feeding parent, and for others, significant dysfunction is noted despite the frenulum being less prominent. These subtle frenulums are often the oral restrictions “missed” by care providers in the context of feeding challenges.
The below video provides a comprehensive discussion of oral restrictions and may be helpful for families as they learn about oral restrictions and the impact to feeding
How and why does it affect feeding?
Babies who are “tongue tied” may have problems making a secure latch to the feeding/bottle. While they may compensate, temporarily, by recruiting their face and jaw muscles, this may cause nipple damage and pain. Parents may notice blisters on the infant’s lips and/or a clicking sound during feeding, indicating a loss of suction, or a baby may simply detach from the breast/chest or leak milk from the mouth. In some cases, a baby may not be able to attach at all. Sometimes, if milk supply is plentiful, the infant “lives on the letdown.” They may be labeled “colicky” or diagnosed with “reflux” as they are exposed to high lactose milk predominately and/or a significant amount of air while feeding. For the feeding parent, the inability to drain the breast/chest effectively can lead to lowered milk supply and recurrent plugged ducts and/or mastitis. And despite what patients are told, feeding should never be painful or result in trauma. Mild tenderness in the first few days is acceptable but anything outside this is pathologic and requires a skilled, comprehensive assessment to determine its cause.
Diagnosis
As mentioned above, diagnosis of an oral restriction can be challenging. Often, health care providers are unable to appreciate the relationship between function and appearance and the need to assess both independently of each other. Further, various medical communities have varying beliefs regarding the validity of oral restrictions and its impact on feeding. For instance, Northern Alberta, inclusive of Edmonton, has long been considered a medical community that did not support this diagnosis regardless of the most recent research and the acknowledgement of this diagnosis by the World Health Organization. This has led many families to seek care outside of our city or outside the socialized medical model.
Conversely, the medical community in Calgary has long been more supportive of the diagnosis of ankyloglossia (tongue tie) and the acknowledgement of its impact on feeding. Calgary has three independent feeding clinics that work closely with each other. As a result, ample educational opportunities are provided to medical learners and it was there that Dr. MacGregor received her early training. Further, in 2019, Alberta Health Services Calgary Zone developed a guideline for assessing infants with suspected oral restrictions. Unfortunately, this guideline has not been formally adopted in Edmonton. Despite this delay, Dr. MacGregor is committed to evidence based medicine and has adopted it in her own practice. Dr. MacGregor is not only committed to improving the quality of care in her own city but is committed to working with local and world leaders in this field. To continue the tradition of collaborative training and expand the number of skilled providers in Edmonton, Dr. MacGregor mentors physicians, dentists and midwives in this skill.
To encourage a review of the most recent evidence for and against this diagnosis and its impact on feeding, this summary may be helpful. Further, this video discusses the impact of tongue mobility on functions other than feeding and nursing.
Controversy
Unfortunately, many patients experience fragmented care when they seek help for their infant feeding and lactation concerns. While they may obtain a frenectomy they often lack appropriate support pre and post procedure to meet their feeding goals and/or resolve their feeding and lactation challenges. Many families referred to our clinic, unfortunately, may have experienced;
Inappropriate timing of a previous frenectomy, failing to take into account the child and parent’s other concerns like feeding aversions, growth challenges, lack of secondary feeding options, torticollis and head shape concerns, and/or parental mental health challenges.
The tool used to complete a previous frenectomy (laser, scissor, scalpel) may not have been appropriate given the severity of restriction or other challenges present. The provider may have taken too much or too little tissue to be effective or scarring and thermal injury may have resulted. Oral aversion are not uncommon in this setting.
The care provider(s) could not speak to the nuances of infant physiology and development nor had the ability to transition a family towards normal physiologic feeding or support the limitations of the infant-parent relationship following the procedure.
In December 2023, the New York Times published an article, “Inside the Booming Business of Cutting Babies’ Tongues” highlighting the many challenges experienced by families who obtain inadequate and fragmented care. While the stories featured in this article are unfortunately often true, the article and author was remiss to not include stories of the transformative benefits of frenectomy; when provided by skillful provider who can offer well timed, complete, trauma-free procedural intervention and support of the other medical and psychological concerns associated with feeding and lactation challenges. A response to this article can be found here. The team at Willow Family Medicine is committed to ensuring families receive continuous, collaborative and comprehensive care and are able to discuss the above article and the concerns highlighted with patients one on one during their visits.
Procedure
If indicated, Dr. MacGregor performs lingual (tongue) and labial (lip) frenectomy. She is trained in release of both “anterior” and “posterior” restrictions; however, this is an outdated diagnostic criteria. This procedure is provided at no cost with Alberta Health Care and is completed with scissors. While these issues are often suspected prior to a visit, to ensure appropriate diagnosis, a successful outcome and a timely workflow, a full intake assessment will be completed regardless of suspicion. If frenectomy is appropriate, infant and parent return for a shorter appointment within 7 days. To ensure the provision of thorough, evidence-based care, no exceptions to this policy will be made. A post procedure visit is scheduled 3 to 10 days after the procedure.
Wound Care
Our team recommends post frenectomy wound care to reduce the risk of reattachment. When done correctly, this care is respectful, gentle and non-invasive. To support families and reduce worry during this time, we provide comprehensive aftercare instruction in the form of hands-on support, handouts and videos and timely follow up visits. Please click here for more information.