For families struggling on their breastfeeding and infant nutrition journey, they are often faced with the question “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 breastfeeding, 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 appreciate 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 fibres 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 breast. In a similar way, a baby’s lips can be attached to it’s 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 breastfeeding 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 breastfeeding challenges.

How and why does it affect breastfeeding?

Babies who are “tongue-tied” may have problems affecting a secure latch to the breast. While they may compensate, temporarily, by recruiting their face and jaw muscles, this may cause nipple damage and pain. Breastfeeding parents may appreciate blisters on the infant’s lips and/or a clicking sound during feeding representing a loss of suction or a baby may simply detach from the breast or leaks milk from the mouth. In some cases, a baby may not able to attach at all. Sometimes, if milk supply is plentiful the infant “lives on the letdown,” he or she may be labelled “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 breastfeeding parent, the inability to drain the breast effectively can lead to lowered milk supply and recurrent plug ducts and/or mastitis. And despite what patients are told, breastfeeding 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 as skilled, comprehensive assessment to determines 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 independent of each other. Further, various medical communities have varying beliefs regarding the validity of oral restrictions and it’s impact of breastfeeding. 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 left many families to seek care outside of our city or outside the socialized medical model.

On the converse, the medical community in Calgary has long been more supportive of the diagnosis of ankyloglossia and the acknowledgement of its impact to breastfeeding. Calgary has four independent breastfeeding clinics which work closely with each other. As a result, ample educational opportunities are provided to medical learners and it was here, Dr. MacGregor received her early training. Further, in 2019, Alberta Health Services Calgary Zone developed a guideline for assessing infants with suspected oral restrictions. This guideline sadly 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. Further, she is currently participating in a research study with Dr. Alison Hazelbaker and the University of Calgary to further this area of research. 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 encourage a review off the most recent evidence for and against this diagnosis and its impact on breastfeeding, this summary may be helpful.

Treatment

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.

Dr. MacGregor 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 after care instruction in the form of hands-on support, handouts and videos and timely follow up visits.