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I cannot breastfeed my baby well, what can I do?
Difficulty in breastfeeding your baby can be due to factors affecting the mother and / or the baby. Both mummy and baby should see a lactation counsellor or a doctor to assess the breastfeeding. Mummy should be examined for breast or nipple abnormalities for example blocked milk ducts, or inverted nipples. The technique of breastfeeding should be assessed to see if the latch is deep enough. Often, different positions which mummy and baby find comfortable in, help to achieve a deeper latch. Your baby is finally examined to exclude abnormalities that impede breastfeeding for example, tongue tie, cleft palate.
I suspect my baby has a tongue tie. How do I know for sure?
The diagnosis is suspected if there are symptoms for example, nipple pain, prolonged breastfeeding time, “windy” baby etc. These happen because the baby’s gums chomp on the nipple when there is a loss of “cushioning” from a mobile tongue. The baby struggles to feed, and gulps in more air than usual. Tongue tie or ankyloglossia is often misdiagnosed, when the problem is actually with achieving a deep enough latch during breastfeeding. This should be confirmed by a doctor who is experienced in managing the condition. A mild tongue tie does not need any intervention, and improvement in breastfeeding technique often resolves the symptoms. A significant tongue tie presents with a firm ridge underneath the tongue on palpation and a shallow latch. The tongue tie is an excessively shortened tissue on the undersurface of the tongue, which impedes the mobility of the tongue. In severe cases, the tongue forms a heart shape when extended.
Does tongue-tie release help speech?
The development of speech is a complex one, comprising brain, hearing and neuronal connections development. Tongue tie plays a small role in the big picture. It is thought that the production of these alveolar (/t/, /d/, /s/, /z/, /n/, /l/) or palato-alveolar (/ʃ/, /ʒ/, /tʃ/, /dʒ/, /r/) sounds are inaccurate, because the movement of the tongue is impeded by the tongue tie.
Children have amazing adaptive abilities and may get around the limitation with speech therapy. Currently, there is insufficient evidence to show that a tongue-tie release helps speech in future1. In an older child, a speech therapist should assess and treat the child first before a tongue-tie release is performed.
When is the best time for tongue-tie release / frenulotomy?
After a lactation consultant has confirmed that the technique of breastfeeding is good and there is still difficulty with breastfeeding your baby, a paediatric surgeon or dentist may be consulted. I perform a tongue-tie release in infancy. In short term follow up studies, it has been shown to relieve nipple pain2, and hence achieve better breastfeeding. The World Health Organization recommends exclusive breast feeding for 6 months, and the best time to perform tongue-tie release is during this time, before giving up breastfeeding. The procedure is performed in the clinic without general anaesthesia.
When your child is older and uncooperative, the procedure needs to be performed under general anaesthesia, because it becomes harder to hold the child while the tongue-tie release is performed. When the child is cooperative, I perform the tongue-tie release under local anaesthesia. After the procedure, your child goes home on the same day.
What happens during a tongue-tie release / frenulotomy?
Topical anaesthesia is applied. A scissors is used to cut the tissue on the undersurface of the tongue. Blunt dissection achieves a wound which is diamond shaped. Minor bleeding is controlled with gauze and finger pressure. A laser achieves the same effect, but is a more expensive equipment which I don’t see a need to pass on the cost to my patient.
How is the recovery after a tongue-tie release / frenulotomy?
Minimal bleeding is expected and the baby should breastfeed immediately after the procedure, which helps to soothe him/her. After the tongue-tie release, the mother should feel breastfeeding is easier and less painful on the nipple.
For older children, I teach myofunctional therapy for the tongue after surgery. This may help to prevent recurrence due to scar tissue.
Does lip tie affect breast feeding?
Lip tie is a shortened band of tissue affecting the inner surface of the lip, and the upper lip tends to be more involved as compared with the lower lip. Currently there is no good evidence to suggest lip tie affects breast feeding3. I do not recommend a lip-tie release to aid breastfeeding.
Are there alternatives to a tongue-tie release?
Yes, monitoring for the spontaneous rupture of the tissue, or adaptation of the tongue to breastfeeding may occur with perseverance and time. It is important not to give up, because breastfeeding confers benefits to baby (for example, more immunity, less allergy), mother (for example, prevent breast engorgement) and improves bonding.
- Salt H, Claessen M, Johnston T, et al. Speech production in young children with tongue-tie. Int J Pediatr Otorhinolaryngol. 2020 Jul;134:110035.
- O’Shea JE, Foster JP, O’Donnell CPF, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database of Syst Rev. 2017;(3):CD011065.
- Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2020 May;162(5):597–611.
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