Tongue Tie (Ankyloglossia) and Its Treatment
Tongue tie (otherwise known as ankyloglossia) is when the tip of the tongue is anchored to the floor of the mouth. Tongue tie may extend all the way to the tip or it may extend partially to the tip resulting in a partial tongue tie. There is also a condition called upper lip tie which is when the upper lip is stuck to the gumline as well as posterior tongue tie in which the tongue tie is hidden under the tongue lining.
- Trouble with breast-feeding
- Swallowing problems
- In toddlers, speech difficulties with sounds requiring a mobile tongue tip (sibilants and lingual sounds)
- In teenagers and adults, unable to "French Kiss". More on adult tongue ties here.
Regardless whether dealing with a newborn or an older child/teenager, the treatment is the same. But when it comes to newborns, tongue tie can lead to feeding problems which can be quite distressing to both child and mother.
With tongue tie, the tip of the tongue is unable to help the infant draw the nipple into the mouth. It also prevents the tongue from being normally positioned between the nipple and lower gumline leading the infant to chew on the nipple. Ouch! Watch video to see how the tongue affects breastfeeding. Watch an ultrasound of an infant breastfeeding to see exactly what is going on in real-time.
Normal Breast Feeding
Tongue Tie Preventing Infant From Drawing Nipple Fully Into the Mouth
Treatment is recommended ONLY if the tongue tie is causing a problem. If no symptoms are exhibited, one does not need to pursue any treatment unless there is a concern for future inadequate milk supply.
Treatment itself is fairly straightforward. If the child is less than 12 months of age, it may be possible to perform in the clinic under topical anesthesia only. If between the ages of 1-12, sedation in the operating room is generally performed as the child is usually uncooperative (needs to keep mouth open AND tongue still). >12 years of age, the procedure can be performed in the clinic as long as the patient is fully cooperative.
In our office, tongue tie releases are most commonly performed using a
Steps to procedure:
The tongue tie is visualized and topical lidocaine is applied using a Q-tip. Depending on the age and how thick the tongue tie is, injection of numbing medicine may also be performed.
The tongue tie is clamped across for about 10 seconds. Care is taken to clamp above the salivary duct openings (Wharton's duct), but below the body of the tongue.
This maneuver crushes the blood vessels closed so when the cut is performed, minimal bleeding occurs.
The clamp is released and scissors (or
That's it! This whole procedure usually takes no more than a few minutes.
Click here to see some pictures of what the wound looks like after the procedure.
After the procedure, tylenol or motrin alone (if even that) is enough for pain control if > 6 months. Infants < 6 months do not typically require anything, but coconut oil, Hyland's Teething Gel, or Orajel Naturals (not regular Orajel) may be applied for pain control. Rarely, if tylenol or motrin needed, dosing chart below.
No antibiotics are needed unless formula fed only. Active bleeding (if occurs) typically stops within 15 minutes. There may be a drop or 2 of blood that may sporadically appear in the area for the next few hours as well as after stretches for a few days.
Breast-feeding may immediately be resumed. In the older child, avoid foods that require biting with the front teeth (apples, carrots, etc) which would cause the food to dig into the surgical site. Stick with soft foods for about one week. After that, a normal diet may be resumed.
It is not unusual for a white eschar to appear along the cut edge. Do not worry if this happens. It is just a scab that is wet (recall what a scab looks like on your hand if you get it wet... it turns white). It will disappear in about 1-2 weeks.
Stretching exercises 5x per day for the first 2 weeks can also be performed to prevent reattachment. Stretching exercises mainly entails pushing the tongue up towards the roof of the mouth while pinching the wound closed (lift method). The motion is analogous to a forklift. The upward pressure should be exerted for about 2 seconds each time. Once a day, sweep a finger under the tongue to assess for reattachment due to scarring. If scar reattachment starts to occur, instead of the lift method, resort to the push method which entails pushing a finger over the wound towards the back of the mouth (this may temporarily choke/gag the infant).
I also encourage all parents to follow-up with a lactation consultant within a week after the procedure. Good lactation consultant practices local to our office include:
• Premier Lactation Services (provides private home visits, weekend visits, and free phone consultations)
• Angela Love-Zaranka, IBCLC, RLC
• INOVA Loudoun Lactation Center
• Julie Oswald, IBCLC as part of Whole Child Pediatrics
• Fauquier Health Lactation Consultants (540-316-4011)
Click here for more information about posterior tongue tie and its treatment.
Post-procedure instructions can be downloaded here.
If your baby has a tongue tie, please contact our office for an appointment.
Posterior Tongue Tie
There is a relatively uncommon and under-diagnosed type of tongue tie known as submucous tongue tie (or more commonly known as "posterior tongue tie" among lactation consultants).
This condition is when the tongue tie is hidden UNDER the mucus lining of the tongue/mouth. You can't see this type of tongue tie, but you can feel it if you run the finger underneath the tongue from side to side where the tongue tie would be. One would feel a tissue band (speed-bump sensation with finger sweep) where the tongue tie would be.
In the picture to the right, green is where the normal tongue tie is located causing restricted tongue motion denoted in light green. Posterior tongue tie is shown in blue which restricts tongue motion denoted in light blue.
High Palate and Upper Lip Tie
Sometimes, even if the tongue tie is released (whether anterior or posterior), breastfeeding problems may persist. Ignoring maternal factors that may be present, the most common reasons why breastfeeding problems may continue afterwards are due to an upper lip tie and/or high palate.
More info on upper lip tie can be found here.
However, regarding the high palate, this issue is when the roof of the mouth is positioned higher than normal. Given the elevated position, the tongue has to raise much higher than normal in order to compress the nipple against the roof of the mouth. Even if the tongue tie is released, the tongue may STILL have trouble elevating high enough to effectively breastfeed in such infants. Although tongue tie release may still be helpful, outcomes are not as good or as predictable. If you take a look at the image below, the red arrow points to a normally positioned palate/roof. In infants with a high palate, the palate/roof may be positioned in a higher location where the orange line drawn.
Unfortunately, there's no good simple way to address breastfeeding difficulties in such infants who have a high palate if tongue tie release does not help. Typically, the next best step is to work with a good infant feeding specialist (SLP) and/or infant occupational/physical therapist. In the Northern Virginia area, I typically suggest seeing:
• Deborah Kotin, SLP in Leesburg, VA (703-858-6667)
Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 9/19/16. DOI: 10.1002/lary.26306
Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol. 2015 Jul 31. pii: S0165-5876(15)00368-7. doi: 10.1016/j.ijporl.2015.07.033.
The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):827-32. doi: 10.1016/j.ijporl.2013.02.022. Epub 2013 Mar 22.
Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeed Rev. 2015 Mar;23(1):11-6.
Evidence of improved milk intake after frenotomy: a case report. Pediatrics. 2013 Nov;132(5):e1413-7. doi: 10.1542/peds.2012-2651. Epub 2013 Oct 7.
Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul;122(1):e188-94. doi: 10.1542/peds.2007-2553. Epub 2008 Jun 23.
Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7. doi: 10.1016/j.earlhumdev.2007.12.008. Epub 2008 Feb 11.
Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999 Apr;30(4):259-62.
Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013 Nov;29(4):458-64. doi: 10.1177/0890334413491325. Epub 2013 Jul 2.
Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad. PEDIATRICS Vol. 110 No. 5 November 1, 2002 pp. e63 (doi: 10.1542/peds.110.5.e63)
Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000 Jan;126(1):36-9.
Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: a prospective cohort series. Breastfeed Med. 2014 Nov;9(9):438-41. doi: 10.1089/bfm.2014.0040. Epub 2014 Sep 19.
Tylenol and Motrin Infant Dosing Chart
For Tylenol (may give every 4 hours, but no more than 5 doses in 24 hours): Infant and Children's liquid tylenol are identical in concentration. Suppositories also available by prescription.
6-11 Pounds --> 40 mg which is 1.25 ml (1/4 teaspoon of infant liquid Tylenol)
12-17 Pounds --> 80 mg which is 2.5 ml (1/2 teaspoon of infant liquid Tylenol)
18-23 Pounds --> 120 mg which is 3.75 ml (3/4 teaspoon of infant liquid Tylenol)
12-17 Pounds --> 50 mg which is 1.25 ml (1/4 teaspoon of infant drops)
18-23 Pounds --> 75mg which is 1.875ml (1 syringe of infant drops)
24-35 Pounds --> 100mg which is 2.5ml (1/4 teaspoon of infant drops)
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