Identifying tongue-tie in infants & three steps to better support breastfeeding

I attended a really interesting masterclass by Babyem recently, led by Sarah Oakley LBCLC & Tongue-Tie Specialist, on identifying tongue-ties, assessing feeding efficiency and better supporting those that want to breastfeed.

A tongue-tie can cause a whole heap of problems when it comes to breastfeeding, for both Mum and baby. Symptoms of a tongue-tie are varied, multifaceted and often overlapping with other feeding challenges, meaning they are often misdiagnosed – both over and under.

Your midwives, maternity support workers or health visitors are rarely sufficiently trained to diagnose a tongue-tie, but they can refer you to a LBCLC (Lactation Consultant) and/ or tongue-tie practitioner. Alternately, as your doula, I can signpost you to these services and information on tongue-ties, the symptoms and impact of one. I do not pretend to have adequate training in breastfeeding, and am unqualified to diagnose a tongue-tie myself, but I have a fascination and passion for breastfeeding and supporting those that want to do it.

Nipple Pain

One of the most common symptoms and impacts of a tongue-tie is nipple pain – but nipple pain does not necessarily means a baby is tongue-tied, and a tongue tied baby does not necessarily mean a Mum will experience nipple pain.

So let’s first look at how a tongue-tie can cause nipple pain: 1) Restriction in extension (tongue doesn’t extend beyond the bottom lip enough) - this can mean the tongue isn’t cushioning the gums so it can feel like the nipple is being bitten or ground; baby can’t draw in enough breast tissue to latch deeply and effectively which leads to nipple pinching; or baby struggles to keep the tongue over the bottom lip leading to slipping or clicking; 2) Restriction in elevation which can prevent baby managing the milk flow effectively - they may adopt a shallow latch (causing nipple pinching) to slow down the flow or they aren’t draining the breast adequately so they use cheek/lip/jaw muscles to better extract milk which causes too much suction, causing pain - both can also lead to milk supply decreasing and is exacerbated if mum has an over or under supply, or a fast or slow let down; 3) Tension in the jaw – this can lead to a narrow gape and shallow latch causing nipple pinching - mum may state that baby won’t open their mouth wide enough, that their mouth is too small or their nipple is too big.

Then lets look at how/ when a tongue-tie may not be painful: 1) A baby can be tongue-tied and still be able to extend their tongue over the bottom lip to cushion the nipple, but may slip off often; 2) A fast flow, oversupply or ‘fire hose’ let down means baby doesn’t need to work to get the milk. However, often after the first couple of weeks as Mum’s supply regulates the let down can slow and supply reduce so symptoms of a tongue-tie emerge later; 3) A weak suck may not cause pain but when baby gets bigger and stronger the tongue-tie symptoms may start to emerge; 4) Some mum’s have a higher pain threshold, ‘tougher’ nipples or just ‘get used to it’.

And why else a Mum may experience pain, if baby isn’t tongue-tied: 1) Poor positioning or attachment – most common; 2) Bacterial infection if the nipple is cracked and/ or bleeding, or fungal infection such as thrush – particularly if Mum and/ or baby had antibiotics during labour or shortly after birth; 3) Raynaud’s/vasospasm – a circulatory problem causing pain, throbbing and burning after a feed - often Mum’s with this have a history of problems in their fingers/ toes as a result to changes in temperature etc; 4) Skin condition such as eczema or dermatitis; 5) Allergic skin reactions – for example to disposable breast pads or nipple cream; 6) Jaw and/ or neck tension can also be a result of uterine positioning or birth trauma (such as forceps/ ventouse delivery); 7) Paget’s disease – a rare type or breast cancer affecting the nipple and causing a red, scaly rash.

Feeding Efficiency

Nipple pain is just one negative outcome of a tongue-tie, it can also affect feeding efficiency. Inefficient feeding leads to baby having especially long or frequent (because they fall asleep after 5 minutes of feeding) feeds - this is often most obvious in the evenings when milk supply is at its lowest - which exhausts Mum and cannot be sustained; it may mean baby does not get enough milk so is hungry (and therefore unsettled), experiences slow weight gain and failure to thrive, which in turn leads to a reduction in milk supply and an exacerbated problem. Alternatively, if baby cannot control the flow of milk to slow it down they may take on excess wind (causing colic symptoms) or excess milk (causing reflux symptoms), or can experience coughing, spluttering or choking on milk – this can be particularly evident in the morning when milk supply is at its highest. Other outcomes could include baby developing sore or blistered lips because they are using their lips to hang-on to the breast or Mum experiencing engorgement (after the first few days when engorgement is considered normal), blocked ducts, mastitis or abscesses because the breast is not being drained effectively.

Your care providers will be looking at the following to help them assess feeding efficiency: frequency and colour of nappies (yellow is normal, green is not), weight gain, feeding patterns (duration, number in 24hrs), babies temperament, mum’s comfort, a ‘deep’ latch, rhythmic jaw movement, evidence of swallowing, sucking pattern (stimulation, nutritive, or comfort), suck to swallow ratio (1-3 sucks per swallow), length of sucking bursts before a pause and whether baby starts again on their own accord, if baby is falling asleep at the breast, are they coming off satisfied and settled for a while, is the breast soft after feeding.

However, signs of inefficient feeding are not necessarily linked to tongue-tie – “varied, multifaceted and often overlapping!” Other factors which could be leading to inefficient feeding include: low milk supply (which could be caused by postpartum haemorrhage, retained placenta etc), babies with low muscle tone (babies with down syndrome often have low muscle tone for example), heart defects, born premature, of low birth weight, with neurological or developmental issues, laryngomalacia or cleft palette.

Managing Flow

As discussed, a tongue-tie can cause babies to struggle to manage milk flow, if it’s coming too fast they may develop a shallow latch (and cause nipple pain) or take on too much wind/ milk leading to colic and/or reflux symptoms; and if it’s too slow they may use excess suction (causing nipple pain) or not take on enough milk leading to hunger, slow weight gain etc. Signs that a baby is struggling to manage flow include: gulping, coughing, choking, or dribbling milk during a feed, particularly if this continues throughout the feed and not just after the initial fast letdown, ‘backing off’ or shallow latch, coming off the breast and fussing either during a feed or at the beginning, pulling and tugging at the breast, tiring at the breast, a suck to swallow ratio higher than 3:1, needing to burp during a feed or vomiting significant amount after a feed.

But, as ever, there are other factors that could be causing the baby to struggle to manage flow. These include positioning or attachment (laid back positions can help baby manage a fast flow), ineffective seal (maybe due to poor positioning), overactive let down, over or low supply, prematurity, low muscle tone, neuro-developmental disorders which affect the suck, swallow, breathe coordination or laryngomolacia.

In summary – breastfeeding is extremely complex! It is marketed as ‘the most natural thing in the world’ but it can be hard work, and it often requires professional support in order to establish and maintain. A poorly resourced NHS and insufficient Infant Feeding Support exacerbate these challenges, it can difficult to know how and where to find the support you need and you may be faced with long wait times for appointments with Lactation Consultants and Tongue-Tie Practitioners. In the Kent Doula Collective we are constantly chatting about who provides what service, and how our clients can access this support. As your doula I bring some knowledge and training on the above issues, and other areas of infant feeding, but more importantly I know where to go should you need further support. So get in touch :)

Doula Bea x