January 29, 2024

Tongue tied: How a small piece of tissue can affect your baby's feeding and sleep

Tongue tie facts & information | Symptoms and effects of ties | When to seek help | Little Ones™ Sleep Article

By Jess Torrisi

Who knew a tiny piece of attached tissue could cause so many issues with a baby’s feeding and sleep? I certainly didn’t know this when I had my first baby and often think about how our experience might have been different if someone had mentioned the possibility of a tongue tie.

Although awareness of tongue ties has improved since then, there is still a lot of misinformation out there and unfortunately there are still a lot of parents receiving poor advice regarding their baby’s feeding difficulties.

In this article we want to shed some light on tongue ties, including some common symptoms to look out for, the impact that tongue ties can have on your baby’s feeding and sleep and where you can seek help if you think your baby might have a tongue tie.

Firstly, what exactly is a tongue tie?

A tongue tie (or ankyloglossia) is a congenital anomaly where the piece of tissue that connects the tongue to the base of the mouth (lingual frenulum) is either too short or too tight and restricts the movement of the tongue. Congenital means present from birth, however, the symptoms of a tongue tie may not be immediately apparent. For breastfed babies in particular, symptoms can start to become more noticeable around the 3 month mark when milk supply is no longer controlled by hormones and becomes more about supply and demand (1).

Why am I just hearing about this now?

Historically, tongue ties have been recorded as being “snipped” by midwives as early as 1697. Midwives were still performing this procedure, with surgical scissors or sometimes with a swift nick of a fingernail, up until the 1940’s. However, as infant formulas and bottle feeding became more popular from the 1950’s onwards, the recognition and treatment of tongue ties became less common.

In more recent years, the World Health Organisation has recommended that parents exclusively breastfeed for the first 6 months and then continue breastfeeding until 2 years or beyond. For a baby with oral restrictions like tongue and lip ties though, this is no easy feat! As a result, many parents have experienced difficulties breastfeeding their babies and the awareness and treatment of tongue ties has started to grow again.

What are the signs and symptoms of tongue ties?

There are many different ways that a tongue tie can present, depending on your baby’s age, the severity of their oral restriction and whether you are breast or bottle feeding. Your baby might exhibit just one or two of these signs or if their restriction is quite severe, you might experience all of them!

Signs to look out for during/after feeds:

poor latch

clicking noises whilst feeding

falling asleep while feeding

taking a LONG time to feed (45 minutes+) or excessive cluster feeding

frequent feeding through the day and/or night (less than 3hrs between feeds)

fussiness and arching away from the breast

reflux symptoms

excessive trapped wind

inadequate weight gain or that horrible term “failure to thrive” (NOTE: this isn't always an indication and many babies with tongue ties can still gain weight well due to feeding more frequently)

Breastfeeding parents may also experience:

pain while breastfeeding

squashed, cracked or bleeding nipples

recurring blocked ducts or bouts of mastitis

difficulties with let down (due to baby’s poor latch or weak sucking)

difficulties maintaining milk supply

Signs to look out for during sleep:

difficulties settling and sleeping on their back (due to reflux/wind)

reliance on feeding to sleep or using a pacifier/dummy to settle to sleep

waking early from naps (often in the first 30 minutes)

waking frequently overnight (every 1-2hrs or even more!)

mouth breathing or snoring

How can a tiny piece of tissue cause all of these issues?

Image sourced from friscokidsdds.com/breastfeeding-tongue-tie-lip-tie/

When the tongue is at rest, it should be touching the roof of the mouth, rather than resting on the bottom. When your baby is feeding, they will drop their tongue over the lower gum to take the breast/bottle into their mouth and once they have latched, the tongue will lift up to the roof of the mouth, creating a vacuum effect. This is what helps to draw the milk out of the breast/bottle and the vacuum also helps to ensure they take in minimal air while feeding (2).

Babies with a tongue tie can have difficulty maintaining a deep latch on the breast/bottle, which means they lose that vacuum effect and take in excess air while feeding. This can then make them quite uncomfortable or in some cases can cause reflux symptoms, as the excess air forces the milk back up the esophagus.

Even with a good latch though, many babies with tongue ties will thrust their tongue forward while sucking, rather than lifting it to the roof of their mouth and this too breaks that vacuum effect. This means they have to work much harder to transfer milk from the breast/bottle. As a result, some babies will get tired or frustrated and give up on the feed before they are actually full, meaning they are going to be genuinely hungry again 1 to 2 hours later!

If your baby isn’t feeding well or is uncomfortable in any way, this is then going to have an impact on their sleep too. Trapped wind or reflux can make it hard to settle your baby in their bed, or it can cause them to wake up uncomfortable 10/20/30 minutes after you put them down. If they are getting hungry again every 1 to 2 hours then this is also going to disrupt their naps during the day and their sleep overnight.

How is a tongue tie diagnosed?

Awareness of tongue ties has come a long way in the past decade but unfortunately not all providers are current in their knowledge or understanding of how oral restrictions can impact feeding and sleep. As a result, some babies with tongue ties will go undiagnosed or will be misdiagnosed with other conditions like colic or reflux.

If your baby is exhibiting any of the signs mentioned earlier in this article, regardless of their age or whether you are breastfeeding or bottle feeding, the first thing we would recommend is seeing a lactation consultant (IBCLC) for a full evaluation of their feeding. They will be able to assess for oral restrictions, and help with correct latch and positioning.

It’s important to note that a diagnosis of tongue tie or ankyloglossia should not be based solely on appearance. The function of the tongue needs to be thoroughly assessed (3). Some babies and children can have a shorter frenulum and yet their tongue functions appropriately, whereas other babies and children can have a tongue that “looks” fine but its functionality is restricted.

How is a tongue tie treated?

If your lactation consultant does identify a tongue tie, the next step will usually be a visit to a paediatric dentist or ENT to see whether surgical intervention is required. This will depend on how restricted the tie is and whether non-surgical interventions (corrections to latch and positioning, the use of nipple shields etc.) have been successful or not.

If surgical intervention is recommended, then this procedure is known as a frenectomy (or similar, depending on where you live) and involves the release of the frenulum attaching the tongue to the base of the mouth and/or the lip to the gum. This procedure can be done surgically or with a water laser. As with any medical procedure, it’s important to discuss both the benefits and potential risks/complications of the procedure with your doctor.

It is generally recommended that you work with a lactation consultant before and after the procedure and many providers will also recommend stretching exercises to help prevent reattachment. Some providers will also recommend body work (chiro, osteo, physio) to help release tension in the neck and face muscles - particularly for older babies who have been using different muscles to compensate while feeding.

My experience with tongue ties…

With my eldest, I really struggled with breastfeeding. As a newborn, he would take over an hour to feed and then he’d be hungry again an hour later - I felt like I was constantly feeding him! He was very unsettled too with lots of trapped wind and some mild reflux. This made it hard to settle him for naps so we ended up contact napping most days and even then, he would often only sleep for 20 minutes at a time!

I mentioned these things to our child health nurse and paediatrician but was told it was normal newborn behaviour and things would improve as he got older. Ha, I wish that was the case! In fact, around the 3 month mark things got worse, as I struggled to maintain my milk supply. Despite wanting to exclusively breastfeed until 6 months, I ended up having to supplement with formula. I also started to get recurring blocked ducts and mastitis - which, again, I was told was normal when you are breastfeeding.

Over the course of 8 months, I saw several doctors and lactation consultants about our breastfeeding difficulties and my son’s wind/reflux symptoms but because he had a good latch and was gaining weight well, the possibility of a tongue tie never came up. As a result, we continued to struggle with his feeding and sleep and I had to stop breastfeeding much earlier than I would have liked. The frustration and disappointment, combined with sleep deprivation, also contributed to my being diagnosed with postnatal depression and anxiety.

A few years later I had my second son and he too had some difficulties breastfeeding, so for the sake of my mental health I decided we would mix-feed this time around. He also made a clicking noise while he was feeding though, which is what finally drew my attention to tongue ties. We saw an IBCLC to have his feeding assessed at 6 weeks old and sure enough, he had both a tongue tie and upper lip tie that was affecting his latch and feeding. The lactation consultant also confirmed that my eldest's tongue tie had been missed when he was a baby.

To avoid the same difficulties we experienced with my eldest, we made the decision to have our youngest son's ties surgically revised at 8 weeks old. My husband was able to stay in the room with him and immediately after the procedure, my son was handed to me so that I could breastfeed him. Amazingly, I could feel the difference straight away - the pain that I had been dealing with at every feed for the past 8 weeks was gone!

Although there was an improvement straight after the procedure, we continued to work with our lactation consultant over the coming weeks to help him learn how to lift his tongue properly while feeding. And although it wasn’t really part of the plan, by 12 weeks old I was able to exclusively breastfeed my son again.

I started on the Little Ones program with my younger son at 5 weeks old, so by 12 weeks old he was in a pretty consistent routine and had some positive sleep associations in place. Once his feeding issues were sorted though, we found his naps started to stretch out longer and he began to sleep for longer overnight too.

This time around, I wasn't in a constant state of anxiety over feeds, or suffering from pain and sleep deprivation, so thankfully I was able to avoid a relapse of PNDA. I was able to enjoy motherhood and bond with my youngest son in a way that I wasn't able to with my eldest - all because of a tongue tie!

Conclusion

Tongue ties are a congenital abnormality that can restrict the function of the tongue and cause difficulties with a baby’s feeding and sleep. If you are experiencing any of the signs or symptoms mentioned earlier in this article, we would recommend seeing a lactation consultant (IBCLC) for a full assessment of your baby’s feeding and tongue functionality.

At Little Ones, we have had a lot of experience with customers whose babies have had undiagnosed tongue ties. By first aiming for the most age-appropriate sleeping and feeding patterns, we were quickly able to see that something else was going on for these babies, inhibiting their ability to feed, settle or sleep well.

"If it were not for this Sleep Program and the amazing support from Little Ones, my baby would STILL be suffering with a bad tongue tie. Several times we took him to the doctor for his tongue tie to be looked at and we were told repeatedly that it was fine because he was still gaining weight. Little did I know that there are other areas a tongue tie affects too - causing extreme windiness, very unsettled behaviour and poor sleep. It's not just about weight gain. By trying to follow the Sleep Program we were able to really see that it was in fact the tongue tie affecting him. If we didn’t know what to aim for sleep-wise, we would have assumed my baby’s bouts of crying and wakeful periods all through the night were “normal” as we were being constantly told by others. Through the support and guidance of the Little Ones Village we were urged to have his tongue tie reassessed and we booked to see a private lactation consultant. She immediately saw that it was causing problems with his feeding - his latch was only lasting about 40 seconds then he was struggling to feed effectively after that, resulting in a big build-up of wind throughout the day, causing his screaming fits in the evening and his waking all through the night. She referred us immediately to get the tie lasered.I honestly cannot thank Little Ones and their staff enough for encouraging me to trust my instincts as a mother and pursue a diagnosis because I *knew* his behaviour wasn’t “normal” and the effects of his tongue tie kept getting brushed off as “newborn behaviour”. If we hadn’t had the Sleep Program to guide us in terms of knowing what his sleep patterns should be like for his age, we would have been in the dark and probably would have continued to believe there was nothing wrong.This has been an absolute lifesaver for our baby and our whole family." - Tammy from New Zealand

Always trust your instincts if you suspect your little one isn't feeding, settling or sleeping as they should be, and don't let people brush off your baby’s continued unsettled behaviour as being "normal", especially if your gut is telling you otherwise.

If you are struggling with your baby’s feeding and sleep, check out our comprehensive Sleep Programs.

References:

Breastfeeding USA. (2010). Losing Your Milk: What seems like dwindling milk can actually be normal changes in baby and you. [online] Available at: https://breastfeedingusa.org/content/article/losing-your-milk-what-seems-dwindling-milk-can-actually-be-normal-changes-baby-and-y [Accessed 24 Jan. 2022].

Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, [online] 84(7), pp.471–477. Available at: https://pubmed.ncbi.nlm.nih.gov/18262736/ [Accessed 24 Jan. 2022].

Australian Dental Association (2020). Akyloglossia and Oral Frena Consensus Statement. [online] Available at: https://www.ada.org.au/Dental-Professionals/Publications/Ankyloglossia-Statement/Ankyloglossia-and-Oral-Frena-Consensus-Statement_J.aspx [Accessed 24 Jan. 2022].