What is a tight tongue tie in babies?

Short tongue tie in babies

The tongue tie serves to stabilize the tongue, and is relevant when we look at both babies and infants but also later in life, as it is basically essential for the function of the tongue during breastfeeding, and also when swallowing and speaking.

The tongue tie is a fold of mucous membrane that is present from birth and that normally extends from the bottom of the mouth to the middle of the underside of the tongue. If the tongue tie is too short/tight or attaches to the tip of the tongue, it can lead to problems with “tongue function”, making the tip of the tongue less mobile. In infants, some will experience breastfeeding problems, while later in life it can cause speech difficulties.

What are the symptoms of a short/tight tongue tie in babies?

The typical symptoms of a tight/short tongue tie (ankyloglossia) are the following:

• The tip of the tongue may be heart-shaped, this will in some cases be clearly observed if the child cries.
• The baby cannot get his tongue past the lower lip/gum
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Secondary symptoms to a tight tongue tie may include:

• Breastfeeding problems – difficulty forming a vacuum and latching on to the breast
• Painful breastfeeding for the mother
• Speech difficulties

How many babies have a short/tight tongue tie?

In recent years, tongue-tie has been in the spotlight, and more and more people who have young children or are otherwise related to it have encountered the term tongue-tie. A Danish research article from 2020 shows that the number of children diagnosed with ankyloglossia (tongue-tie) has increased significantly in the period from 1996 to 2015.

The incidence of ankyloglossia (tight tongue tie) has increased from 3.2 per 100,000 in 1996 to 13.6 per 100,000 in 2015. This means that there has been a fourfold increase in the number of children diagnosed with a tight tongue tie/ankyloglossia. During the same period, the number of children who have had their tongue tie cut (frenotomy) has increased sevenfold. From this, it can be immediately deduced that there has been a greater increase in tongue tie cutting than the incidence of children with a tight tongue tie.

Diagnosing a tongue tie that is too short/tight in babies

The diagnosis of a tight tongue tie can be made in different ways. However, this creates challenges as parents may experience different advice/guidance, making it difficult to decide which form of treatment is the right one.

There is agreement that it is good practice to use the Tongue-tie and Breastfed Babies assessment Tool (Tabby) in children with breastfeeding problems where a tight tongue tie is suspected. Tabby can thus be used to assess the appearance of the tongue tie and the mobility of the tongue based on four “measurement points”.

These measurement points in Tabby are the following:

• What does the tip of the tongue look like?
• Where is the tongue tie attached to the gum?
• How high can the tongue be lifted (with the mouth wide open)?
• How far can the tongue reach?

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For each of the 4 points, 0 – 1 – or 2 points can be scored. Based on a total score, the degree of ankyloglossia is assessed and what measures are relevant for the individual child.

Causes of too tight/short tongue tie in babies?

The cause of a tight/short tongue tie is unclear. However, research suggests that there is a hereditary nature, why it is seen more frequently in some families than others.

When should a parent seek help or guidance for a tight/short tongue tie?

It is important to seek help if breastfeeding infants do not gain enough weight. It may also be relevant if the child becomes upset and very restless during breastfeeding, and if it hurts the mother. Breastfeeding should, as far as possible, be a good and pleasant time for both mother and child. If there are challenges with breastfeeding, help can be obtained from several different professional groups in the healthcare system.

Midwife

The midwife is often one of the first healthcare professionals involved in establishing breastfeeding, after which it will more typically be the health visitor who takes over contact with the parents.

Health care nurse

The nurse is an important contact regarding the child’s well-being. Many nurses also have in-depth knowledge of breastfeeding and can provide guidance and advice on breastfeeding.

Breastfeeding counselor

Breastfeeding counselors/breastfeeding consultants typically function as a supplement to the health visitor in advising and supporting breastfeeding.

Ear, nose and throat doctor

Ear, nose and throat (ENT) doctors will be relevant to seek if you have any doubts about whether your child has a tight/short tongue tie, and they can also advise and possibly perform tongue tie cutting.

Pediatrician

Pediatricians are experts in examining children for possible illnesses, and it is also their specialty to advise on medical treatment for children and babies.

Osteopath

Osteopaths can supplement breastfeeding challenges, as these can also be caused by tension around the skull, jaw muscles, neck muscles, and restrictions around the neck and chest.

Why is it important for the tongue to be able to move?

The tongue has several purposes that are important in everyday life. Including when we eat to distribute the food in the mouth. The first part of digestion starts in the mouth by chewing the food well and adding digestive enzymes from the saliva. The tongue then ensures that the food is pushed back in the mouth towards the pharynx, where it is swallowed and passed on in the digestive system.

Furthermore, the movement of the tongue, along with the lips, plays an important role in pronunciation.

In babies, it is important that the tongue is mobile enough for the baby to grasp the mother’s breast and create vacuum/negative pressure for good breastfeeding. Breastfeeding problems combined with a tight/short tongue tie can cause painful breastfeeding and in some cases sores on the mother’s nipples. If the sucking technique is poor, clicks can be heard when the baby loses vacuum, while also swallowing a lot of air. Suboptimal sucking technique can reduce milk supply, which can make breastfeeding long and “hard” for the baby, while incomplete emptying of the breast can cause mastitis and pain for the mother.

Treatment of short tongue tie in babies

Based on manual treatment and a tight tongue tie, the current evidence (research) in the area is sparse. When examining whether manual treatment is justified, there are also no clear recommendations based on research.

There are weak recommendation regarding offering tongue-tie clipping (frenotomy) rather than breastfeeding guidance alone, for infants up to 4 months with a tight tongue-tie and concomitant breastfeeding problems.

​If we look at whether manual treatment of biomechanical conditions in relation to the mouth and surrounding structures has a beneficial effect in breastfed infants, there are two things that can currently be deduced:

Manual treatment of biomechanical conditions should not be routinely offered to infants with a short/tight tongue tie who also have breastfeeding problems.
Due to the lack of research in the area, it has not been possible to conclude whether manual treatment has beneficial effects, but at the same time there is no research indicating possible harmful effects of manual treatment.
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When using manual treatment, it is important to note that treatment needs may vary from individual to individual, depending on the starting point, but if the focus is on the sucking technique, there should be a clear effect on this within 1-2 treatments. Depending on the tension in the tissue, additional treatments may be needed in some cases.

Tight/short tongue tie in babies and breastfeeding

The baby uses its tongue during breastfeeding to grab the mother’s breast to create a vacuum.

If the tongue tie is short/tight, some children may find that the tongue cannot reach beyond the lower gums, so the child cannot properly grasp the breast and create the necessary vacuum. In such cases, breastfeeding may be a problem for both the baby and mother.

The mother may experience breastfeeding as painful, while the baby may easily “fall off” the breast and may “click” during breastfeeding. If it is difficult for the baby to form a vacuum, it may be a struggle for him to get enough breast milk, which can lead to crying and restlessness during breastfeeding.

A sign of suboptimal breastfeeding can be insufficient weight gain in the baby, which you should be aware of. Incomplete emptying during breastfeeding increases the likelihood of the mother developing mastitis, and difficulty breastfeeding can lead to poor milk supply to the breast.

In some cases, it will be possible to achieve good breastfeeding despite a tight tongue tie if you get help/advice from professionals, possibly breastfeeding counselors. Babies are very adaptable, and can often develop techniques to make breastfeeding successful. It must be emphasized that breastfeeding should be a good experience for both baby and mother.

Treatment of a tongue tie that is too tight/short in babies – what do you do?

It is recommended that you consider offering frenotomy, rather than breastfeeding guidance alone, to infants up to 4 months with a tight tongue tie and concomitant breastfeeding problems.

The research behind this has only a weak recommendation.

​Typically, tongue tie clipping is performed by ENT doctors after assessing the tongue tie. The procedure may vary depending on the individual case, and you should therefore visit the individual doctor and inquire about the procedure at the clinic.

This may be relevant both in terms of anesthesia (local anesthesia/general anesthesia), and be dependent on whether it is anterior or posterior lingual frenulum. The most important thing is that you as a parent can make an informed choice, where you have the best possible basis for assessing the effects/side effects/risks associated with cutting the lingual frenulum.

Where can you cut a tight/short tongue tie?

Tongue ties will in most cases be diagnosed and cut by ear, nose and throat doctors. In some cases, there may be dentists who also cut the tongue tie.

When should a tight/short tongue tie be cut?

Examination and treatment of ankyloglossia in breastfed infants (2020) states that regardless of the appearance of the tongue, there will be no reason to cut the tongue tie (frenotomy) during the child’s breastfeeding period, provided that it does not cause problems with breastfeeding and the child is also gaining weight satisfactorily.

However, if you experience pain and difficulty when breastfeeding, and at the same time see signs of a short/heart-shaped tongue, you should see a doctor to have your child’s tongue assessed.

Some are referred by their primary care physician to a pediatrician, while it is also an option to see an ear, nose and throat doctor for an assessment of tongue tie.

In the event that you have a baby who, within the first 4 months of life, has a tight tongue tie and breastfeeding problems, you may consider supplementing breastfeeding guidance with a clip (frenotomy) of the tongue tie.

Osteopathic treatment of a too tight/short tongue tie

A short tongue tie can be diagnosed, but without the need to have it cut. It will always be a matter of assessment for the individual. Osteopathy cannot directly lengthen/cure a tight/short tongue tie, but can serve as an important part of the treatment for babies who have challenges with breastfeeding and sucking technique.

Thus, osteopathic treatment for babies with a tight tongue tie will focus on:

• Free movement of the neck and chest.
• Release tension around the neck muscles, including the muscles around the pharynx.
• Ensure optimal function of the tongue and jaw muscles.
• Craniosacral techniques with a focus on:
• 9th cranial nerve (n. glossopharyngeus) which is important for the child’s sucking technique and ability to form a vacuum.
• 10th cranial nerve (n. vagus) which is important for digestion, and also motor function around the pharynx, larynx and palate.
• 12th cranial nerve (n. hypoglossus) which is important for the tongue muscles

Short tongue tie and speech in babies and children

A short tongue tie will not prevent children from learning to speak, but it can cause challenges in making certain sounds and can make certain words difficult to pronounce. The mobility of both lips and tongue is essential to ensure a good foundation for pronunciation.

Heart-shaped tongue in infants and babies – sign of tight/short tongue tie

The appearance of the tongue is assessed as one of 4 parameters in TABBY, as an expression of the structural condition of the tongue along with an assessment of where the tongue band is attached to the gum.

Thus, a heart-shaped tongue may raise suspicion of a tight tongue tie – but a tight tongue tie cannot be assessed solely based on the shape of the tongue.

It is recommended that the Tongue-tie and Breastfed Babies Assessment Tool (Tabby) be used for systematic assessment of tongue-tie.

Prevention of a tongue tie that is too short/tight in babies

A short/tight tongue tie cannot be immediately prevented, as it is a congenital condition, but in severe cases where the tongue tie is very tight and limits free movement of the tongue, it may be important to have this diagnosed early so that necessary treatment can be initiated to ensure the best conditions for breastfeeding and well-being.