Anne was worried about breastfeeding her new son, James. She had struggled to breastfeed her daughter, Samantha, now 2. Initially Samantha was not gaining weight. Breastfeeding was painful; Anne’s nipples were cracked and sore. She dreaded the next feeding. Eventually Samantha was diagnosed with “tongue-tie” but her pediatrician was not trained to treat it. Finally, at a month of age, Samantha had her tongue “clipped” by an ear, nose and throat doctor, but by then Anne had developed a breast infection and, discouraged, gave up on breastfeeding.

Now with James, she was again struggling—difficulty latching, sliding off the breast, and nipple pain. This time, though, the hospital pediatrician and lactation consultant noticed that James, like his sister, was tongue-tied. Anne was pleased to hear that the hospital pediatrician knew how to do a frenotomy (“tongue clipping”). He went to the nursery for 5 minutes for the procedure, returned to her room, and latched on to the breast without difficulty or pain!

Tongue-tie, or ankyloglossia, is a condition in which the frenulum (the thin flap of skin under the tongue that attaches to the bottom of the mouth) is short and limits tongue motion, especially the ability to lift and stick it out. The frenulum may be attached near the tip of the tongue and on the back of the lower gum. Ankyloglossia is rarely a serious medical problem, with the exception of causing difficulty with breastfeeding.

When a baby breastfeeds, the tongue is extended and curled into a U-shape on the underside of his mother’s breast. The nipple and surrounding breast tissue should be drawn deeply into the baby’s mouth, near the back of the throat, so that when he suckles, the nipple is not pinched against the roof of his mouth. For tongue-tied babies, the limited tongue motion may prevent the baby from taking the breast deep in the mouth and interferes with latching.

A mother-baby couplet with tongue-tie may exhibit:

“Heart-shaped” tongue, with a dent or divet in the tip of the tongue, especially when crying

Inability of baby to latch onto the breast, settling his mouth on the nipple and then pulling off repeatedly

Latches on but tends to “slide off” the breast during the feeding; only weakly attached to the breast

Clicking sounds or sucking in of the cheeks while nursing

Nipple pain throughout the feeding that doesn’t improve with relatching; nipple may appear pinched like a tube of lipstick; bruising, scabbing, cracking of nipples.

Excessive weight loss or failure to gain weight despite nursing adequately

Mastitis (breast infection) and/or low milk supply, usually due to infrequent or incomplete emptying of the breast

None of these signs absolutely means a baby is tongue-tied, nor does every tongue-tied baby have difficulty breastfeeding. Preterm or sleepy babies may also have difficulties latching at the breast. Nipple pain can occur in mothers who have infants without tongue tie, and usually improves with attempts to adjust the latch. Each mother-baby pair is different, and some babies who appear to have a significant tongue-tie are able to breastfeed very well. Others who appear to have a fairly mild degree of tongue-tie struggle greatly to breastfeed. This is why it is critical for an experienced lactation consultant to evaluate each situation to determine the root of the problem and what action to take.

Treatment of ankyloglossia in the newborn is simple, fast, and can easily be performed in the hospital or office by a trained pediatrician. The baby is swaddled and the tongue is gently lifted up using fingers or a special instrument. The frenulum is then quickly snipped with sterile scissors. The tongue is then again gently lifted to ensure the frenulum has been completely clipped. The entire procedure takes less than 15 seconds and does not require anesthesia. The frenulum is very thin and has few nerves, meaning there is very little pain associated with the procedure. Baby can breastfeed immediately after the procedure, and mothers often notice improvement with the first feed.

If left untreated, the frenulum may stretch and breastfeeding may improve on its own with time and practice. For others, the nipple pain may be so severe that mom quits nursing entirely. Some babies will fail to gain adequate weight because they don’t transfer milk effectively from the breast. And some mothers may develop mastitis and/or low milk supply as a result of the breast not being effectively emptied at each feeding.

Tongue-tie is not the cause of all breastfeeding problems, and frenotomy is not a cure all. For those infants who are having breastfeeding trouble, however, it should be considered as a possible cause and treated if appropriate. Many pediatricians are able to perform the procedure in the hospital prior to discharge or in the office.

Careful evaluation of the infant and mother can overcome many breastfeeding obstacles. For further information on breastfeeding problems and barriers, please refer to this article by my colleague, Dr Sarah Lenhardt.