Introduction

Tongue-tie, also called Ankyloglossia, is a congenital abnormality of the tongue, where a membrane called the frenulum that attaches the tongue to the floor of the mouth becomes thickened or tightened. When this happens, tongue mobility is reduced.^1,4 

The prevalence of tongue-tie is said to vary between 1% and 10%, but there is a lack of standard diagnostic criteria and no universal definition. It is especially tricky to diagnose in infants, as they tend to naturally have a more thickened, tightened or shortened frenulum. The male to female ratio is reported to be 3:1.^{2, 4 ,5}

Tongue-tie is associated with breastfeeding difficulties, with 25%‐80% of infants who have tongue‐tie also having breastfeeding problems.² It may be symptomatic or asymptomatic, and the American Academy of Paediatrics encourages early treatment for symptomatic tongue-tie to minimise breastfeeding problems.³ Babies may also have an increased frequency of feeding without adequate weight gain as a result of tongue-tie, and these problems may contribute to early cessation of breastfeeding.^5,7

It may affect mothers as well, who sometimes report strong and persistent pain or cracked and bleeding nipples during breastfeeding as a result of the baby's inability to latch properly. Latching refers to an infant's ability to take enough breast tissue into their mouth to hold on to the breast properly during feeding. 

On rare occasions, speech and dental problems have also been associated with tongue-tie as a long-term complication, but this is not scientifically proven.⁵

Breastfeeding is of great benefit to both mother and infant; therefore, any condition which affects successful breastfeeding in women who choose to breastfeed is considered a public health problem that needs to be addressed.⁵

Therefore, this article explains how tongue-tie affects breastfeeding and provides solutions for overcoming the challenges that come with tongue-tie.

The role of the tongue in breastfeeding and securing a latch

The role of the tongue in breastfeeding is very important. Functional studies done to monitor tongue movement during breastfeeding have shown that the tongue is a major component of the suckling reflex.^11,12

The tongue movement during suckling comprises a combination of compression and suction, which enables milk to be expressed from the areola to the nipple and then into the baby's mouth. Efficient and effective breastfeeding depends on the baby having an adequate length of free tongue at the tip, adequate overall movement of the tongue, and sufficient flexibility of the floor of the mouth.¹¹

Babies with tongue-tie try to compensate for the restriction in movement by:¹²

• Using their jaws to increase the compression on the breast which often causes a shallow latch onto the breast, resulting in an increase in pressure, eventually leading to soreness and cracking of the nipples. Nipple pain causes the milk reflex to slow down and the baby to further increase jaw pressure, thereby establishing a vicious cycle of increased pain and pressure while suckling.
• Secondly, the babies use their lips instead of their tongues to move milk from the breast, resulting in frequent ‘delatching’ during feeding and therefore prolonged feeding, even if the latch is maintained.

How tongue-tie impacts breastfeeding/latch issues

Tongue-tie causes varying degrees of reduced tongue mobility and has been associated with several functional limitations, which may include breastfeeding problems, odd swallowing habits, speech problems, an inability to clean the mouth and stress.⁴ It affects how the baby eats, the mother’s health, and both the mother's and the baby’s mood.

Symptoms and signs in infants include¹⁰

• Poor latch and suck
• Clicking sound while breastfeeding (signifies poor suction)
• Ineffective milk transfer
• Weight loss
• Irritability/colic
• Fussiness
• Difficulty maintaining a good grasp on the breast

Mothers may present with¹⁰

• Nipple pain/cracked nipple
• Painful breasts (engorgement)
• Low supply of milk
• Clogged ducts
• Mastitis (inflammation or infection of the breast)
• Frustration, disappointment, and discouragement with breastfeeding
•  Premature weaning

Impact on achieving a proper latch

Achieving a proper latch becomes difficult in tongue-tie as a result of:

• Shallow latch: This occurs due to the baby’s inability to extend the tongue far enough, leading to ineffective attachment to the breast and slipping off^6,7
• Nipple pain: When the latch is shallow as a result of the restricted and abnormal movement of the tongue, the friction and pressure in the nipple increase, causing pain, cracks, and bleeding⁹

Challenges with milk transfer⁷

• Limited tongue movement: As a result of the restricted motion of the tongue, the baby is unable to create the suction effect needed to extract milk effectively, leading to incomplete emptying of the breast and a reduction in milk supply over time
• Poor weight gain in infants: When babies don't get enough milk, they may struggle to gain adequate weight and grow along the appropriate centile

Increased feeding times

• Prolonged feeding sessions: Babies with tongue-tie often spend a lot of time trying to breastfeed without getting enough milk. This can make it very hard and upsetting for babies when it's time to eat, making the baby very tired and exhausted.

Maternal breastfeeding complications^2,6

• Engorgement: As a result of poor drainage of milk, breast engorgement occurs, giving rise to an increased risk of mastitis and discomfort in the mother
• Blocked milk ducts and mastitis: Due to the ineffective milk removal from the ducts, milk stasis occurs, leading to clogged ducts and, in turn, inflammation
• Reduced milk supply: Eventually, the body begins to receive signals to produce less milk due to the reduced removal of milk

Emotional and psychological impact on mothers

In addition to the difficulties faced with the feeding mechanism, tongue-tie may have a negative psychosocial impact on the breastfeeding relationship and maternal mental health as well.⁸ Therefore, mothers may present with:

• Frustration and anxiety: Following persistent feeding difficulties, mothers may feel overwhelmed
• Guilt and self-doubt: Some mothers may think it is their fault that their baby has trouble eating, because it's hard to breastfeed. They may feel they are not good enough and have failed their babies
• Postpartum depression risk: All these challenges may make mothers feel low in mood after the birth of their babies. Some mothers may progress to postpartum depression

Baby’s feeding behaviour

• Fussiness during feeds: Babies can get really upset and cry a lot if they can't get enough food when sucking
• Frequent feeding attempts: Babies may also need to feed more often to get enough milk, which can tire both the mom and baby
• Gassiness and colic-like symptoms: Poor latch often makes babies take in a lot of air when suckling, which can make them very gassy and feel tummy upset

Long-term implications

• Speech and oral health issues: There is no recent evidence that tongue-tie causes speech problems. A few studies have suggested a relationship between tongue-tie and speech, but the studies are of low quality. Therefore, firm conclusions are difficult to draw. If tongue-tie is untreated, it may affect speech development and teeth alignment⁴
• Difficulty transitioning to solids: If untreated, severe tongue-tie can affect chewing and swallowing as a result of the restricted movement

Cycle of breastfeeding difficulties

• Mutual frustration: The inability of the baby to feed properly can frustrate both the baby and the mother. These struggles can impact the bonding between mother and baby over time

Summary

Tongue-tie can make breastfeeding very difficult for both mothers and babies, as it impacts tongue movement, causing trouble for babies to latch on well and feed properly. From bad latching and sucking issues to a lot of stress, the effect on the baby and mother’s physical and mental health is often large. 

For babies, this might be a bad latch, trying to feed a lot, getting upset, and not gaining much weight. For mothers, it can cause nipple pain, cracked or bleeding nipples, full breasts, blocked ducts, and even mastitis. These problems can be really stressful for mothers and their babies and result in stopping breastfeeding earlier. On the emotional side, both mother and baby may feel upset, and mothers might feel guilty or even progress to postpartum depression.

However, with the right checks, early correction or treatment if needed, and care from health workers, it can be easily managed. If you are having problems with breastfeeding, reach out to your healthcare team early, as breastfeeding should be an enjoyable experience for both mother and baby. 

If you or someone you know is finding it hard to breastfeed because of tongue-tie, don’t delay in getting help. If you take good care and the condition is managed properly, you can have a great time feeding your baby.