During gestational development there is a strong cord of tissue in the center of the mouth that guides the development of the mouth structures. This is located under the tongue and is known as the lingular frenulum. It typically thins and recedes over time and does not present a problem for most babies.
When the frenulum extends to the end or tip of the tongue it can impact babies’ ability to successfully breast feed; it may cause problems with speech or oral hygiene in an older child. This is referred to as ankyloglossia or being tongue-tied. The cause of this is unknown. However, it is felt to have a genetic component since it tends to run in families.
Jenny is a three-week-old whom I have been seeing frequently since the nursery primarily because of feeding issues. Mom successfully breast fed her older child until one year of age and thought it was a breeze. Jenny has been a real challenge for her. At first we thought there may be an issue with mom’s supply. I had her quantify how much fluid she consumed in a 24 hour period, making sure it was at least three quarts a day. Jenny was not gaining weight as she should, causing mom to become very frustrated. “She latches on vigorously. But then she seems to stop, as if she broke the seal. She makes a clicking sound when she does eat,” she added. “What’s more, it is extremely painful when she latches on. It is not at all like feeding her brother.”
The major frustration for mom was the fact that if Jenny was given pumped breast milk in a bottle the baby wolfed it down without any problem. Examining Jenny, I put my little finger in her mouth and she had a good suck. But when I examined her oral cavity with a tongue depressor, she instinctively pushed her tongue out. In doing so the tongue didn’t quite extend over the gum, and it had a bow or heart shape to it. I informed mom that Jenny was tongue-tied and that this problem could be easily remedied with a simple procedure.
The three areas where ankylogolssia can cause problems are with breast-feeding, speech and oral hygiene.
Breast-feeding: When a baby breast-feeds the tongue protrudes over the gum while suckling, making a seal. If the tongue does not go beyond the gums a phasic biting reflex is triggered that leads to chewing. This is very painful for the mom, leading to ineffective suckling. Babies that are bottle fed do not have this problem because the milk is easily transferred with little tongue effort. Tongue-tied babies will also make a clicking sound, or frequently pull off while breast-feeding.
Speech: Older children who are tongue-tied may have problems with speech, but it is more of a problem in pronunciation of certain sounds. These include, r, t, d, z, th, l, sh, or the ability to roll the r’s. It is fairly obvious how vital the tongue is in making these sounds.
Oral hygiene: Older children with ankyloglossia are more likely to have problems with cavities and gingivitis. The tongue is important in cleaning the oral cavity. It can sweep debris from the teeth, especially in the back. We use our tongue to dislodge food particles that have become stuck in-between the teeth. When one is tongue-tied this function is lacking.
The diagnosis of ankyloglossia is a clinical one and should be readily identified. For the newborn one can inspect the tongue and oral cavity as well as determine the baby’s ability to latch on especially when being breast-fed. For older children, one can have them stick the tongue out to see if it bows or is heart shaped. Also look to see if they can easily touch the roof of the mouth or move the tongue side-to-side. Better yet, ask if they can lick an ice cream cone or a lollipop.
Not all cases of ankyloglossia need intervention; this must be done on an individual basis. The definitive treatment is a simple surgical procedure called a frenotomy or a frenulectomy. This is an office procedure which entails snipping the thickened frenulum with a pair of blunt-nosed scissors. It is reported to be less painful than having one’s ears pierced.
Years ago a frenotomy was routinely done by pediatricians in their offices. When I did my residency in the mid 1980’s it was ingrained in me that this should be done by an ear, nose and throat (ENT) specialist. It was believed that the thickened frenulum may have a decent blood supply that could lead to more than expected bleeding which might be problematic. I have followed that dictum while in practice and do send my patients to the ENT. It is a personal and individual choice however. A pediatrician may feel comfortable in doing this in his/her office. In rare cases the ENT may elect to do a more involved procedure called a frenoloplasty. This involves suturing the frenulum after it has been snipped. This requires general anesthesia and would be done in a hospital or surgical center.
After determining that Jenny did have ankyloglossia I called the ENT who was able to see her the next day. She clipped the frenulum without any problem. For the follow-up visit mom was thrilled because she painlessly breast-fed that night. Jenny did so much better. Mom stopped by three days later for a weight check and the baby had gained six ounces in three days. Good weight gain is about one ounce a day. Needless to say mom, Jenny and I were all very pleased.