Tongue Tie and Tongue-tie release

I cannot breastfeed my baby well, what can I do?

Difficulty in breastfeeding your baby is due to factors affecting the mother and / or the baby. I recommend both mummy and baby to see a lactation counsellor if they have not already done so. I examine the mum for breast or nipple abnormalities. The technique of breastfeeding is assessed to see if the latch is deep enough. Often, the correct positions of the baby and the mother help to achieve a better latch. The baby is examined to exclude abnormalities that impede breastfeeding for example, tongue tie, cleft palate.

I suspect my baby has a tongue tie. How do I know for sure?

The diagnosis is suspected if there are symptoms for example, nipple pain, prolonged breastfeeding time, “windy” or “cranky” baby during or after breastfeeding, etc. The mother’s nipple and breast pain occur because the baby’s gums chomp on the nipple when there is a loss of “cushioning” from a mobile tongue. The baby struggles to feed, and gulps in more air than usual. Tongue tie or ankyloglossia is often misdiagnosed, when the problem lies with achieving a deep enough latch during breastfeeding. This needs to be confirmed by a doctor who is experienced in managing the condition.

A mild tongue tie does not need any intervention, and improvement in breastfeeding technique often resolves the symptoms. Monitoring for the spontaneous rupture of the tissue, or adaptation of the tongue to breastfeeding occurs with perseverance and time. It is important not to give up, because breastfeeding confers benefits to the baby (for example, better immunity, decreased allergy), the mother (for example, prevent breast engorgement) and improves bonding.

A significant tongue tie presents with a firm ridge underneath the tongue on palpation and a shallow latch. The tongue tie is an excessively shortened tissue on the undersurface of the tongue, which impedes the mobility of the tongue. In severe cases, the tongue forms a heart shape when extended.

Does tongue-tie release help speech?

The development of speech is a complex one, comprising brain, hearing and neuronal connections development. Tongue tie plays a small role in the big picture. It is thought that the production of these alveolar (/t/, /d/, /s/, /z/, /n/, /l/) or palato-alveolar (/ʃ/, /ʒ/, /tʃ/, /dʒ/, /r/) sounds are inaccurate, because the movement of the tongue is impeded by the tongue tie.

Children have amazing adaptive abilities and may get around the limitation with speech therapy. Currently, there is insufficient evidence to show that a tongue-tie release helps speech in future (1). In an older child, a speech therapist should assess and treat the child first before a tongue-tie release is performed.

When is the best time for tongue-tie release / frenulotomy?

After a lactation consultant has confirmed that the technique of breastfeeding is good and there is still difficulty with breastfeeding your baby, a paediatric surgeon or dentist may be consulted. I perform a tongue-tie release in infancy. In short term follow up studies, it has been shown to relieve nipple pain (2), and hence achieve better breastfeeding. The World Health Organization recommends exclusive breast feeding for 6 months, and the best time to perform tongue-tie release is during this time, before giving up breastfeeding. The procedure is performed in the clinic without sedation.

When your child is older and uncooperative, the procedure needs to be performed under sedation, because it becomes harder to hold the child while the tongue-tie release is performed. When the child is cooperative, I perform the tongue-tie release under local anaesthesia. After the procedure, your child goes home on the same day.

What happens during a tongue-tie release / frenulotomy?

A scissors is used to cut the tissue on the undersurface of the tongue. Blunt dissection achieves a diamond shaped wound. Minor bleeding is controlled with gauze and finger pressure. A laser achieves the same effect, but is a more expensive equipment which I don’t see a need to pass on the cost to my patient.

For older children, I use diathermy to control any bleeding encountered during the tongue tie release.

How is the recovery after a tongue-tie release / frenulotomy?

Minimal bleeding is expected and the baby should breastfeed immediately after the procedure, which helps to soothe him/her. After the tongue-tie release, the mother should feel breastfeeding is easier and less painful on the nipple.

For older children, I teach myofunctional therapy for the tongue after surgery. This may help to prevent recurrence due to scar tissue.

Does lip tie affect breast feeding?

Lip tie is a shortened band of tissue affecting the inner surface of the lip, and the upper lip tends to be more involved as compared with the lower lip. Currently there is no good evidence to suggest lip tie affects breast feeding (3). I do not recommend a lip-tie release to aid breastfeeding.

What are the costs for a tongue-tie release?

I take reference from the Ministry of Health, Singapore, Fee Guidelines.

Tongue-tie release or frenulotomy for a newborn baby to 6 months old before fully grown teeth, the estimated total cost is $900,subject to the prevailing Goods and Services Tax (GST) rate. This includes consultation and consumables. These are payable via Insurance, Child Development Account full amount, and Medisave up to $550.

Lactation consultation techniques are separately chargeable at $90, subject to the prevailing GST rate.

For children older than 6 months old or have fully grown teeth, the timing of surgery depends on the clinical examination. The estimated total cost, for the procedure done under sedation, is $2200 to $2400, subject to the prevailing GST rate. This includes the anaesthetist fees, surgeon fees, medications and consumables. These are payable via Insurance, Child Development Account full amount, and Medisave up to $550.

If the child is cooperative, there is no need for sedation. The estimated total cost is $1200 to $1400. This includes the surgeon fees, medications and consumables. These are payable via Insurance, Child Development Account full amount, and Medisave up to $550, where applicable.