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Tongue tie, a case study

A baby boy was born full term via normal vaginal delivery after the mother having an uncomplicated pregnancy. Parents were adequately informed about breastfeeding technique prior to delivery having attended an antenatal seminar. Baby was put on the breast from birth and fed on demand being with his mother in rooming in. During the next few days, there were no problems with significant weight loss or jaundice.

Mother came back home on Day 3 and already had painful cracked nipples. Mother and baby were reviewed 2 days after discharge in a paediatric IBCLC clinic. Attachment of the baby on the breast and latch on were assessed. Mother used proper breastfeeding technique, but the baby had difficulties in latching on because of a short lingual frenulum restricting the movement of his tongue. Parents were informed about the problem and encouraged to seek an immediate appointment with a paediatric surgeon in order to incise the frenulum.

Parents were initially reluctant to proceed with the procedure. Over the next two weeks, baby kept on gaining weight and mother had less pain in her nipples. Nipple sores were no more present after 20 days of life. During the monthly follow up, mother felt that exclusive breastfeeding was going well. However, parents had second thoughts about the tongue tie of their baby, and decided to have it incised at 2 ½ months of age, mainly due to concerns about future problems with speech.

For the 2 ½ months following the operation and at monthly reviews in the clinic, mother reported an overall better experience with breastfeeding her baby. Baby seemed more vivid on the breast, had no problems latching on, swallowed milk faster and continuously, and intervals between feeds significantly increased. Baby’s weight and length charts based on the WHO growth standards for infants are shown

 

below;   TONGUE TIEwho2

 

The chart for length shows a more or less stable line on the 50th centile for boys. However, on the chart for weight, a small drop from the 50th centile at birth to the 15th centile at 2 months of age is observed. Then, after the incision of tongue tie, it seems that the rate of weight gain increased, resulting in a baby on the 60th centile at 5 months of age (he gained with exclusive on demand breastfeeding about a kilogram from 3 to 4 months and about another kilogram from 4 months to 5 months and one week).

Discussion

Short lingual frenulum (tongue tie) is a recognized cause of cracked and painful nipples during breastfeeding. It is also a readily treatable cause, with surgical management commonly resulting in less pain for the mother. There are various anatomic classifications of tongue tie with grades of severity, but the most important factor to consider is the function of the tongue. Tongue tie having a significant negative impact on the movement of the tongue (inability of the tongue to protrude above the lower gums, reduced overall movement of the tongue, folded or heart-shaped tongue) is likely to cause problems with latching on the breast. Significant tongue tie can also be associated later on with speech

and articulation problems.

This case study illustrates that the problems of cracked nipples in the initial period of establishing breastfeeding traditionally associated with tongue tie might just be the tip of the iceberg. This mother had accurate and detailed information about breastfeeding prior to delivery, had an initial uncomplicated period after delivery, proceeded with good initiation of exclusive breastfeeding early, had the baby on the breast immediately after birth and had rooming in inside the hospital – both not commonly seen at least in combination in maternity wards in Greece –, avoided bottles and teats and had a prompt review of her breastfeeding technique by a trained IBCLC within 48 hrs of coming back home. Breastfeeding optimization from birth and a good technique from the mother’s part might contribute to an even and prompt establishment of exclusive breastfeeding and a well looking baby, despite the tongue tie. The initial 3-week period of painful nipples the mother had is quite common for a first time mother in this country, although one could argue that with such a level of breastfeeding optimization from birth, there should be no pain, thus the pain was due to the baby’s tongue tie. During the first two months, weight gain of the baby was satisfactory – not optimal according to WHO growth standards, but still not causing major concerns. When parents on second thought decided to proceed with surgical incision of the short frenulum at the age of 2 ½ months, baby’s breastfeeding behavior changed positively and baby started gaining even more weight. The rate of weight gain over the next two months was more than expected at 3 and 4 months of age and looked compensatory to the restrictive rate pattern over the first two months attributed to the tongue tie.

Short lingual frenulum in babies might not be associated only with prolonged and/ or excessively painful and cracked nipples in the mother, as traditionally thought. There might be milder cases or other cases of mothers having optimal breastfeeding technique and prompt practices that promote exclusive effective breastfeeding, which show up as a suboptimal breastfeeding behavior of the baby on the breast, as suboptimal weight gain, as a “colicky” or demanding baby or as a baby that keeps being on the breast all the time. Surgical incision of short lingual frenulums resulting in significant restrictions in movement of the tongue of the baby should be offered and strongly recommended as soon as the diagnosis is made in all mothers with the intention to breastfeed their babies. The procedure is easily done at infant age, with a use of a local anesthetic, is unlikely to result in significant bleeding, lasts for only a few seconds to minutes and results in a baby able to feed on the breast again within seconds from the incision. The procedure can have a strongly positive impact on the health of the mother’s nipples, on the behavior of the baby on the breast, on overall quality of the breastfeeding experience of both mother and baby, and eventually on the exclusivity and the duration of breastfeeding. Even if parents do not decide to proceed with the procedure soon after birth – commonly as a result of underestimation of the problem, of inappropriate reassuring information by health professionals and of a fear of parents for their baby undergoing a surgical procedure – , they should be encouraged to opt for the procedure even later on, because incision of a tongue tie can have a positive impact on overall breastfeeding experience even if done months after birth.

 

Stelios Papaventsis MBBS MRCPCH DCH IBCLC 2015

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