Tongue Tie

At Agave Pediatrics we are committed to helping children breastfeed for their short term and long term health. Breastfeeding is the most natural and beneficial kind of nutrition for infants.

Some mothers face challenges in breastfeeding which are best evaluated by professionals like Lactation Consultants, Midwives and Physicians. Very often these challenges are overlooked and moms have to resort to formula feeding. The Surgeon General has called for all related professionals to help mothers in breastfeeding and take steps to make it easier. Below is an excerpt from the Surgeon General’s declaration:

Everyone Can Help Make Breastfeeding Easier, Surgeon General Says in “Call to Action”

Benjamin cites health benefits, offers steps for families, clinicians and employers

WASHINGTON, DC, Jan. 20, 2011 – Surgeon General Regina M. Benjamin today issued a “Call to Action to Support Breastfeeding,” outlining steps that can be taken to remove some of the obstacles faced by women who want to breastfeed their babies. 

“Many barriers exist for mothers who want to breastfeed,” Dr. Benjamin said. “They shouldn’t have to go it alone. Whether you’re a clinician, a family member, a friend, or an employer, you can play an important part in helping mothers who want to breastfeed.”

“Of course, the decision to breastfeed is a personal one,” she added, “no mother should be made to feel guilty if she cannot or chooses not to breastfeed.”

While 75 percent of U.S. babies start out breastfeeding, the Centers for Disease Control and Prevention says, only 13 percent are exclusively breastfed at the end of six months.  The rates are particularly low among African-American infants.

Many mothers who attempt to breastfeed say several factors impede their efforts, such as a lack of support at home; absence of family members who have experience with breastfeeding; a lack of breastfeeding information from health care clinicians; a lack of time and privacy to breastfeed or express milk at the workplace; and an inability to connect with other breastfeeding mothers in their communities.

Dr. Benjamin’s “Call to Action” identifies ways that families, communities, employers and health care professionals can improve breastfeeding rates and increase support for breastfeeding:

  • Communities should expand and improve programs that provide mother-to-mother support and peer counseling. 
  • Health care systems should ensure that maternity care practices provide education and counseling on breastfeeding.  Hospitals should become more “baby-friendly,” by taking steps like those recommended by the UNICEF/WHO’s Baby-Friendly Hospital Initiative.
  • Clinicians should ensure that they are trained to properly care for breastfeeding mothers and babies.  They should promote breastfeeding to their pregnant patients and make sure that mothers receive the best advice on how to breastfeed.
  • Employers should work toward establishing paid maternity leave and high-quality lactation support programs.  Employers should expand the use of programs that allow nursing mothers to have their babies close by so they can feed them during the day.  They should also provide women with break time and private space to express breast milk.
  • Families should give mothers the support and encouragement they need to breastfeed.

Family members can help mother’s prepare for breastfeeding and support their continued breastfeeding, including after her return to work or school.

According to the “Call to Action,” breastfeeding protects babies from infections and illnesses that include diarrhea, ear infections, and pneumonia. Breastfed babies are also less likely to develop asthma, and those who are breastfed for six months are less likely to become obese.  Mothers themselves who breastfeed have a decreased risk of breast and ovarian cancers.

A study published last year in the journal Pediatrics estimated that the nation would save $13 billion per year in health care and other costs if 90 percent of U.S. babies were exclusively breastfed for six months. Dr. Benjamin added that, by providing accommodations for nursing mothers, employers can reduce their company’s health care costs and lower their absenteeism and turnover rates.

“I believe that we as a nation are beginning to see a shift in how we think and talk about breastfeeding,” said Dr. Benjamin.  “With this ‘Call to Action,’ I am urging everyone to help make breastfeeding easier.”

Tongue Tie Progam at Agave Pediatrics

In our experience Ankyloglossia (Tongue tie) plays a major role in limiting breastfeeding for the mother and the child. We have a program to help identify and treat Tongue ties for our patients in the practice and for infants who are referred to us. We have have had tremendous success with our program and to date have done more than four hundred (400) frenotomy procedures.

We have tried to address common parental questions and concerns reagarding the Program in this section.

Tongue ties and breast feeding:

A lingual frenulum is a small fold of tissue that extends from the underside of the tongue, in the middle, to the floor of the mouth. In babies that are tongue tied this fold of tissue is considered “tight”, restricting the baby’s ability to protrude the tongue. In turn, the baby is unable to obtain a good latch when trying to breast feed. Some tongue ties are not as noticeable but may still be causing problems when breastfeeding. To read further on the effect of tongue ties and breastfeeding please follow this link.

 Mechanics of breastfeeding:

It is important to consider the role of the tongue in breastfeeding. When a baby attaches to the breast, the tongue extends and grooves to cup the breast, removing milk with a rolling motion while lifting up to compress the breast. A tongue-tied baby may have difficulty extending the tongue over the lower gum line. When Baby’s tongue is too tightly bound to the bottom of the mouth, forming a seal and creating a positive pressure can be a difficult maneuver. Mothers may find that their babies do not empty the breast well enough to gain weight normally. The impact of a significant tongue tie on the ability of a baby to be breastfed is very often severe. As a consequence, many mothers who plan to breastfeed their babies are compelled to wean them to the bottle much earlier than expected. It is not always possible to predict which tongue ties will inhibit breastfeeding, as characteristics of the mother’s breasts also have an effect on such factors as milk transfer.Maternal and infant symptoms along with the length of the frenum (or the apparent severity of the tongue tie)determines whether the baby will be able to breastfeed efficiently.

 How common is it?

 Estimates vary, but a commonly quoted figure is that 1 in 20 babies have some sort of tongue tie. It’s more common in boys and there may be other members of the family who have also had a tongue tie. Many tongue ties are minor and do not require treatment. However a tongue tie that is interfering with breast feeding may require assessment, which may lead to possible treatment (frenotomy). Parents of infants and toddlers with tongue tie are sometimes advised that the tie will “stretch”, or “break” permitting a free range of movement, as the child grows. These stretching and breaking phenomena have not been formally studied or documented in the medical or speech-language pathology literature.

Why do some doctors and midwives think tongue ties are not important?

Nowadays we aim to promote breastfeeding much more strongly than in the past, because of the health benefits to the baby and to the mother. Our knowledge on what makes babies breastfeed successfully has also increased. As a result there is more evidence that the presence of a tongue tie can interfere with feeding.

A good latch when the baby nurses is the most import function a baby does when breastfeeding. The baby leads with his chin, opens his mouth very wide, most of the dark part of around the nipple is sucked into the mouth, the tongue moves outward from the mouth to cover the bottom gum ridge and cup the bottom of the breast, lip are visible around the seal and not sucked in.

Can my baby breast feed with a tongue tie?

Some can, some manage OK, some find it difficult, and some can’t. Some babies also have trouble latching or swallow too much air when trying to breastfeed. The difficulties a baby is having do not always depend on the visual appearance of the tongue tie.

What are the symptoms of a tongue tied baby?

Sometimes mothers will experience painful feeding, grazing or damage to the areola or nipple, or even mastitis (swelling of the breast). Babies may latch on poorly, require several attempts to latch and become frustrated. They may make a clicking noise when feeding. Feeding may be prolonged, and the baby may still be hungry and be irritable, or be ready to feed again within an hour or two. Some babies have problems with excessive gas and may be in pain or suffer from vomiting as a result of swallowing air. These are some of the more common symptoms of a tongue tie causing problems with breast feeding.

Maternal nipple pain is reported to inhibit an adequate milk ejection reflex, and the presence of all or even some of the above problems can interfere with acquiring milk. The unsatisfied infant, tired from suckling, but comfortable in his mother’s arms will often fall asleep on the breast, only to awake still hungry and needing further feeding.

 Symptoms of tongue-ties:

Inability to breastfeed successfully in the presence of a tongue tie can cause a variety of challenges for the infant, the mother and the family. For the baby, these may include:

For infants:

  • Poor Latch
  • Clicking on the breast
  • Gumming the breast
  • Baby acting frustrated on the breast
  • Frequent latching and unlatching from the breast
  • Inversion of upper or lower lip while breastfeeding
  • Inadequate weight gain
  • Excessive sleepiness/ exhaustion on the breast
  • Inadequate opening of the mouth
  • Problem with introducing solids
  • Excessive fussiness, gassy, colic
  • Excessive spitting up
  • Poor bonding between mom and baby
  • Difficulty with bottle feeding

For the Mother:

  • Nipple damage, bleeding, blanching or distortion of the nipples
  • Mastitis, nipple thrush or blocked ducts
  • Severe pain with latch or losing latch
  • Sleep deprivation caused by the baby being unsettled
  • Depression or a sense of failure
  • Milk supply issues, because of poor emptying
  • Poor maternal infant bonding
  • Nipple flattening after breast feeding
  • Lumps in the breasts

Possible Speech issues:

Severe tongue-tie can cause problems with speech. Certain sounds are difficult to make if the tongue can’t move freely (especially ‘th’, ‘s’, ‘d’, ‘l’, and ‘t’).

In addition to forming specific sounds, tongue-tie may also make it hard for a child to lick an ice cream cone, stick out his tongue, or play a wind instrument.

We do not perform frenotomies for possible speech issues in the future. This can be best performed by ENTs if these issues should arise.

Clinical reasons for a frenotomy:

  • Painful attachment at the breast.
  • Nipple trauma / nipple breakdown.
  • Failure to thrive / poor milk transfer.

Who can treat it?

Doctors, nurse practitioners, physician assistants certified or professional trained to do the frenotomy procedure.

 Things that make a difference:

  • Finding tongue tie early
  • Strong commitment to breastfeeding the infant
  • Being seen by Health Provider for diagnosis
  • Having professional support and guidance
  • Getting treatment quickly


Frenotomy, is safe in the hands of those who are trained and are able to administer pain relief and deal with any unexpected issues. A medical assessment by a pediatrician is an important part of the check-up, as parents may also wish to discuss other health concerns and feeding issues about their baby.

Lingual frenotomy is often performed on newborns and neonates with a tongue-tie to enable them to latch and suckle. Lingual frenotomy is sometimes referred to as “tongue clipping”. It is done with a local anesthetic.

The baby is stabilized and the tongue is elevated using a tongue depressor. The salivary gland openings are identified. 0.2ml of Lidocaine is infiltrated on both sides of the frenulum. The lingual frenulum is identified and it is cauterized above the openings of the glands. Center of frenum (0.8 cm) is cauterized. Bleeding is unusual and if it occurs it is stopped by application of pressure. With the possibility of bleeding it is a requirement that the baby receives the Vitamin K shot in the hospital, after delivery. The infant can breastfeed immediately


Healing and follow-up:

  • Minimal discomfort
  • Most often go to the breast soon after the procedure. Immediate improvement in suck and decrease in pain for mom is often observed
  • May need Tylenol q 4hrs, if seems to be in discomfort
  • After 1-2 days you will see a thick, white plaque which will go away in 4-5 days
  • Some tongue ties are much more severe than others and may require more than one procedure to completely release the tongue. This is uncommon.

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