My baby has a suspected tongue-tie and I am struggling to access division due to the COVID 19 restrictions. What can I do?

With the reduction in services including postnatal support, breastfeeding support groups and tongue-tie division services it is an extremely stressful time for new parents. If your baby is struggling to feed and has a suspected or confirmed tongue-tie you may feel the situation is somewhat hopeless.

However, it is important to understand that the impact of a tongue-tie (or restricted lingual frenulum) on breastfeeding will vary depending on how much the restriction is impairing tongue function. Not all tongue-ties will impact feeding. A study done in Southampton identified that 10.7% of babies within their sample had a tongue-tie but only 4.8% required division (Hogan et al, 2005). Other factors also contribute to the impact of tongue-tie on breastfeeding including positioning and attachment, milk supply, nipple shape and size, oral and facial anatomy (for example a high palate or a recessed lower jaw), tensions and strains in the neck, head and jaw area as a result of the birth (more common in babies who have been born with ventouse or forceps, being breech, born by caesarean section and so on).

Around a fifth of the babies that come to me for division under normal circumstances don’t end up needing one because the feeding issues can be managed successfully with breastfeeding management and sometimes bodywork (osteopathy/chiropractic).

So, whilst some NHS and private tongue-tie services have closed and those that remain are working under restrictions and only seeing the more severe and urgent cases, it is important to keep in mind that there is lots that can be done to help improve and maintain breastfeeding whilst we wait for the pandemic to settle and restrictions to be lifted.

Tongue-ties can impact feeding in a variety of ways. Some babies cannot latch at all initially, especially if birth has been complicated with interventions. A significant percentage of these babies will latch given time and lots of skin to skin (information here). Many babies start to latch well when the milk starts to come in at around day 3-5 and the breast becomes firmer and there is more milk flow. Most babies with a tongue-tie will latch but the latch is shallow, and the nipples become sore and sometimes damaged. Some babies struggle to sustain the latch and slip off the breast. In this situation some babies will use their lower jaw to hang on to the breast and this clamping with the jaw can be very painful.

If a baby’s latch is shallow this can impact on the baby’s ability to drain the breast effectively and some babies with tongue-tie struggle to create sufficient vacuum to draw enough milk from the breast and will keep falling asleep at the breast. These babies will often be very frequent feeders or spend long periods at the breast without ever seeming to be satisfied. In these babies’ weight gain can become a concern and an early warning sign is a lack of wet and dirty nappies. (See information on what to expect in terms of nappies here). Inadequate breast drainage is also a risk factor for engorgement, blocked ducts and mastitis.

Flow regulation can also be difficult for babies with tongue-tie and some babies will gulp and choke, whilst feeding, especially at the milk ejection reflex (the let-down) at the start of a feed. Their difficulty in managing flow is believed to contribute to wind and reflux.

So, if division is not available what can be done to sustain breastfeeding? The priority is to feed the baby. This can be extremely challenging if your baby can’t latch, is struggling to latch well, your nipples are sore and damaged, and your baby is never settled and satisfied. Most babies with a tongue-tie will be able to latch and get at least some of the milk they require from the breast. Where supply is abundant and comes in early, as if often the case in mothers who have breastfed before, there may be no nipple pain or issues with weight gain in the early weeks because there is sufficient flow to compensate for the effects of the tongue restriction. However, in cases where nipple pain is severe then steps need to be taken to try to manage and minimise this. Accessing help with positioning and attachment is always the place to start. Your midwife can help you immediately after birth and you should be given information on how to access your local NHS infant feeding team. There are also lots of resources online to help guide you. This is just one of many. Many breastfeeding support groups are now offering free weekly group sessions online and some breastfeeding counsellors and International Board Certified Lactation Consultants (IBCLCs) can also offer support with positioning and attachment via one to one video consultations.

There are certain latching techniques that can help in tongue-tie situations. Two which I find most effective are:
• Laid back positioning
• Breast shaping

However, some more severely tongue-tied babies struggle to latch in the laid-back position.

If improving positioning and attachment does not make the nipple pain manageable, there is severe damage, or in cases where baby cannot latch or suckle effectively at the breast then a nipple shield can be helpful. But it needs to be the right size for your nipple, and you need to have a midwife, lactation consultant or breastfeeding counsellor observe baby feeding with the shield to ensure they can transfer the milk through it. Some tongue-tied babies cannot create enough suction to draw milk form the breast with a shield in place and this can be dangerous in terms of hydration and weight gain. However, used appropriately shields are a useful tool is helping a non-latching baby to latch and feed and can also act as protection from further nipple damage and reduce pain. More information on shield use can be found here.

There will be cases where neither improving positioning and attachment or using shields will be enough to address the nipple pain or latching difficulty and, in these situations, expressing milk and feeding baby by an alternative method is an option. Some mums find that the nipple pain can be managed if they combine some breastfeeding with giving baby expressed milk. Others find that resting the nipples completely and expressing for each feed is the better option for them.

Expressing may also be necessary for babies who cannot drain the breast effectively so are feeding frequently or constantly, are not satisfied after feeds or have issues with weight gain. In this situation, if mum is able to breastfeed comfortably, then she can express after first offering both breasts, using breast compression to maximise milk intake. This expressed milk can be given as top ups after feeds. Your infant feeing team, breastfeeding counsellor or lactation consultant can provide support with expressing and can help you ensure your baby is getting enough expressed milk. For more information on expressing see here.

Expressed milk can be given in a variety of ways. Most parents think just about bottles as that is what we are all familiar with. If bottles are to be used, then it is important this is done in a responsive way and that feeds as paced to avoid over feeding. Information here. The use of bottles, especially early on, is thought to potentially cause nipple confusion which can then cause further difficulty with feeding at the breast. So other options that can be used include:
• Cup feeding
• Finger feeding
• Lactation aid

Again, your NHS infant feeding team, a breastfeeding counsellor or IBCLC can help you decide how best to feed your baby when they are not going to the breast and give you guidance on how to use these methods safely.

Adequate breast drainage is not just important in terms of ensuring baby gets enough. It is important in preventing blocked ducts or mastitis. But effective and frequent drainage of the breast right from birth is also vital in terms of establishing a good milk supply and sustaining it long term. A real risk with babies who are tongue-tied is low milk supply due to their inability to effectively drain the breast. So, if a baby is not latching effectively, has weight issues, is not producing the
expected wet and dirty nappies and is not draining the breast well then expressing is crucial to protect your milk supply.

Protection of the milk supply is the single most important thing if you want to breastfeed long term. Most breastfeeding difficulties, whatever their cause, will be much easier to overcome if mum has established and maintained a good milk supply. For babies who are not going to the breast at all you will need to express at least 8 times per day for about 10-20 minutes, preferably with a double electric pump during the first 6 weeks to establish and secure a supply. A full supply on average will be around 700-800mls produced over a 24-hour period but it will take 2-4 weeks to get up to this level. This may sound like a lot of work so seeking advice from your infant feeding team, a breastfeeding counsellor or lactation consultant in this situation will be really helpful as they can help you develop a pumping plan that is sustainable for your situation. They will also have lots of handy hints and tips on what type of pump to use, flange fitting, pumping techniques to optimise milk production and cleaning your breast pump.

There will be situations where mums struggle with expressing and where formula will be suggested. It is important that any formula given is first and foremost prepared correctly. for information see here.

Secondly the formula needs to be given in amounts that are adequate to ensure baby’s nutritional needs are met. However, often when there are worries about weight gain the amounts given can be far more than is needed and this is detrimental to breastmilk supply. So, formula supplements need to be given with care whilst maximising breast stimulation and drainage to preserve and optimise supply. This is a fine balance and again something your NHS infant feeding team or an IBCLC can provide help with.

Flow regulation difficulties (gulping and choking) associated with tongue-tie are some of the easier issues to address conservatively whilst you wait for a tongue-tie assessment and division. Laid back feeding positions utilise gravity to slow down flow and hand expressing or pumping off a small amount of milk before a feed can also reduce the force of the ‘let-down’. Catching the ‘let down’ in a muslin can also be effective. These measures can also help reduce wind and reflux. Keeping babies upright after a feed for at least 20 minutes will also help a baby bring up any wind and reduce vomiting. There can be other causes of excessive wind and reflux, such as allergy or over supply, so talking this through with your NHS infant feeding team or an IBCLC can be helpful.

I hope what you have taken from this blog is that there is a lot that can be done to help you in your breastfeeding journey whilst you wait for tongue-tie assessment and division. Any delay in accessing division does not have to mean the end of breastfeeding. The strategies I have described here (and this is by no means an exhaustive list) I use every day when I am doing divisions because a division alone will rarely ensure successful breastfeeding. There are always other issues to address and accessing the right infant feeding expertise and having support from other mothers via groups is essential. This help and support is still available. It is just in an online or telephone format. So please don’t give up. Contact your NHS infant feeding team who can provide you with help and support and sign post you to local breastfeeding support groups. You can find a breastfeeding counsellor, IBCLC or tongue-tie practitoner by contacting:

• La Leche League
• NCT
• Association of Breastfeeding Mothers
• Lactation Consultants of Great Britain
• Association of Tongue-tie Practitoners

The is also an excellent source of help and support National Breastfeeding Helpline

You can contact me via my website
My free breastfeeding groups (both available online) can be accessed via Facebook:
Ely Milks
Bury St Edmunds

Other useful information:
Covid 19 and implications for tongue-tie division in infants
A Parents Guide to Tongue-tie

References
Hogan M, Westcott C, Griffiths M (2005) A randomised, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health; 2005 https://www.ncbi.nlm.nih.gov/pubmed/15953322

Sarah Oakley RN, HV, IBCLC Independent Nurse, Health Visitor, Lactation Consultant and Tongue-tie Practitioner. 5/4/2020.