Treating Tongue Tie: Evaluation of the Mother-Baby Dyad
Updated: Jan 21
When evaluating pediatric patients with ankyloglossia, or tongue-tie, in the context of feeding difficulties, it is important to obtain a thorough history of the mother. Exploration of factors including mother’s health status during pregnancy, and labor and delivery details can provide insight into reasons for feeding troubles. In addition, a focused physical exam of the pediatric patient and assessment of the child’s breastfeeding sequence can help distinguish tongue-tie from other diagnoses.
We’ve provided the highlight reel below, but you can listen to the full podcast here.
The BackTable ENT Brief
Insight into etiology of feeding difficulties can be gleaned from a careful history of the mother. Key factors to explore include maternal health during pregnancy, specifically thyroid status, as well as labor and delivery details. Extended labor induction time can falsely inflate the birth weight of a child, so the 24-hour weight may be more accurate. C-section delivery is a risk factor for delay in lactogenesis. Conversely, previous breastfeeding experience is correlated with faster lactogenesis. The role of birth control on milk supply is unclear, and limited good quality evidence is available.
A focus on functional status of the tongue is important when evaluating tongue-tie. Movement of the tongue following stimulation of suckle response can serve as a proxy for suction generation ability. Just as important is the coordinated undulation of the tongue from posterior to anterior which is necessary to coax milk out of ductules. Physical exam can also help distinguish tongue-tie from other conditions including torticollis, laryngeal cleft, or obstructive sleep apnea.
Disclaimer: The opinions expressed by participants of the BackTable ENT Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable ENT.
History Taking for the Mother-Baby Dyad
Dr. Shah, Dr. Agan, and Dr. Lene-Voit discuss the various factors to consider in the evaluation of the mother-baby dyad. In particular, the importance of the mother’s history is highlighted. Factors to consider include mother’s thyroid status in pregnancy, labor induction time, method of delivery, current hydration status, and previous breastfeeding experience. Furthermore, specific information regarding the child’s breastfeeding sequence is essential when determining the cause of feeding difficulty. The role of birth control on milk supply is unclear, and limited good quality evidence is available.
..I would love to hear more about the mother as a patient as well in the sense of tell us just specific concrete things that you... what's part of your H & P in clinic when the baby and mom comes in?
..The first things that I'm looking for are signs that there might be a latch issue because that's directly related to the baby's ability to extract milk, but then there are also reasons why maybe baby is doing fine but mom may not have as good a supply. And of course, it's kind of difficult to tease that out because it could also be related to negative feedback from baby not doing a great job extracting because of a tie or a poor tone or any other reason.
But I asked mom about her thyroid status in pregnancy, which is something that all OBs test for…I ask her if she's breastfeeding if her breasts feel full before a feed and then empty afterwards. This is more on the baby side, but I ask about the suck, swallow, breathe sequencing to make sure that baby's sucking a few times then swallowing then breathing rather than just suck, suck, suck, suck, suck and not really needing to swallow because that can be an indicator that they're not extracting very much milk.
I've had a couple of moms who make so much milk and they're coming to me because of difficulty eating in it. It turns out not that the baby doesn't have a tongue-tie it's just that mom has so much milk that the baby's almost choking on it because there's either a forceful letdown or there's just so much milk the baby's kind of overwhelmed by it. And usually that's in younger babies. Usually as babies get older they can handle fast flow a little bit better or they come up with mechanisms to deal with it.
Right. What other things do you take into consideration?
So some people have different responses to birth control. There's not a lot of great evidence to support that in populations, either estrogen containing birth control or something like the Depo shot or a progesterone implant affects supply. But some moms swear that it does. And so I always ask about it just to have it in the back of my head. If they had a prolonged induction then the baby could have sort of falsely inflated birth weight, and especially in very young infants who haven't regained their birth weight yet it's useful to know that because we might be shooting for a target that's falsely inflated, and we might think there's a problem when there actually isn't.
And so in that case, I'll try to see if we can figure out what the 24-hour weight was because that's more likely to be a little bit closer if the induction took longer than 24 hours and mom got a fair amount of fluids in labor. If mom had a C-section, that's a risk factor for potential delay of lactogenesis too, so the transition from colostrum to a more mature milk. And particularly if there's any hemorrhage that happens. And so I ask about skin to skin mode of delivery. No one ever has any idea I'm sure. I mean, I don't know how many bags of fluids I got in labor either, but as a general rule if it took a long time, it's probably a little bit higher risk.
Scheduled C-sections are higher risk for delay in lactogenesis than our sections where mom labored for a while and then had a section for failure to progress or some form of fetal distress. But the trade-off is that when we're seeing those moms with really young babies, they're still pretty exhausted from the process of laboring and then having a section. So it can be hard to tease that out.
The other thing is there's so many demands on a new mom's time. Sometimes it's something as simple as how much water are you drinking, and they're not taking care of themselves because they're trying to take care of this baby. And then if they're not hydrating it's hard to give baby hydration if you're dehydrated.
So I don't ask everyone all of those questions, but sort of according to how the history is going those are some things that I definitely do ask. I ask primip versus multip, "Have you successfully breastfed in a child before?" And I find that the more kids that a mom has had that, and this is born out by the evidence as well, that the quicker milk usually comes in and the more sense they have as far as at least comparatively what the quality of the latches.
So the quality of the latch is related to if she's had multiple kids. Is that what you're saying?
I think she just has more of an experience-base to know what a normal latch is. And especially in the beginning, when you have a small baby with a small mouth, there can be sort of a size mismatch between nipple and mouth and even a very mobile tongue and non-retrognathic chin and a good anatomy baby with a tongue that can be very mobile to extract milk might still have a hard time with latch and there might be painful latch. But something that's a warning sign for me is pain that lasts more than the first couple minutes or so of the feed. There's a lot written by lactation consultants about lipstick shaped nipples. And then cracked fissured nipples are certainly something that I worry about.
Physical Exam Considerations for Evaluating Tongue-Tie
Dr. Lene-Voit outlines her physical exam techniques which focus on assessing functional status of the tongue. She aims to stimulate the suckle response and then uses the movement of the tongue as a proxy for suction generation. In addition, she closely observes for coordinated undulation of the tongue from posterior to anterior. Through this evaluation, she is able to distinguish tongue-tie from other conditions including torticollis, laryngeal cleft, or obstructive sleep apnea.
When do you decide to go ahead and do the frenotomy…?
When I do the physical exam, I look visually to see if there's a tie. But to me, what matters a lot more is the functional exam. And tell me how you all do this, but I use a gloved finger and I stick it on in there and kind of tickle the palette to try and stimulate the suckle response. And then I feel the tongue move and I try to see how good of a hole baby has on my finger as kind of a surrogate for how much suction they're able to generate. But then also there's a that what's as important as the suction is actually the massaging movement from posteriorly to anteriorly of the tongue, sort of coaxing milk out of those ductules. And so if I don't feel that tongue kind of undulating in a coordinated fashion from posterior to anterior, I don't know that I think that cutting the frenulum is going to help a ton.
Of course, I look to see if they can stick their tongue out of their mouth past their gums, but that hasn't been shown to be a totally helpful parameter in all cases. And so I honestly don't know how much weight to put to that. I always document it, but I feel like the sort of functional assessment is a little more reassuring for me if I'm going to recommend the procedure. There are some situations where the baby seems to have torticollis, their jaw seems really stiff, or they're having other symptoms that make me worried they have a laryngeal cleft or something like that. And if I'm getting any sort of antenna signals that they had tone issues or mom says anything that makes me think, "Oh, maybe they have sleep apnea," I really am very reluctant especially the first time I meet them to do a procedure.
I know that the clinical consensus statement wasn't all that worried about cutting a tongue-tie being an issue for OSA…But I like a little bit more data in that situation. So if they seem, if something just seems a little off, then I feel a whole lot better about having Speech [speech language pathology] look at them first.
Dr. Felicity Lenes-Voit is a practicing ENT and an Assistant Professor in the Department of Otolaryngology at UT Southwestern Medical Center.
Host Dr. Gopi Shah is a practicing pediatric otolaryngologist and Assistant Professor of Otolaryngology at UT Southwestern. Host Dr. Ashley Agan is a practicing general otolaryngologist and Assistant Professor of Otolaryngology at UT Southwestern.
Cite this podcast:
BackTable, LLC (Producer). (2020, October 20). Ep. 08 – Treating Tongue-Tie [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable ENT Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable ENT Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.