Tongue Tie & Revision

Tongue Tie: When You Choose to Not Revise

Once it has been established that a baby 1) fails the HATLFF and 2) has a tongue tie diagnosed by a revision provider, parents are left with the difficult decision: should I revise?

There are some breastfeeding circles that believe very strongly that, yes, you should.

Here at Balanced Breastfeeding, we don’t believe in “should.” We believe in presenting parents with the information and support they need to make the best decision for their family.

If you decide to not have your baby’s tongue tie revised, we have devised some strategies to help protect your breastfeeding relationship.

Breastfeeding a baby with a tongue tie generally falls into three categories (reminder: breastfeeding must be comfortable and effective):

  1. Breastfeeding is comfortable and effective and the tongue tie doesn’t seem to be causing any issues.
  2. Breastfeeding is effective but not comfortable or it is comfortable but mom’s nipple is misshapen when the baby unlatches.
  3. Breastfeeding is comfortable, but not effective.

Before I proceed with my recommendations, I want to emphasize the importance of working with a quality IBCLC. A quality IBCLC doesn’t say, “Your baby needs to have his tongue revised.” She doesn’t circle back and blame not revising the tie for difficulties managing breastfeeding in the future. She simply accepts the parents’ choice to revise or not and continues to work with the breastfeeding situation at hand. She should still be working with the parents to actively manage the discomfort or ineffectiveness of breastfeeding in other ways.

Also, tongue ties rarely exist in the absence of other breastfeeding issues. A mother may have too much milk or too little milk. The baby may have a high arched palate or low tone. The mother may have severe nipple trauma that we are working together to heal. The baby may have reflux or excessive painful gas or be high needs and fussy.

My point is that none of this is black and white. You cannot read this blog and self-manage. That said, I know too many women are struggling to get access to compassionate, quality lactation care. So, I will still post my recommendations.

Here is what I want every mother breastfeeding a tongue-tied infant to know:

If breastfeeding isn’t comfortable but is effective, be prepared to manage discomfort long term and be on alert for breastfeeding to become ineffective.

If breastfeeding isn’t effective, but is comfortable, be prepared to help maintain efficacy long term and be on alert for it to become uncomfortable.

If breastfeeding is comfortable and effective, be on alert for it to become uncomfortable and/or ineffective at any point in the breastfeeding process.

Here are recommendations we make to the parents who choose to not revise their baby’s tongues:

  1. Keep the baby well-fed.

Be prepared for the baby to be satisfied at some feedings and hungry after others. This is particularly true if you feel like your breasts aren’t well-drained and baby is frustrated at the breast. Tongue-tied babies thrive off of “easy milk.” This is the first let down that happens with just a flick of the tongue. In the first six weeks of breastfeeding, especially if you have a baby who is gaining well and you have an ample milk supply, this may be all baby needs to get a full feeding. However, when your milk supply stabilizes around six to eight weeks, the first easy let down may not be as abundant and your baby may now need to create more vacuum to elicit the second let down. Since your baby probably has limited vacuum, she may not be able to elicit a second let down, or she may fall asleep at the breast from fatigue before she is done nursing. This leads to an incomplete feeding for baby (which can lead to very frequent feedings, a foremilk/hindmilk imbalance, poor weight gain, etc.) and it can lead to a quickly depleting milk supply.

  1. Maintain an ample milk supply.

Since an even, regulated milk supply or a low milk supply can be more challenging for a baby with a tongue tie, in some cases, it may be beneficial to maintain somewhat of an overabundance of milk for the tongue-tied baby in order to keep breastfeeding a bit easier for him. It is not reasonable or realistic to pump after every breastfeeding session, so we recommend pumping one to three times a day within 15 minutes of finishing a breastfeeding session. Keep this milk handy in the fridge or freezer for frustrated feedings, but you may find you don’t need to use it on a regular basis. This pumping serves the purpose of completely draining your breasts, hence supporting a slight overabundance of milk.

Be prepared to boost your supply if it drops.

  1. Manage nipple discomfort.

Some mothers who have babies with tongue ties have little to no nipple pain. Others have severe nipple trauma that may take months to heal. If you have had any nipple pain or trauma from breastfeeding, be prepared to actively manage your nipple discomfort. You may find this comes in waves. Some days you may be comfortable directly nursing all day. Other days you may need to pump in place of one or a number of feedings to give your nipples a break. Being keenly aware of how your nipples are feeling and being willing to take a step back when they are starting to feel bad is critical to your long-term breastfeeding success.

  1. Keep close tabs on baby’s weight.

Check in on baby’s weight every two to four weeks. We highly encourage mothers to check in with us at the baby’s three-month mark. Oftentimes, babies are seen by the pediatrician at one month, two months, and four months. The two- to four-month gap is when we often see a drop off in supply and/or infant weight gain. If at any point you get a comment from the pediatrician such as “The weight gain isn’t as much as we’d like” or “She dropped her percentile” followed by “Let’s just watch it” or “It is time to supplement,” it is time to check back in with your IBCLC. Although there is nothing wrong at the time, there is a fair chance that we are getting an early peek at issues to come.

  1. Continue oral sucking exercises.

General sucking exercises include those we recommend for babies after revision. We often encourage different oral exercises based upon the limitation in baby’s oral range of motion, for instance, if baby has a tight jaw or a strong biting reflex. When you are checking in with your IBCLC, she should also be encouraging new and different sucking exercises to help offset baby’s tendency to fall into compensatory oral habits.

  1. Consider baby bodywork.

It is very important that your baby’s whole body, not just his tongue and jaws, are moving freely. We know that babies with tongue ties develop compensations in their jaw and lips, but there is also a strong possibility that the rest of your baby’s body is compensating. Asymmetrically tight neck, shoulder, and hip muscles can limit baby’s ability to not only breastfeed efficiently, but to comfortably move his body. Finding a trusted infant body worker can be a very helpful support measure. Check next week’s blog for more information about infant bodywork.