Does your baby have a heart-shaped tongue?

Dana Schmidt immediately noticed that her fourth child breastfed differently than her first three. When the baby latched on, Schmidt felt a sharp pain and her daughter Kate couldn’t seem to get enough milk.

“I had this horrible, horrible pain — like glass shards —every time the baby sucked,” says Schmidt, who lives in Branford, Connecticut.

Schmidt asked her pediatrician about the problem, but the doctor wasn’t sure what the problem was. Schmidt and her husband studied their baby’s mouth and noticed that her tongue looked similar to a heart. When her husband googled “heart-shaped tongue,” the couple saw a picture of what might as well have been their daughter’s tongue reflected back at them from a doctor’s website.

“We were looking at pictures and were like, ‘Yes! That’s what she has.’” Schmidt recalls. They called right away to hear the doctor’s perspective on Kate’s condition, known as ankyloglossia, or tongue-tie.

What is tongue-tie?

A small piece of tissue, called the lingual frenulum, connects the bottom of the tongue to the floor of the mouth. In tongue-tie, the frenulum is attached closer to the tip of the tongue than the back, so it is shorter and tighter than usual, which can restrict the tongue’s movement. When an infant tries to lift its tongue and the center stays tethered down, it creates the heart shape that Schmidt and her husband noticed with Kate.

Tongue-tie occurs in 4 to 10 percent of babies and is more common in males. But it’s important to note that up to 50 percent of the time, tongue-tie does not cause difficulties breastfeeding, and the frenulum will stretch itself out over time, eliminating the problem.

In certain cases, though, tongue-tie leads to significant breastfeeding troubles. Since the child is unable to latch on properly, they might use their gums or jaws on the nipple, which can cause intense pain. Restricted tongue movement also makes breastfeeding harder and less successful for the baby, who can tire out before drinking enough milk.

What is a frenotomy?

The procedure to correct tongue-tie is called a frenotomy (or frenectomy), in which doctors cut the frenulum with a sterile scissor, scalpel or laser so the tongue can move freely. The procedure is safe and quick, with low risks of pain, bleeding, scarring, and in very rare cases, infection. Frenotomies are not usually performed with anesthesia, but if they are, the risks could increase, says Dr. Steven Handler, an ear, nose and throat specialist at Children’s Hospital of Philadelphia.

Frenotomies, often covered by insurance, cost $200 to $500 when performed with a scissors and $800 to $1,200 with lasers, says researcher and lactation consultant Catherine Watson Genna of New York City.

The evidence

Reviews of the literature provide some data to support the procedure, although the evidence is not robust. One United States-based review concluded that there are small improvements to the mother’s reported quality of breastfeeding and nipple pain, as did a review conducted in Ireland. A Canadian review determined that “overall, there is evidence that frenectomy is a safe procedure with demonstration of benefit for short-term breastfeeding effectiveness.”

The most important takeaways are that “you should be well informed of what your options are, you should see someone who is really knowledgeable about ankyloglossia, and you should see a lactation consultant,” says Dr. Anna Morad, a tongue-tie researcher and pediatrician at Vanderbilt University School of Medicine in Nashville, Tennessee.

However, there is somewhat of a divide within the field. Doctors are wary of performing a potentially unnecessary procedure, while lactation consultants and mothers may push for it to reduce the mother’s pain, to avoid formula, and to prevent potential problems down the road like speech articulation.

The lack of robust data only serves to widen this divide. Frenotomy is a challenging procedure to study, both in terms of reliably quantifying the problems before the procedure and the benefits afterward. It’s particularly hard to study in randomized control trials, considered the gold standard for scientific research, because mothers can usually identify if their baby had a frenotomy or not, which could lead them to subconsciously over-report improvement.

Should my baby have the procedure?

If you experience pain breastfeeding, a pediatrician should make sure the baby truly has tongue-tie and that the condition is causing genuine difficulties, Handler says. After that, the pediatrician can check to make sure there are no other factors at play, like a cleft palette or weight-gain problems. The mother should also see a lactation consultant to make sure she’s breastfeeding properly and to experiment with other techniques, Murphy says. After that, the doctor may move forward with a frenotomy.

“[Doctors should] really make sure you look at the baby’s overall health and well being, and then you evaluate whether the baby needs a tongue tie operation or not. We should be very balanced about it,” says Dr. John Murphy, a researcher and neonatologist at the National Maternity Hospital in Ireland.

Schmidt worked through these steps with Kate.

First, her health maintenance organization recommended that she switch to formula. When she pushed for another option they sent her to a pediatric surgeon who would use anesthesia, but Schmidt wanted to avoid that.

The next stop was a pediatrician and certified lactation consultant, who recommended a frenotomy. The doctor snipped Kate’s tongue with a scissors, and there was no bleeding or side effects. “That’s all there was to the procedure, and I could feel the difference immediately in how Kate sucked,” Schmidt says.

By the time this happened, though, Schmidt was struggling with her milk supply so she had to supplement breastfeeding with pumped milk, which was time consuming and exhausting. When her next child, a son, turned out to have tongue-tie he had a frenotomy right away.

Although the process was difficult, she’s glad that it happened because the experience shaped a part of her future.

“It was a little bit more of a struggle, but it made me to go on to advocate for other women who have tongue-tie and become a board certified lactation consultant,” Schmidt says.