Not All Breastfeeding Problems Are Caused by Tongue-Tie

by Bobby Ghaheri

As is the case with the identification of any new medical problem, there is bound to be excitement about helping those in need. Sometimes, that excitement can lead to false attribution of a problem to that "new" diagnosis. While tongue-tie or upper lip-tie are not technically new diagnoses, the correlation between tight frenula and breastfeeding problems is a relatively new one. Because I treat many babies each year where babies are having problems from tight frenula, I inevitably end up turning away many babies who aren't needing treatment.

Not every nail needs the same hammer. Tongue-tie and lip-tie may cause some, but not all, breastfeeding problems.

The first place any mom and baby should go when breastfeeding problems arise is an IBCLC (international board certified lactation consultant). Here is a great post on how to choose a lactation consultant. 

There are many potential causes of breastfeeding problems. I asked a group of great lactation consultants for a list of other causes for breastfeeding problems (specifically, pain). Here's what they came up with:

  • Technique problems - This includes poor latch technique, especially with positioning. Often, inexperienced moms picture breastfeeding like how a baby feeds from a bottle (this can also happen if the baby has nipple confusion when going from a bottle to the breast). They present the nipple instead of the breast, which can cause pain. Poor positioning can certainly be a problem (often caused by the wrong kind of pillow or how the baby is held). Nursing an acrobatic toddler who may forget that he/she is breastfeeding when something more interesting comes by can cause pain.
  • Anatomical problems in the baby - There are anatomical issues other than tongue-tie or lip-tie that negatively impact breastfeeding. One of the most common is tight oral/neck musculature. This can stem from a traumatic birth, suboptimal intrauterine positioning, or torticollis. Congenital disorders of the baby can affect their oral or facial anatomy that can make breastfeeding extremely difficult (cleft lip or palate, for instance). 
  • Specific factors affecting the breasts - While some of these factors can be caused by tongue-tie or lip-tie, diseases of the breasts themselves can be the sole cause of problems. Raynaud's disease or vasospasm can make breastfeeding extremely painful. Overly engorged breasts may make it difficult for the baby to latch on to a taut breast. Mastitis, plugged ducts, thrush and blebs can come from trauma during biting or chewing by the baby. Some moms have allergic reactions to products applied directly to the breasts (or to fragrances in toiletries or laundry). A small subset of moms have pain with letdown, or a painful milk ejection reflex. Others have severe negative emotions associated with letdown, called a dysphoric milk ejection reflex. A history of nipple piercings may have caused nerve sensitivity for mom during breastfeeding.
  • Psychological or other health factors that can affect breastfeeding - Postpartum depression can magnify any discomfort at the breast or can be interpreted as discomfort. This becomes especially apparent when the baby has other reasons to have breastfeeding problems (specifically with tongue-tie or lip-tie). Any history of sexual abuse can become a major hurdle for successful breastfeeding. Primary pain disorders like fibromyalgia can also become very problematic for a mom who is trying to nurse. Some moms experience increased discomfort when menstruation returns.
  • Equipment misuse - Improper use of a nipple shield can certainly cause problems breastfeeding, either leading to inefficiency of transfer, frustration for the baby or frank pain for mom. Additionally, improper use of a breast pump can cause undue pressure and pain on the nipples.

This list is by no means exhaustive. It is only meant to demonstrate that a mom who is experiencing difficulty with breastfeeding needs to visit someone who is versed in diagnosing these potential problems. Obviously, tongue-tie and lip-tie can play a role in breastfeeding problems, but I worry about the panacea-like mentality that can result when trying to solve a problem for a mom and baby. This is made even more likely given the desperation these dyads feel when something so basic and important becomes difficult.