Tongue Ties in Breastfeeding Babies – An Irish Perspective

Last week I got a call from a breastfeeding supporter who was reduced to tears with worry in relation to a mother and baby who she was supporting. The baby was having trouble breastfeeding and the breastfeeding supporter was almost certain that the baby had a tongue tie. The mother concerned could not afford to pay privately for a tongue tie division. It is very hard to get a referral from a maternity hospital to private providers and the waiting list for public providers is currently approximately between 3 and 4 months long.  
This was not an unusual call, I receive calls of this nature on a regular basis. While some parents can access a tongue tie division easily, others desperately struggle to access services. Some parents can access clinics, having had no prior assessment for breastfeeding issues, and have their babies tongue tie divided without delay. Others go for weeks experiencing every breastfeeding issue imaginable.
I see some mothers and babies from whom breastfeeding has not improved post division. This usually occurs as a result of incomplete division. It could also be that the problem was not a tight frenulum in the first place or that full lactation assessment and history wasn’t completed which would have identified the cause of low supply before intervention occurred.

Tongue Tie and Breastfeeding in Ireland

Currently, in Ireland, there is no standardised national or local H.S.E. operated frenotomy service for breastfeeding babies. No audits of tongue tie divisions are available as most are operated as private services. Yet, there are plenty of private services for parents who have the funds to pay for a frenotomy. Our most dismal breastfeeding rates occur within the lower socioeconomic bracket. We need to support these mothers to be able to breastfeed by providing them with all of the services other, more resourced mothers, have access to.
There is a national policy in place, however, like many areas in the Irish health service, there has been no follow-up to provide a workable service once the policy was devised. The policy addresses for Neonatologists, Paediatricians & HSE staff and it was drafted by a working group (of which I was a part). However, it was then deconstructed, changed and signed off without the working group’s approval.
One positive development in relation to the issue is that the HSE breastfeeding website has a newly updated information page on tongue tie for parents. But still, we have no public service for these babies.
I hear stories of babies being referred from maternity hospitals to public clinics and then being given an appointment for 4 months down the road. Nobody can sustain breastfeeding problems for that long. In other instances, parents are relieved to get a quick appointment but then no division is done. They are informed that the baby’s tongue tie is ‘minor’ or ‘mild’. These mothers are advised to simply pump their milk and give their babies a bottle instead. ‘Breastfeeding is painful’, they are told, it comes with the territory. These specialists suggest that tongue ties are over diagnosed, referring to it as ‘an industry’.

Is Tongue Tie Over Diagnosed?

I am frequently asked whether too many babies are being diagnosed and treated with TT (Tongue Tie) in Ireland today. Midwives, mothers and voluntary counsellors enquire why all the babies in my breastfeeding support group have had a TT release. I, personally, have been very confused by the lack of action on the tongue tie issue in Ireland. Have we got it wrong? Are these specialists right, are too many babies having divisions?
I decided to examine the rates of tongue tie division in Ireland per week compared to the amount of newborn babies initiating breastfeeding also per week.

Tongue Tied Babies – The Percentages

In Ireland, 200 babies are born every day for a weekly total of 1400. The national average breastfeeding initiation rate is 56%. This includes all babies who are introduced to breastfeeding, whether it is sustained or not.
It should be noted that this rate sits at a healthy 75% initiation in some areas and less than 20% in others. Examples of areas that have a high breastfeeding rate are Wicklow and South County Dublin. The initiation rate here is over 70% in some pockets, but it falls to 68.3% by the time of the first Public Health Nurse visit at around 1-2 weeks. There is then a further drop to 44.1% at 3 months of age.
Those located in an area with a high breastfeeding rate will naturally encounter more tongue tie divisions taking place. This may explain why some professionals suggest that it is over diagnosed. It can also account for a high incidence of tongue tie procedures in some breastfeeding support groups. Mothers who have been experiencing problems need support and are more likely to attend breastfeeding groups. They also seek out more experienced groups and ones which they feel will be more receptive to their particular issues.  
Thus if we take the national initiation rate of 56% for Ireland, we can estimate that 784 babies start off breastfeeding per week. We know that the reported incidence of tongue tie in babies is 4-11% according to the literature. However, this number accounts for anterior ties only, it does not include numbers for posterior ties.
I approached some of the leading providers in Ireland and obtained approximate numbers of babies attending the clinics on a weekly basis. From this research, it appears that approximately 65 tongue tie divisions are currently being performed across Ireland per week.
65/784*100= 8.29%
This gives us a reasonable percentage of the numbers of babies who are breastfeeding and currently receiving TT release. This number stands at 8.3%, right in the middle of the incidence rate reported in the literature. Considering that posterior rates are not represented in the literature, it is actually likely that under-diagnosis may be occurring. What is clear is that the rate is not off the scale. It is not increasing and tongue tie procedures are not being carried out everywhere.
Even if, for argument’s sake, we were to drop the rate of breastfeeding to 40%, as it is in some areas, the amount of tongue tie divisions would still only be 11.6% of breastfed babies. This does not represent an over-diagnosis in my book.
One study reported that only 50% of babies with a tongue tie will have problems breastfeeding. However, the fact is that clinics only see the babies who present with a problem. A certain percentage of these babies have a posterior tongue tie but we have no incidence rates of posterior tongue tie (PTT) at present. Current thinking is veering towards looking at other reasons or differential diagnosis of PTT. 

To address the question of whether there are too many babies being diagnosed and treated with TT. I must say that some days when I see people’s personal accounts online, I think that there are. Unless a baby’s suck and breastfeeding has been assessed by an International Board Certified Lactation Consultant (IBCLC) tongue tie cannot be out ruled as the cause of the problem. While I agree that not every baby who has a tight frenulum requires a division, most will benefit from it and it will make breastfeeding easier. However, there can be other factors at play that exacerbate the problem or which can masquerade as tongue tie.

Ireland Needs a Tongue Tie Action Plan 

What I cannot understand is why our neonatologists and paediatricians have dismissed this problem. How can they silence lactation consultants in the hospitals & HSE and not allow them to refer babies?  Why won’t they allow a team of midwives or lactation consultants to be trained to perform tongue tie divisions in the maternity wards? That, at least, would be a start.  
This problem is far from being resolved. In my view, if every mother/baby pairing who are experiencing problems were provided with a feeding assessment by an IBCLC prior to tongue tie division we would see better results post frenotomy. This, in turn, would promote increased confidence in the existing services. There is a definite need for a national training programme in tongue tie division in Ireland.
So, where does that leave the distressed breastfeeding supporter who I spoke to last week? I am glad to report that she contacted me to say that, in conjunction with the mother, she approached a frenotomy provider who has agreed to perform the procedure at a reduced rate or via a payment plan to ensure that the baby can overcome this problem. The supporter is also maintaining regular contact with the mother to help her through this difficult time.
While this should relieve the current issue for this mother/baby pairing, there are many others up and down the country who remain unable to access the services needed to allow these young babies to avail of one of their most basic needs, to be able to feed.
©Nicola O’Byrne   RGN RCN IBCLC  October 28th 2016.

Joint Statement on the Upcoming Pregnancy and Baby Fairs

We, Amanda Glynn IBCLC (, Carol Smyth IBCLC ( and Nicola O’Byrne IBCLC ( ) have come together to make the following statement re International Board Certified Lactation Consultants (IBCLCs) attending non-WHO Code compliant baby fairs.
The adoption of and adherence to the International Code of Marketing of Breast-milk Substitutes is a *minimum* requirement and only one of several important actions required in order to protect health practices of infant and young child feeding. (Resolution WHA 34.22)

Why would a formula company invite a breastfeeding advocate and/or healthcare expert, such as an IBCLC, to attend its Pregnancy and Baby fair?
Having an expert such as an International Board Certified Lactation Consultant associated with a Code violating company, lends credibility to it's products and activities. It’s a clever marketing ploy that achieves endorsement by association, whether or not that was the IBCLC’s intended outcome. When an IBCLC has an association with a formula manufacturer, directly or indirectly, we believe that the IBCLC is not meeting his or her responsibilities under the spirit of the Code. It is our contention that lending support to such events not only serves to undermine the professional integrity of the IBCLC credential and profession but also threatens future breastfeeding advocacy efforts. 
Stand holders and presenters at baby fairs are there to increase sales through discounts and complimentary gifts, which in turn builds brand awareness and loyalty. Some of the stand holders and presenters have chosen to further promote this non-Code compliant Pregnancy and Baby fair by offering mothers “free” attendance tickets. It is worth noting that even when a company offers free tickets to an event, the cost of providing those free tickets is simply absorbed by the marketing department of the formula company and added to the price of the products that fall within the scope of the Code. We do realise that the two upcoming Pregnancy and Baby fairs are being run by an event company. However, we believe the main sponsors are funding the bulk of the costs.

Recognising the complexity and susceptibility of the Code as a minimum standards document which is open to interpretation, we further our commitment to upholding the spirit and intention of the Code by declaring that we will not accept, or offer to the public, any inducements (such as free tickets, samples, gifts, material items containing logos etc.) relating to products or entities which fall within the scope of the Code. To strengthen our adherence to the provisions and obligations of the Code and to avoid any conflict of interest, we further declare that we will not offer nor accept any invitation to speak at non-Code compliant events.
Amanda Glynn -
Carol Smyth -
Nicola O’Byrne - 
For further information on WHO Code and IBCLC Code of Professional Conduct please use these links

No... Your Baby Won't Swallow His Tongue!

I can't believe I'm writing this post but this needs to be addressed. Today at the tongue tie clinic, I was asked three times by different parents if this was possible? To divide so far back the baby might swallow it's own tongue.... It is years since I heard this myth being touted by doctors, midwives and lactation consultants (it's the latter that really astonishes me..)
One  very anxious mother asked - " I know this is a stupid question, but could he swallow his tongue afterwards?"
Various people in the maternity hospital had said to today's parents..
"It's a dangerous procedure , your baby might swallow its tongue"
"I wouldn't advise getting that tongue tie divided, its only mild, it will stretch and more importantly the tongue might double back on itself and choke the baby"   Wow, three myths in one sentence!
Let's have a little anatomy lesson..

The tongue is an amazing thing - it is a muscular hydrostat (this means it can change shape in many ways-  like an elephants trunk or an octopus's tentacles) . I can understand this might make people nervous of going near it with a scissors.

 This is why tongue tie division should be performed by someone who has had surgical training.

However it is necessary to have good movement of the tongue for a baby to breastfeed well. 
Scaring parents by telling them myths is unfair and not supportive of women, babies or breastfeeding. It's unprofessional, personal opinion and has no place in a ethical  evidence based profession, such as the IBCLC. 

The tongue is a muscle that is connected to the hyoid bone in the throat and the mandible (the lower jawbone). The frenulum is a piece of tissue that is underneath the tongue - it is not connected to the tongue muscles. When a frenulum is divided ( a tongue tie release)-  the trained person doing the procedure cuts back as far as the muscle. They don't cut into the muscle. They cut the tissue in front of it and make a diamond shaped wound.  This diamond gives the baby extra lift, lateral movement and extension to manage the  mechanical work of breastfeeding.
Look at this image below, Can you see where the tongue is connected in both places? It's just not possible for the tongue to fold back on itself.
Image from

Here's another nice video going into a lot more detail on the muscles and  nerves of the tongue and also the hyoid bone. 

I'm thinking my blog post is going to address the "money making racket" of Tongue Tie in Ireland.


Here is a piece I wrote for recently... 

Are you thinking about breastfeeding? If so, you might be confused about where to even start. I was.
And even when I did feed, I encountered problems. The details of which are for another day. But, with perseverance and some professional help from a Lactation Consultant (aka Lifesaver/Legend/Fairy Godmother), I got there in the end. And it was worth every single second.
For some, nursing isn't a problem. For others, it takes a little time to get into the groove and some help along the way. And then there's the few that need help with spotting things like Tongue Tie to get them there.
When you're plodding along with your bump, you just don't know which of these boxes you might fall into. Chances are it'll all happen easily and naturally, and in most cases, it really does. But, despite this, everyone – even the natural nursers – need a helping hand with things like knowing how long to feed, whether to feed both sides, when to wind, when to start expressing, and just how much or how little to express.
If there's one piece of advice I could tell my naïve self before I had my first baby (Full disclosure: I was clueless), it's that the best money you will ever spend, hands-down, is on a breastfeeding course with a Lactation Consultant or a one-on-one session once the baby rears its little head.
So, I chatted with leading Lactation Consultant, Nicola O'Byrne – the go-to woman in Dublin, renowned for her brilliant approach and gentle nature – for a little bit of her wisdom for preparing to nurse.
1. Your breasts have been preparing to feed and nurture your baby since the minute you became pregnant. Be confident and learn as much as possible before the baby arrives so that if you run into a problem, you will know what to do and where to get good effective help.
2. There's no need to prepare your nipples for breastfeeding. There are tiny glands around your areola that secrete oils and get them ready for the important job ahead.
3. Breastfeeding pillows are not really necessary – I find they can cause more problems than they help. Put lots of pillows and cushions under your arms and let your body support your baby by lying back when breastfeeding.
4. Going to a breastfeeding class is a great idea. You will learn lots and you'll know what to do if you run into trouble like if your baby not latching easily after the birth. A good class will shows lots of videos, have practical demos and lots of chat. In my class, everyone has time to ask questions and can stay behind if there is anything they would prefer not to discuss in the group.
5. What should you buy? Generally, I recommend a sleep nursing bra or a breastfeeding vest for the hospital. These are much more comfortable to wear in bed. Two nursing bras is sufficient for the early weeks.
6. Should you buy a book? Yes (and give it to your partner to read!). I recommend The Womanly Art of Breastfeeding by La Leche League International. It’s a breastfeeding bible, beautifully written and easy to dip in and out of.
7. Going to a breastfeeding group before you have your baby is invaluable. Most mothers think they can't go beforehand, but the voluntary groups welcome pregnant mothers with open arms. You get to see lots of babies breastfeeding and chat to the trained counsellors. Sometimes in Ireland, it’s easy to assume that everyone has problems breastfeeding. Going to a group will show you that there are lots of happy mothers and babies out there.
8. Websites to learn about breastfeeding? At the moment,Nancy Morbachers Natural Breastfeeeding channel on Youtube is my favourite. And the HSE has recently updated the National Breastfeeding Website.
Nicola O’Byrne is a lactation consultant in Dublin who holds regular breastfeeding classes. Find out about booking and class times via her website,

What does crawling have to do with breastfeeding?

Sometimes I  will suggest  a mother brings her baby to a bodyworker ( CST, Osteopath or chiropractor) . If a baby is having problems breastfeeding on one side or if a baby won't extend it's tongue and or head  to feed, or if the baby clamps its jaws-  it causes problems breastfeeding. Most of these babies hate being on their tummies (because its not comfortable).
 This is a wonderful article from an Occupational Therapist on why crawling is so important.

Crawling starts with tummy time...

Tweets from the recent 2014  IATP conference included a lot of discussion about tummy time. Michelle Emanuel an Occupational Therapist from Cininnati Childrens Hospital spoke about the benefits of putting babies on their tummies as part of rehab after tongue tie division.  
Her website is here for more info ( click here)

If you find that your baby hates tummy time sometimes wearing them in a stretchy wrap sling can build up tolerance to extending their head and neck . That in turn works the abdominal muscles. 
Here are some ideas for adapting tummy time to make it easier for your baby. 

Happy World Breastfeeding Week!
In February, I started working with Dr Siun Murphy, Consultant Plastic Surgeon, Blackrock Clinic, Dublin. We divide tongue ties in babies up to 1 year old mainly for breastfeeding issues. Ive learnt so much in the last 6 months and really enjoy Wednesday mornings with the team in Blackrock. Its just fantastic to see the relief on parents faces when the procedure is done. Most can see or feel a difference in the babies feeding straight away.  We've had IBCLCs and  HCPs come in to observe and learn about tongue tie. 

Officemum Interview

A quick hello from Lactation Land.
Today OfficeMum published an interview with me about the realities of being a working mother with 5 children.
I guess reading it might explain why theres so few posts on this blog!
So I do hope to post a bit more this year. If anyone has  suggestions about what they'd like to see then please let me know.