One of the more common signs of a tongue tie is when the baby clicks while feeding. In general, a click happens when anything breaks the seal between the tongue and its target (breast, bottle, pacifier, finger). It usually happens when the jaw is moving down, away from the target. Why does it happen?
Let’s briefly review infant tongue mechanics. For illustrative purposes, we’ll assume it’s for breastfeeding but the same information holds for bottles too. Here’s what is supposed to happen:
The baby opens the mouth widely and latches on to the breast with that wide mouth.
The middle (not the front) of the tongue presses up into the breast, towards the palate. This is the source of initial seal formation.
Once the seal has been made, the jaw goes back down. As the jaw goes back down, the tongue is still holding on to the breast so there’s no loss of that seal (it’s supposed to stay up). As the jaw goes down in the setting of the seal being maintained, it increases the volume of the oral cavity. That decreases the pressure in the mouth (aka vacuum) and milk from the breast is withdrawn. This is described by Boyle’s law (with constant temperature, pressure is inversely proportional to volume). The principle is the same as when your diaphragm goes down and increases chest cavity volume to take a breath.
As the jaw goes down, the tongue has to have the ability to stay up on the breast to keep the seal. This is called tongue-jaw dissociation.
Anything that prevents the tongue from staying up on the breast will pull the tongue off of the breast - this is how a click can occur. It’s a seal break. The tongue cannot remain dissociated from the jaw so it acts in a yoked fashion (ie, jaw goes down, tongue goes down).
What can cause the click to occur? The most important thing to understand is that a click does NOT automatically mean tongue tie. It certainly could be a tongue tie - the tie is pulling the tongue back down off the breast. Other causes include:
Muscle tension - if the muscles under/around the tongue are tight, they don’t have the flexibility to allow the tongue to go up and the restricted movement can break the seal. For the professional doing the release, the muscle tension MUST be assessed by physical exam (see my technique) and be improved/resolved before you can consider doing a tongue tie release. If there are tight muscles and you don’t know which is the culprit (the tie or the muscle tension), then you need bodywork/time to resolve the muscle tension to prove/disprove the need for a frenotomy.
Poor breastfeeding technique - an incorrect hold/baby support/latch initiation can minimize contact between the tongue and the breast. It can make the latch artificially shallow and that minimized contact = minimized seal = more likely to seal break. This is why working with an IBCLC is mandatory before considering a procedure (in my clinic).
Vaulted palate - the higher the palate, the higher the demand for upward tongue movement. This means that in two babies with identical tongue ties but different palates, a baby with a vaulted palate is more prone to clicking.
Retrognathia/micrognathia - this describes the situation where the baby’s jaw is receded or extremely small - both situations serve to minimize the contact between the tongue and the breast (because the tongue follows where the jaw goes).
Poor tongue muscle tone - officially called lingual hypotonia, it’s important for everyone to understand that even if the tongue has good mobility, a click can occur if the tongue musculature isn’t strong enough to physically hold the breast seal. In instances where there’s difficulty determining whether a tie needs to be released or not, oral motor exercises to try and strengthen the tongue can be very important. It’s also very important to counsel parents about this possibility after a full frenotomy has been performed. Just having mobility doesn’t make the click go away. Once the tongue has mobility, it needs to develop strength (via oral motor exercises).
Lingual reattachment following frenotomy - even if a full frenotomy was performed (including release of the posterior tongue tie portion), if the post-procedure wound management is inadequate, the wound can draw into itself and pull the tongue back down. An appropriate aftercare protocol is needed to optimize mid-tongue elevation. Understanding proper wound management goals is key. If the wound isn’t properly managed and reattachment occurs, clicking can persist or return.
Why should we care about clicking? The most important reason is that a click allows air to enter the baby’s swallowing attempt. This is called aerophagia (literally, “eating air”). In my professional experience, aerophagia is the root cause of infant reflux. It’s not acid reflux, which explains why some of the largest studies on the topic show that acid reducing medications don’t really help infant reflux much (1). My group has published three studies demonstrating the positive impact that frenotomy has on infant reflux, and the reason improvement happens is because the seal on the breast is improved with release of the tie (2-4). There are four other studies also demonstrating that infant reflux improves with frenotomy (5-8). Additionally, seal break reduces breastmilk transfer and reduces efficiency. If the baby cannot maintain the seal, then they cannot maintain suction. Anything that limits suction subsequently limits the baby’s ability to effectively extract milk from the breast.
One last very important consideration is that aerophagia can occur in the absence of an audible click. How is that possible? Let’s go back to where we started - for a tongue to break the seal and click, the baby must first be able to make the seal. If the baby never makes the seal, then they can never break the seal. In those instances, the tongue dysfunction can still allow air into the system. In fact, many of those babies will begin to click AFTER the frenotomy - I consider that progress because now the tongue can actually make contact with the breast. What needs to follow is tongue strength.
I hope to see medical education change to incorporate the existing data that already show the mechanism of infant latch. In many instances, it’s clear that the doctor taking care of the mom/baby/dyad doesn’t understand the mechanism of infant latching and diminishes the impact infant reflux has on a family. If the thought processes described above start to click with the doctor, maybe the baby will stop clicking.
References
1) https://pubmed.ncbi.nlm.nih.gov/19745761/
2) https://pubmed.ncbi.nlm.nih.gov/27641715/
3) https://pubmed.ncbi.nlm.nih.gov/29787680/
4) https://pubmed.ncbi.nlm.nih.gov/34491142/
5) https://pubmed.ncbi.nlm.nih.gov/35945826/
6) https://pubmed.ncbi.nlm.nih.gov/33337908/