Nine Days Old, Feeding Constantly, and Losing Weight

Quick answer: A tongue tie only needs releasing when it is causing a functional problem — usually feeding difficulty with pain for the mother and poor weight gain for the baby. The appearance of the frenum matters far less than what the tongue can actually do.

The call

She was crying on the phone, which happens more often than people admit at nine days postpartum.

A mother in Nofei Aviv, second baby, feeding every ninety minutes around the clock, each feed lasting close to an hour, nipple pain she described as unbearable, and a baby who had not regained his birth weight.

Somebody at the tipat chalav had mentioned a tongue tie. Nobody had assessed it.

What we found

Assessment of a tongue tie is functional, not cosmetic, and that distinction governs everything.

The appearance: a thin frenum attached close to the tip of the tongue, extending to the floor of the mouth. When he cried, the tongue tip notched into a heart shape.

The function, which is what matters:

• He could not lift his tongue tip to the roof of his mouth with the mouth open.
• He could not extend the tongue past the lower gum ridge.
• He could not lateralise it to either side.
• On a gloved finger, the suck was shallow and rapid, with the tongue humping rather than producing a smooth peristaltic wave, and he broke suction repeatedly.

The maternal findings, which are half of the assessment and are frequently not examined at all: nipple trauma with visible compression striping, a misshapen nipple after feeding, and pain throughout the feed rather than only at latch.

The weight: 9 per cent below birth weight at day nine, when most babies have regained it by day ten to fourteen.

That combination — restricted function, maternal pain and trauma, poor weight gain — is what justifies release. Any one alone usually does not.

When a tie should be left alone, which is at least as important:

• A tie that looks tight but the baby feeds well and gains weight. Appearance alone is not an indication.
• A tie in a baby with a shallow latch that resolves with positioning help. Many feeding problems are positional and a lactation consultant fixes them without any procedure.
• Asymptomatic ties found incidentally in older children with normal speech and eating.

Tongue tie release has become fashionable, and a proportion of procedures are done on babies who did not need them. The assessment is the safeguard, and it must include watching a feed.

We watched a full feed before deciding.

What we did

A frenotomy, the same day.

The procedure: the baby swaddled, the tongue lifted with a grooved retractor, and the thin frenum divided with sterile blunt-ended scissors. It takes a few seconds. The frenum in a newborn is thin and largely avascular; bleeding is a drop or two and stops with pressure.

No anaesthetic is used for a simple anterior tie at this age, which surprises parents. The tissue has minimal innervation, the procedure lasts seconds, and the crying is predominantly about being held still.

He was fed immediately afterwards, on the spot, which is both comforting and the first test of whether it worked.

Lactation follow-up at 48 hours, which is the part that determines the outcome. Releasing the tie removes the restriction; the baby still has to unlearn a compensating suck pattern he has practised for nine days. Without follow-up support, a meaningful proportion of releases produce disappointing results for exactly that reason.

Stretching exercises were discussed. Practice varies considerably and the evidence is not strong. We advised gentle tongue movement play rather than an aggressive wound-stretching regime.

The outcome

Feeding was more comfortable at the first feed and substantially better within 48 hours. Feed length halved over the following week.

He regained birth weight by day sixteen and tracked normally afterwards. Her nipple trauma healed in about ten days.

She fed him for fourteen months.

What to do if this happens to you

1. Get a feeding assessment, not just a look in the mouth. Function decides this, not appearance.
2. See a lactation consultant first or alongside. Many feeding problems are positional.
3. Ask what the specific indication is. Restricted movement plus symptoms — not appearance alone.
4. Ask about follow-up support. Release without it often disappoints.
5. Act promptly if weight gain is poor. This is time-sensitive for feeding establishment.
6. Be cautious of release offered without a feed being observed.

Feeding difficulty in a newborn? Ramat Beit Shemesh Urgent Dental Care assesses function, not just appearance. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.