Tongue-tie
Is tongue-tie under diagnosed or over diagnosed?
In my opinion, both
Tongue-tie has been under diagnosed until recently but is now being over diagnosed and both create problems
What is tongue-tie?
It depends who you ask
Classic tongue-tie has the following characteristics:
The tongue is tethered to the base of the mouth by a band of tissue which runs towards the tip of the tongue
The tongue can’t reach the inside of the lips
This may cause issues with breast feeding, dental care and how words sound
It does not cause speech delay
Even if there is a “notch” in the tip of the tongue (see image) it may not affect how the tongue works
The natural, elastic tissue may stretch over time and “fix” itself
It is not how it looks, it is how it works that matters
What about lip tie, buccal tie and posterior tongue-tie?
There are theories about lip, buccal and posterior tongue ties which have become popular since 2005
Many are working in this space to define, observe or treat and to research the outcomes
It is a very controversial space
There is a lot of disagreement about what is and is not normal
If we decide that lip, buccal or posterior ties cause problems feeding and this is not the case, we create more problems than we solve
Some of the problems we may be creating include
Side effects of treatment such as bleeding, infection, pain and scarring
Oral aversion (see below, under posterior tongue-tie)
If we assume it is a feeding problem due to a tie, we may overlook other causes of feeding problems and delay getting proper advice
Cost
The Australian Collaboration for Infant Oral Research (ACIOR) issued a position statement in October 2017 to try and address some of these concerns
Upper lip tie
There is normally a strand of tissue that connects the middle of the upper lip with the gum—have a look at the inside of your own upper lip
This tissue can be thin or thick and may run all the way down to the bottom of the gum and even a little way on the inside of the upper gum
Some think that this may affect breastfeeding, however newer research into the mechanics of breastfeeding demonstrate that this is not the case
Concerns have also been raised about a long, thick band being responsible for a gap in the upper front two teeth. If this does not improve with age, there may be a benefit from treating it in later childhood. Treatment in babies however may make things worse, by leading to scar tissue which itself causes a gap between the teeth
Buccal tie
This describes the connection between the side of the mouth, on the inside of the cheeks, and the gums
There is natural variation in how this looks
There is no scientific evidence to say that variations affect feeding
Posterior tongue-tie
When you lift the tongue up to the roof of the mouth, in most people you will see and can feel a strand of tissue in the centre of the tongue
Recent research has identified a broad base of tissue which helps to anchor the tongue to the mouth. We all have this tissue, but it is more obvious in some people than in others and is especially obvious when we lift the tongue up. There is no solid evidence that it causes any problems
There is evidence that cutting through this tissue may cause damage to the nerve, may risk bleeding (less common with laser than with scissors) or infection and that the scar tissue which forms may create problems
Regular tongue movement is usually recommended after cutting or laser treatment of a “posterior tongue-tie”, as it is thought this will stop the tongue from reconnecting to the floor of the mouth. Unfortunately, it can distress babies and result in them not wanting anything to be put into their mouth (oral aversion), including the breast. Some babies who were already fussy become even worse after surgery
The Australian Dental Association’s Tongue-Tie guideline has the following to say:
Posterior Tongue Tie - The term ‘posterior’ tongue tie was introduced in 2004 through an opinion piece published in the American Academy of Pediatrics newsletter by Coryllos, Genna and Salloum, classifying the distance of the tongue tip to the leading edge of the frenum.
There is a lack of evidence from dissection studies to support such an entity. Use of this term can result in a normal lingual frenum being classified as abnormal. The term ‘posterior’ tongue tie should not be used as a medical diagnosis.
In short, lip-ties, buccal-ties and posterior tongue-tie are modern phenomena which are now thought to simply represent variations on normal anatomy. Treatment of these variations, while often done with good intentions, may do more harm than good
If not tongue-tie, then what?!
Many of the babies who are thought to have tongue-tie are struggling with unrecognised feeding issues
It is a very difficult space for everyone, including healthcare professionals, trying to work out why babies fuss during a feed
Breastfeeding should not cause pain for you or baby
Position is very important — if you and baby fit together well and baby is securely held, feeding is much easier
The information on this site is not specific to your individual situation and it is important that you find a suitable health care professional who has the knowledge or the contacts to point you in the right direction
Any assessment of fussy behaviour during infant feeds starts with listening and then with looking.
In other words, taking a history followed by an examination of baby and observation of a feed. This takes time
There is an increasing recognition among midwives, lactation consultants, early childhood nurses, GPs, obstetricians and paediatricians that tongue-tie is a solution to only a very small number of fussy feeders
Where can I get more information?
A good summary of tongue-tie is available on the Raising Children and Better Health websites. The Australian Dental Association, working with other healthcare professionals, released a guideline in June 2020, with strong messaging and useful information (see flowchart below). There are a number of free and some paid resources available at Possums online
Take home message:
Tongue-tie is real. But most of what is being described as tongue-tie in the past 10-15 years or so has turned out to be a misunderstanding of normal anatomical variation and the mechanics of breastfeeding. As more research is conducted and there is better information to share with women and with the health-care team, this messy space should become clearer.