Tongue-tie for clinicians
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
Most health care professionals are trying to do their best to understand and to assist the individual in their consulting room. This is especially important in some fields and feeding a newborn is obviously of critical importance. Despite breastfeeding being a fundamental human activity, there are gaps in research and it is a difficult area to research. When babies fuss and cry, when breastfeeding hurts, when babies are not attaching well or feeding for what seems forever, it is natural that women seek help and that we would want to help.
It starts, as it always should, with a good history followed by a thorough examination (see the oromotor assessment clip below) which includes an assessment of the breast feed. This does not fit neatly into medical appointments, so cultivate good relationships with local experts, be they GPs, early childhood nurses, midwives or lactation consultants. The Australian Dental Association has written a helpful guideline, with midwifery and allied health input, and they stress the importance of function over appearance.
Chart from the Australian Dental Association’s guideline (June 2020) which has strong messaging and useful information
Dr Pam Douglas, GP, researcher and founder of possumsonline.com describes three waves of medicalisation of breastfeeding problems—GORD, allergies and the latest, tongue-tie. It is important that we understand what is normal infant behaviour, how to identify breastfeeding problems and that we know how to help or have our referral pathways sorted out. It is time for most of us to revisit oral anatomy and to understand what is and what is not tongue-tie and what is being described as lip, buccal and/or posterior tongue-tie. In this series of videos, Pam and I discuss the history of tongue-tie diagnosis, the oromotor and breastfeeding assessments.
Resources for consumers are available on the “late pregnancy” and “after” pages. For convenience, I have included the consumer information on lip, buccal and posterior tongue-tie on this page.
MJA article on the increase in frenotomies funded by Medicare 2006-2016 (Australia)
Ultrasound studies of breastfeeding infants
In the above video, Dr Pam Douglas outlines a pragmatic approach to the oromotor assessment. This is one part of a thorough history and examination of a infant who is experiencing issues with their feeding. It is not sufficient on its own. It is how the tongue functions in context, for example during breastfeeding, rather than how the tongue and oral tissue look and move during oromotor assessment that is important. PS, Pam and I do know that infants don’t need to be able to lick an ice cream and that the tongue may become more mobile with time!
Follow up comments by Dr Douglas: In this conversational video about oromotor assessment of an infant, I don't specifically mention tongue extension, which is a key concern for clinicians, of course! Actually, ultrasound studies show us that the tongue only needs to extend to the lower alveolar ridge to transfer milk successfully. It doesn't even need to extend beyond the lower lip. Nor does the tongue need to lift to halfway up the oral cavity to breastfeed - lift of the tip of the tongue is not a meaningful sign to try to observe. Many infant tongues appear short. When you rest your forefinger on the baby's lower lip, or gently travel the pad of your forefinger over the baby's lower lip and midline gum, you will usually trigger an extension reflex, although babies don't always wish to co-operate at that moment in time. When I see the tongue extend I'll say to parents: 'see, that's good mobility, more than is needed for breastfeeding', so that they feel they've seen this for themselves, too - although mostly they've already been watching the tongue. I may ask if they've noticed the tongue come out previously.
In this video, Dr Pam Douglas and I have a practical discussion about the anatomical structure involved in "posterior" tongue-tie (the lingual frenulum) and the implications of the procedure to cut or laser it.
The anatomy of the in-situ lingual frenulum is outlined in a clinical research paper, lead author Nikki Mills, who is a Paediatric ENT surgeon from the Starship Children’s Hospital, Auckland NZ.
Gestalt breastfeeding
Gestalt breastfeeding resources
Making sense of frenotomy studies
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
Where can I get more information?
A good summary of tongue-tie is available on the Raising Children and Better Health websites. 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.