Tongue-tie for clinicians

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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.

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

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. Speech Pathology Australia have information. There are a number of free resources available, as well as a $37 online Gestalt Breastfeeding program 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.