Everyone’s tongues are wagging about “ties”… at least that’s how it seems to many parents of babies and young children. “Ties” are being blamed for breastfeeding problems, sleep problems, digestion problems, wind, reflux, babies crying in car seats, as well as potential future problems with speech, and obstructive airway symptoms such as snoring. Social media, especially, is flooded with discussions about “ties” and associated recommendations from parents who have jumped on the “ties bandwagon” which has rapidly gained momentum over the past year or so. But what scientific evidence is there to support all these claims?
What is a tongue tie?
Definitions vary, but generally a tongue-tie is identified when the tissue connecting the underside of the tongue to the floor of the mouth – called the LINGUAL FRENULUM – is tight and compromises tongue mobility. A visible membrane under the baby’s tongue which is restricting tongue mobility is called an ANTERIOR TONGUE TIE, or sometimes a CLASSIC tongue tie.
This is a mild congenital variation of normal that CAN cause infant feeding difficulties, but it is not true that tongue-tie is the cause of most breastfeeding problems. There are a multitude of factors which can contribute to feeding difficulties, particularly breastfeeding problems, and assessing and assisting breastfeeding mothers and babies needs to be approached from a holistic perspective by a breastfeeding expert.
How common is tongue tie?
Properly performed scientific research identifies true tongue tie (ANTERIOR TONGUE TIE) in 3- 5% of babies. When a RESTRICTIVE frenulum is attached closer to the base of the tongue rather than the tip, it is referred to as a POSTERIOR tongue-tie. This is present in fewer babies – one-third of the 5% = 1.6%. (Todd,2015)
What is the appropriate treatment of a true tongue-tie?
Simple frenotomy (snipping the frenulum membrane) using sterile scissors to release a restrictive tongue-tie has been shown to improve tongue mobility and aid more comfortable and effective breastfeeding in most cases. However skilled breastfeeding support is a crucial component of helping the mother and baby to then develop a successful breastfeeding relationship.
How will a breastfeeding expert assess and assist a mother and baby who are struggling with breastfeeding?
Every mother and baby combination is unique. Breasts and nipples differ, and so do babies. Babies are often temporarily affected by their birth journey and can take time to recover and respond to their innate reflexes which help them to initiate and establish breastfeeding. Most breastfeeding difficulties are related to “mother/baby fit” and can be resolved by making adjustments to how the baby comes to the breast, which enables optimal positioning and attachment which is comfortable for that unique mother/baby combination.
Which health practitioners can help mothers and babies to sort out breastfeeding problems?
Midwives, Lactation Consultants (IBCLC’s), and Child Health Nurses all have specific training to understand lactation and assist mothers with breastfeeding. Australian Breastfeeding Association Counsellors are trained to guide and support mothers through the learning curve and refer to Lactation Consultants for complex issues. Speech Pathologists have specific training in understanding tongue function and swallowing in infants but generally depend on midwives and lactations consultants to assist mothers to gain breastfeeding skills. Likewise, most GPs and Paediatricians have limited skills with assisting mothers who have breastfeeding problems and often refer to LCs for support.
So, what’s the problem – why is there a “Tongue-Tie Phenomenon” out there in parent land?
There are two elements to the recent increase in awareness of tongue-ties which has led to the phenomenal increase in diagnosis and treatment of tongue-ties, both real and perceived. Dentists and Parents.
Parents have been led to believe by a few dental practitioners, particularly via social media, that the incidence of Posterior Tongue Ties (PTT) is far greater than 1.6% of babies, and propose at least 10% – that is one in ten babies – have a PTT. Parents have also been led to believe PTT is the likely cause of most feeding problems including wind and reflux, as well as the cause of potential future problems with speech and airway problems such as snoring. The “condition” of PTT has gained great momentum as some parents see the treatment of PTT as a necessary intervention (read magical quick fix) for current and possible future problems, and it has become established in their belief systems as a real concern.
In addition to PTT, other “conditions” such as UPPER LIP TIE (ULT), and BUCCAL TIES have been added to the problematic frenulum list, and treatment of these have been added to the surgery menu by certain practitioners – primarily DENTISTS.
A variety of other health practitioners (chiropractors, osteopaths, body workers, and some LCs) have been influenced by the one-day education sessions provided by the dentists who are promoting the treatment of PTTs, ULTs, and BTs by LASER. However, “There is no scientific evidence that proves laser frenectomy is superior to scissors frenotomy in tongue-tied babies… before laser became available most tongue-tied babies received scissors frenotomy with excellent results” Dr Alison Hazelbaker, 2016.
Who is qualified to diagnose and treat a tongue-tie?
HERE LIES THE PROBLEM.
“Part of the problem is the lack of appropriate screening for the condition. There is only one screening tool for tongue-tie that has been proven through scientific research to accurately identify tongue-tie in babies – the Assessment Tool for Lingual Frenulum Function (ATLFF) which evaluates functional and appearance aspects of the baby’s oral anatomy.” “Simply looking under a baby’s tongue or pressing back against the baby’s tongue base will not render an accurate diagnosis” 3 Alison Hazelbaker, 2016
Unfortunately, this is how many PTT’s are identified and “diagnosed” by practitioners who have been educated by the dentists, without consideration of the whole mother baby breastfeeding story. Examination of a baby’s tongue using the “press back at the base” method will reveal a posterior frenulum in at least 50% of babies. There is no scientific evidence to support the proposition that observing a frenulum at the base of the tongue this way means the baby has, or will have, problems.
Nevertheless, many parents have been convinced that expensive laser surgery to the base of their babies’ tongues by a dentist will solve their breastfeeding problems. Most often the practitioner who has referred the parents to the dentist (called a Preferred Provider by the Dentist) will be involved in weeks of follow up treatments to assist the recovery process. The parents pay at least $1000 per laser procedure, so it’s very expensive.
Then the parents continue to pay for the recommended follow up treatments for several weeks by chiropractors and often an LC. The parents are also advised to perform wound stretching exercises in the baby’s mouth every day for weeks, which is invasive and painful for the baby and most parents don’t enjoy it much either. There is no evidence to support these wound stretches, which are intended to stop the wound healing back together. In spite of this, it is not uncommon for these deep wounds to heal together – and then the parents are often advised to have the procedure performed again.
What about Upper Lip Ties?
More often than not, the dentist performing the laser surgery to sever the base of the baby’s tongue will also recommend severing the upper lip frenulum at the same time. There is absolutely no scientific evidence to support the severance of the upper lip frenulum to assist with breastfeeding. In the majority of babies (93.3%) the upper lip frenulum (LABIAL FRENULUM) looks exactly like the images which dentists refer to as an UPPER LIP TIE. Unlike the tongue frenulum, “the upper lip frenulum changes over time with growth and development. The frenulum gets smaller, thinner, and will insert higher up on the gum line as the teeth erupt. (8.9) By the time a child has permanent teeth, the upper lip frenulum looks nothing at all like it did during infancy”. (Alison Hazelbaker, 2016)
For breastfeeding, the upper lip only needs to rest in a neutral or slightly everted position to seal the breast and function in synchrony with the tongue and jaw. “…A baby who has a retracted tongue, either due to tongue-tie or torticollis, will often have tense lips. Once the tongue position is corrected the lips resume their normal position and function” (Alison Hazelbaker, 2016)
The latest addition to the laser surgery menu for babies is “Division of Buccal Ties”. The buccal fat pads are part of the normal oral/facial anatomy and join to specific ligaments and muscles which function in relation to sucking and chewing from infancy to adulthood. These are there for a very good reason in infants, and there is no scientific evidence to support severing them to aid sucking – in fact they play a major role in breastfeeding by assisting the vacuum required to maintain an effective latch. Their size will naturally reduce with maturation changes as the baby grows through childhood.
About now you are probably getting the message that the diagnosis and treatment of tongue-tie has become a very divisive issue (pardon the pun) among health professionals, and also among parents.
I acknowledge, some parents may have success stories about laser treatments, particularly when anterior tongue-ties are divided. The scientific evidence supports the benefits of releasing a restricted tongue, however deeply severing the base of a baby’s normal tongue “is a recent phenomenon which lacks a credible scientific basis” (Wattis et al, 2017).
Many experienced breastfeeding experts around the world (although this is clearly a “first world problem”) are deeply concerned about the huge numbers of babies receiving laser treatments, many unnecessarily. Dentists’ Tongue-tie Clinic waiting rooms are full of mothers and babies every day, lining up to have their babies’ “ties” released. Unfortunately, many of us are left picking up the pieces of shattered breastfeeding relationships where the surgeries were unhelpful, and in fact, destructive to breastfeeding.
However, the united voice of concerned breastfeeding advocates is now becoming louder, which is why I am speaking up about this too. I recently co-authored a paper with two other eminent breastfeeding clinicians which was published in the peer-reviewed ABA Journal “Breastfeeding Review” in March 2017. In this article we reviewed the scientific evidence about tongue-tie, frenotomy, lip ties, reflux and swallowed air, and the rising trend of laser frenectomies with multiple “ties” released. Our common concerns were validated, and opened the conversation (at times heated) among other breastfeeding practitioners to critically examine the evidence (or lack of) surrounding the “ties phenomenon”.
Where does this leave the parents trying to make sense of all this information?
When the health professionals disagree it is very difficult for the parents to make sense of advice provided by trusted caregivers. It is the responsibility of all health professionals to work within the domain of their discipline and not beyond the scope of their practice. Lactation and Breastfeeding are specialist areas which are usually beyond the scope of other health professionals unless they have undertaken and passed the exam to gain International Board Certified Lactation Consultant credentialling. Even then, some IBCLCs do not hold health professional qualifications as well, and instead come from breastfeeding support backgrounds such as ABA and La Leche League, so might not have training in analysing the validity of research and studies.
The facts, as my concerned colleagues and I see them are:
Simple release of a restrictive tongue-tie by a practitioner credentialed to perform a frenotomy CAN be beneficial to breastfeeding babies, especially when on-going support from a breastfeeding expert is provided.
In the case of a restrictive posterior tongue tie which is causing breastfeeding problems, we believe a paediatric ENT Specialist is the appropriate person to surgically release a baby’s frenulum if needed, preferably in collaboration with a Lactation Consultant.
In making an informed decision, we should consider the words of Dr Alison Hazelbaker: “As guardians of our babies, all parents and health care providers need to be sure that the benefits of any surgical procedure outweighs its risks. Our vulnerable babies depend on us to do so.”
breastfeedingtoday-llli.org/tongue-tie-lip-tie-diagnosis-treatment-aftercare/ Dr Alison Hazelbaker
“Three experienced lactation consultants reflect upon the oral tie phenomenon” Wattis L, Kam R, Douglas P. Breastfeeding Review 2017;25(1):9-15. (Australian Breastfeeding Association) http://search.informit.com.au/documentSummary;dn=704771949095754;res=IELHEA