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All tied up about tongue ties….

By: | Tags: | Comments: 0 | August 15th, 2017

Here is an article that presents a balanced view about tongue ties – bottom line seems to be that it all needs to be about function – and for that the best place to start is with a lactation consultant…..

Health Professionals Concerned About Over-treatment Of Ties

By Renee Kam IBCLC in Baby. Last updated on August 4, 2017

If you’re a new parent who spends any time on breastfeeding peer support Facebook groups no doubt you’ve come across the topic of ties.

Perhaps you may be experiencing breastfeeding challenges and asked on such groups for some help.

Subsequently, perhaps it has been suggested your baby might have ties and you should see someone who is ‘tie-savvy’ from the group’s provider list.

So, what now?

‘Ties’ is a collective term used to describe tongue-ties, upper lip-ties and buccal ties. All of these relate to connective tissue restricting movement in the mouth and causing a functional problem.

Definitions of tongue-tie vary, but it’s generally agreed a tongue-tie exists when the lingual frenulum (connective tissue under the tongue) restricts tongue movement in a way that negatively affects function.

Upper lips-ties occur when the frenulum, underneath the upper lip, known as the labial frenulum, is deemed to cause a functional problem.

Buccal ties occur when frenula underneath the cheek are deemed to cause a functional problem.

The prevalence of tongue-tie appears to fall between 4 to 10%, with inconsistency in diagnostic criteria likely contributing to variation in estimates.

Broadly and simply speaking, some tongue-ties can be obvious – where the frenulum attaches close to the tip of the tongue and these may be referred to as ‘classic’ or ‘anterior’ tongue-ties.

Other possible tongue-ties are less obvious and may be referred to as ‘posterior’ tongue-ties.

Few would argue against there being genuine indications for releasing a tongue-tie. When a tongue-tie is causing a functional problem, releasing it can help improve function. A tongue-tie release is a surgical procedure performed either by scissors or laser.

But, are too many supposed tongue-ties and other ties being released?

There are many health professionals who are concerned too many ties are being released and hence too many unnecessary surgical procedures are being performed on babies.

Dr David McIntosh, a paediatric ENT surgeon, feels when it comes to the release of ties “Too many inappropriate ones and not enough appropriate ones” are being done.

Karen Palmer, a neonatal nurse (10 years), midwife (22 years) and International Board Certified Lactation Consultant (IBCLC) (23 years) indicates she “fought hard 10 years ago to get simple tongue-ties simply cut, to allow more effective, pain free feeding where necessary.”

She did not think for a minute “the spectrum would travel this far.” Karen feels that while anterior tongue-ties are being managed appropriately, posterior tongue-ties, upper lip-ties and buccal ties “are being done far too often.”

She adds “A few years back we had never heard of these things and other ways were found to manage breastfeeding issues and support mothers. Now, surgery has become the default position. The wide variation of IBCLC practise with no discernible improvement in breastfeeding rates tells a story.”

Heather Harris, midwife (46 years) and IBCLC (25 years) is also concerned tongue-ties, upper lip-ties and buccal ties “appear to have become a mainstream intervention for any breastfeeding or perceived breastfeeding problem.” She feels “Surgical intervention seems to be the first ‘go to’ option whenever there is a breastfeeding issue.”

Anne Cullen, is another IBCLC who is concerned about the number of ties being release. She says “I have huge concerns that there are professionals that are release far too many tongues and the increase I have seen just over the past two years in lip and buccal releases has me very worried.”

Holly Tickner, a speech pathologist who has specialised in the area of paediatric feeding difficulties for over a decade, thinks “the pendulum has swung too far in each direction. Probably fifteen or twenty years ago tongue-ties were being missed and not being diagnosed – the science behind breastfeeding and tongue-tie has come a long way in recent years and we know a lot more about it now than back then. But at the moment the pendulum is swinging a little too far to the other end.”

Holly is concerned about “the current trend of having surgery for oral ties without a functional assessment first. A functional assessment takes into account what the tongue and mouth look like, as well as how they work.”

In Holly’s opinion, it’s not enough “to just have a physical examination of the mouth.” Holly is meeting “far too many older babies and children who have had oral surgery done first before trying anything else, and often the parent has been led to believe that it will provide a quick fix, and instead the parents have seen no changes (or worse yet, the surgery has caused new problems).”

There is also a concern some parents are obtaining information related to ties from certain tongue-tie and breastfeeding peer support Facebook groups.

When asked if he thought if such groups were helpful, Dr McIntosh responded “No, in 99% of cases – never say never.”

Heather indicated “Most social media pages dealing with this modern phenomenon appear biased, and jealously guard their territory to the extent that any opposing views are blocked and banned. It is not a reliable source of credible information and like attracts like, thus the old FOMO feeds this frenzy.”

Holly does not feel such Facebook groups “are the best place to gather information that is specific to your child, particularly as everyone has had a different experience and offers different advice – it can get really confusing to know what to listen to or believe.”

So, in what ways might tongue-tie negatively affect function?

Breastfeeding And Ties

A tongue-tie can negatively affect breastfeeding. For example, a tongue-tie might reduce how well a baby can remove milk from the breast and it might increase the risk of nipple pain and damage.

The latest systematic review on the topic of tongue-tie and breastfeeding concluded:

“Frenotomy [name of surgical procedure to release a tongue-tie] reduced breastfeeding mothers’ nipple pain in the short term. Investigators did not find a consistent positive effect on infant breastfeeding. Researchers reported no serious complications, but the total number of infants studied was small. The small number of trials along with methodological shortcomings limits the certainty of these findings. Further randomised controlled trials of high methodological quality are necessary to determine the effects of frenotomy.”

There have been no systematic reviews undertaken about any possible effect upper lip-ties or buccal ties might have on breastfeeding due to significant lack of evidence.

There is negligible evidence with regards to breastfeeding and upper lip-tie, and zero evidence with regards to breastfeeding and buccal ties.

Karen thinks anterior tongue-ties “can negatively impact breastfeeding and the effects can be seen in the early days and weeks.” However, she feels “posterior tongue-tie diagnosis can be subjective.” In Karen’s opinion upper lip or buccal ties don’t impact breastfeeding at all.

Similarly, Heather believes “anterior tongue-ties can (but not always) impact negatively on breastfeeding as the tethered tongue may not be able to draw the breast far enough into the mouth to effectively extract milk resulting in poor milk transfer and potential nipple trauma.”

However, Heather feels the ‘upper lip frenulum is a normal part of infant oral anatomy and should never be interfered with at this age – if ever.”

She continues “The belief that the top lip needs to be flanged to enable a good latch is erroneous and demonstrates a poor understanding of normal breastfeeding attachment.” Furthermore she believes that buccal ties have nothing to do with breastfeeding.”

Likewise, Anne thinks “Tongue-ties can affect breastfeeding, although having a restrictive frenulum doesn’t necessarily lead to breastfeeding problems.” Anne says she has “personally never seen a lip tie or buccal tie that needs releasing due to a breastfeeding problem”.

If parents are concerned about whether ties may be affecting breastfeeding, Karen suggests they contact their primary practitioner first (nurse, midwife or GP) for a holistic assessment of their baby.

From there, Karen suggests a referral to an IBCLC for further assessment if necessary. She feels “IBCLCs definitely need to be part of that team to sit and observe a feed first and foremost, but other factors from pregnancy, birth and the neonatal time need to be taken into account.”

Karen indicates she is “always aware that many medical issues present first as feeding problems so therefore a thorough assessment is required before a specific road is gone down.”

If Heather feels a tongue-tie is interfering with breastfeeding, she feels the most appropriate line of referral is to a medical practitioner who has extensive experience in assessment of and safe division of anterior tongue-ties.

She adds she “would never refer to a dentist or speech pathologist or ‘body worker’ for such an issue at this early age.” She adds that with regards to upper lip-ties there’s “no such thing so would never refer anywhere, same with buccal ties.”

If a parent is concerned their baby has a tie, Anne suggests “Mothers should always consult an IBCLC first to work on latching and positioning.”

In terms of diagnosing ties, Anne says she prefers “a team approach so I’d like to see a certified lactation consultant working in conjunction an ENT or other paediatric medical specialist.”

She thinks “any feeding problem needs to be looked at holistically so that we can identify the root of the feeding problem. Feeding problems can even be related to a mother’s state of wellbeing and the support around her, they are often not problem that can just be solved with a ‘quick fix’ tie release.”

Heather, Karen and Anne all agree that if a tongue-tie isn’t obviously contributing to any current functional problem, it shouldn’t be released pre-emptively.

Karen says “A baby has a lot of growing and developing to happen first. There is no harm in a ‘wait and see’ approach.” Likewise, Heather says “If there are no obvious problems I can see no advantage in a surgical intervention. Ain’t broke, don’t fix it.” Anne says “There is never any justification for performing a preventative release on a baby.”

There are other ways tongue-ties may impact function too.

Treatment Of Tongue-tie For Reasons Other Than Breastfeeding

Treatment of ties for reasons other than breastfeeding currently lacks evidence.

Speech Problems And Eating Solids

Holly highlights that not all tongue-ties cause speech problems. “It’s important to make a point of saying that tongue ties do not necessarily cause speech issues. You can actually achieve clear speech without needing a huge range of tongue movement, and we are very good at compensating (even if the tip of the tongue is quite restricted)” says Holly.

She goes on to say “It is actually quite uncommon for speech pathologists to come across speech impairment that is a result purely of tongue-tie.  Occasionally surgery for tongue-tie is recommended to help with speech sounds or clarity, but it’s actually not that common.”

With regards to upper lip-ties and buccal ties Holly says “Lip-ties and buccal ties have not been studied in relation to speech sounds, but it would be unlikely that they would have any impact on speech clarity or the range of sounds you could make.”

When it comes to ties and eating solids, Holly indicates “having a tongue-tie does not necessarily mean you will have problems with eating or learning to eat. Many children have trouble learning to eat and they have no oral ties at all.”

In terms of evidence about ties and eating solids, Holly says “There currently isn’t any science to support the link that tongue-tie (or oral ties in general) cause problems with eating solids. Anecdotally you hear of the classic ‘Can’t lick an ice-cream’ problem for people with a very restricted tongue tip, and there are also reports of people who are messy eaters because they can’t lick food from around their mouths or off their lips fully. So there are reports of some functional issues (of course, there are other ways to eat ice-cream without using a full tongue lick and there are other ways to clean your mouth without licking all around).  Some people hypothesise that a tongue-tie could affect learning to chew, but this is not commonly seen.”

If a parent is concerned about how ties may be affecting their child’s speech, Holly recommends seeing “a speech pathologist who specialises in seeing children with speech problems (Google for terms like: articulation problems, phonological disorders, motor speech disorders).”

If a parent is concerned about how ties may be affecting their child’s eating, Holly recommends seeing “a speech pathologist who specialises in seeing children with eating problems (Google for terms like: feeding difficulties, oral motor delay, swallowing difficulties).”

Holly also recommends “seeing a paediatric ENT because sometimes there are actually other physiological things going on in the child’s mouth that need dealing with first (and the tongue-tie is a bit of a red herring).”

If a child is experiencing no current speech or eating problem attributed to ties, Holly doesn’t think ties should be released pre-emptively. Holly says “There also appears to be a trend to have oral ties surgically treated ‘just in case’ it causes speech problems – it is unethical for a health professional to recommend this.”

Airway Problems

With regards to airway issues and tongue-tie, there have been some associations drawn from the research but insufficient evidence to draw very clear conclusions at this point.

According to Dr McIntosh, it’s possible a tongue-tie might reduce “maxillary expansion forces of the tongue” but “The jury is still out”.

Put in simpler terms, a tongue-tie might mean the tongue doesn’t exert as much pressure up onto the top jaw bone and this may affect how this bone develops. Then, since the shape of the top jaw bone can affect the nasal airway, this may impact breathing.

It’s interesting to note tongue-tie may also be associated with forward growth of the lower jaw bone, and this actually opens up the airway!

Any of these possible orofacial growth and development scenarios take years to manifest. Given the current evidence, what may or may not occur in the future in this regard doesn’t justify releasing a tongue-tie in infancy.

If a parent is worried about how a tongue-tie may impact their child’s airway, Dr McIntosh recommends seeking advice from a paediatric ENT as “they are the airway specialists”.

Orthodontic Problems

With regards to orthodontic issues and tongue-tie, again there have been some associations drawn from the research but insufficient evidence to draw clear conclusions.

According to Dr McIntosh, it’s possible that a tongue-tie might contribute to a “narrow maxilla and protruded mandible.”

In simpler terms, this means a narrow top jaw bone and a protruded lower jaw bone and hence possible orthodontic problems.

Again, if these things were to occur, they would take years to manifest. Again, given the current evidence, they wouldn’t be a reason to justify releasing a tongue-tie in infancy purely on the grounds to possibly help prevent orthodontic issues later on.

If a parent is worried about how ties may impact orthodontic issues in their child, Dr McIntosh recommends parents seek advice from a dentist and paediatric ENT surgeon.

Angus Cameron, Associate Professor of Dentistry in Australia, indicates on his website “Releasing an upper labial frenum is a traumatic procedure that may also lead to more dental problems later including the persistence of an anterior diastema (gap between the front teeth) that is difficult to close orthodontically.”

If ties are released, some providers insist on performing stretches on the wound that results. But are these stretches actually necessary?

Wound Stretches After Tie Release May Not Be Necessary Or Appropriate

The idea behind stretching the wound after a tie release is to help prevent reattachment.

However, there is no evidence such stretches actually provide any benefit at all. Karen has strong reservations about them, saying “I think they can be stressful and painful. Feeding alone and crying should be exercise enough.” She also feels that they could increase the “risk of infection to vulnerable mucous membranes, risk of pain and oral aversion”.

Dr McIntosh indicates such stretches “just hurt for no proven benefit.” Alternatively, he just gets “the babies breastfeeding as that’s what we are doing it for and otherwise get the kids to do some simple exercises to maintain range of motion, especially elevation.”

Heather too has strong reservations about these post-tie release stretches, indicating “deliberately disturbing any inflicted lesion by ‘stretching’ is barbaric and is only done in cultures which make tribal scarring as part of initiation. To do it on the oral mucous membrane of a baby, who relies on its mouth for livelihood is cruel and painful. It must result in stress for both baby and mother or whoever is doing the manipulation and surely lead to many cases of oral aversion. I don’t know how it could not.”

Anne thinks wound stretches “cause physical pain to the infant and sometimes have led to the formation of excess scar tissues.” She also feels they can be distressing for mothers and says “Emotionally speaking it is very hard on most mothers. They are concerned (and rightly so) about causing pain to their baby, and they often feel guilty if they don’t ‘do them right’ or don’t do them ‘enough’.”

Holly thinks wound stretching has appeared to coincide “with the introduction of laser surgery for oral ties.” Holly has worked with many babies and children who have had oral surgery (not just for tongue-tie) and indicates “wound stretching is not something that is typically done.”

Holly goes on to say “Generally, every effort is made not to disturb the fragile healing process, and every effort is made to ensure that babies are comfortable, settled, and able to feed without developing oral aversion.”

Sadly, Holly has had “babies (and their distraught mothers) come to see me with severe oral aversion after having repeated ‘wound stretches’ done to their mouths after tongue tie surgery. Oral aversion is a very serious condition for a baby to experience as it affects their hydration, nutrition, growth and stress responses (and it’s very slow and tricky to fix).”

There certainly is a lot of confusion, speculation and conjecture surrounding the topic of ties. This can make it very difficult for parents who are concerned about their baby possibly having a tie to try to navigate through things and make sense of it all.

The truth is we don’t fully understand the topic of ties and more quality research is needed but this only comes with time.

If you’re worried your child may have a tie, it’s best to seek advice from the appropriate health professional (e.g. lactation consultant for breastfeeding issues, speech pathologist for speech issues, specialist paediatric dentist for dental issues, ENT surgeon for breathing issues etc).


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