Tongue tie is understood to be an anatomical difference where the lingual frenulum (piece of tissue connecting the tongue to the base of the mouth) is short or tight. It can lead to reduced tongue mobility / function and in some cases a negative impact on breastfeeding.
Some research suggests that our current understanding of tongue tie is based on misunderstood oral structures and a tendency to view normal variations in anatomy as problematic. The issue of tongue tie attracts speculation due to the reliance on appearance as a diagnostic parameter, the lack of internationally used definition and the subjective nature of tongue tie assessments. Furthermore, rates of tongue tie have increased exponentially over the past 20 years, casting doubt around the true prevalence of the condition.
In this post we will discuss what the literature says in terms of tongue tie characteristics, prevalence, diagnostics and treatment.
What are the characteristics associated with tongue tie?
- Specific variations in tongue shape, for example a heart shaped tip of the tongue.
- Restricted tongue movement (both vertically and laterally).
- Specific variations in frenulum shape, flexibility and opacity.
- Difficulty achieving and / or maintaining a deep latch at the breast.
- Slow weight gain.
- Nipple damage and pain when feeding.
Ideally, when assessing for tongue tie a practitioner will consider all of the above in line with a validated assessment tool, and will encompass a thorough review of breastfeeding to rule out other causes of related issues.
How does it impact breastfeeding?
Tongue tie is believed to affect a baby’s ability to breastfeed due to the restricted movement of the tongue. This restriction interferes with baby’s ability to stabilize the nipple and create the required seal and vacuum with their mouth. Nipple pain along with indicators that baby is struggling to breast feed (such as slow weight gain and difficulty maintaining a latch) may be indicative of a tongue tie.
Tongue tie that is impacting breastfeeding will often present as a collection of signs: slow weight gain, windy or upset baby, slow feeding, nipple pain and nipple damage for mum alongside the characteristics of baby’s tongue and frenulum noted above.
However, not all babies identified to have a tongue tie experience breastfeeding difficulties. A study in Brazil including around 400 healthy infants identified a tongue tie rate of 15% within the group, yet less than 9% were experiencing breastfeeding problems. Furthermore, the authors found no association between tongue tie identification and breastfeeding difficulties.
How common is tongue tie?
Rates of tongue tie diagnosis have been increasing exponentially since the 90’s. Between 2004 and 2019 the number of diagnosed tongue ties in a representative sample of infants in the US rose by 291%. The rates of tongue tie reversal surgery have also increased by around 10%.
A Cochrane review completed in 2017 reported tongue tie prevalence was between 4-11%, according to a collection of older studies. Another systematic review reported a rate of 8% from a sample size of around 24,000 infants.
In the Brazilian study described above, ankyloglossia was identified in 15% of babies by a paediatric dentist. It is possible that not all of these 15% of babies would have been diagnosed if they were reviewed by other practitioners or if they were not included in the study, as not all experienced breastfeeding difficulties. This reflects the difficulty surrounding diagnosis due to the subjectivity and lack of definition.
How is tongue tie diagnosed?
Various classification systems and questionnaires based on measurements of the frenulum and characteristics of the frenulum and tongue are used to diagnose tongue tie. These include the TABBY and BTAT tools which only assess tongue appearance, the ATLFF which assesses tongue appearance and function, and the Martinelli tool which assesses tongue appearance, function, feeding and medical history. Tools for measuring breastfeeding difficulties are sometimes used alongside these assessments. .
How is tongue tie treated?
Frenotomy is the term for the surgical division of a tongue tie. In this procedure the baby is swaddled, and their tongue is lifted to expose the frenulum before it is snipped using surgical scissors. Most commonly this is done without anaesthetic and babies are often encouraged to feed directly afterwards as this is believed to encourage a calming and pain-relieving response.
Sometimes a laser is used to perform the division, this method is reportedly becoming more popular.
Frenuloplasty is another optional treatment for tongue tie, however, this is most commonly used for children over the age of 1. This involves division of the frenulum and re-suturing in a way that frees the tongue. This procedure is usually done under general anaesthesia.
References
Carnino, J. M., Walia, A. S., Lara, F. R., Mwaura, A. M., & Levi, J. R. (2023). The effect of frenectomy for tongue-tie, lip-tie, or cheek-tie on breastfeeding outcomes: A systematic review of articles over time and suggestions for management. Int J Pediatr Otorhinolaryngol, 171, 111638. https://doi.org/10.1016/j.ijporl.2023.111638
Ferrés-Amat, E., Pastor-Vera, T., Rodriguez-Alessi, P., Mareque-Bueno, J., & Ferrés-Padró, E. (2017). The prevalence of ankyloglossia in 302 newborns with breastfeeding problems and sucking difficulties in Barcelona: a descriptive study. Eur J Paediatr Dent, 18(4), 319-325. https://doi.org/10.23804/ejpd.2017.18.04.10
Francis, D. O., Krishnaswami, S., & McPheeters, M. (2015). Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics, 135(6), e1458-1466. https://doi.org/10.1542/peds.2015-0658
Hill, R. R., Lee, C. S., & Pados, B. F. (2021). The prevalence of ankyloglossia in children aged <1 year: a systematic review and meta-analysis. Pediatric Research, 90(2), 259-266. https://doi.org/10.1038/s41390-020-01239-y
Messner, A. H., Walsh, J., Rosenfeld, R. M., Schwartz, S. R., Ishman, S. L., Baldassari, C.,…Satterfield, L. (2020). Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg, 162(5), 597-611. https://doi.org/10.1177/0194599820915457
Mills, N., Keough, N., Geddes, D. T., Pransky, S. M., & Mirjalili, S. A. (2019). Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy, 32(6), 824-835. https://doi.org/https://doi.org/10.1002/ca.23410
O’Shea, J. E., Foster, J. P., O’Donnell, C. P., Breathnach, D., Jacobs, S. E., Todd, D. A., & Davis, P. G. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev, 3(3), Cd011065. https://doi.org/10.1002/14651858.CD011065.pub2
Ricke, L. A., Baker, N. J., Madlon-Kay, D. J., & DeFor, T. A. (2005). Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract, 18(1), 1-7. https://doi.org/10.3122/jabfm.18.1.1
Rowan-Legg, A. (2015). Ankyloglossia and breastfeeding. Paediatr Child Health, 20(4), 209-218. https://doi.org/10.1093/pch/20.4.209
Souza-Oliveira, A. C., Cruz, P. V., Bendo, C. B., Batista, W. C., Bouzada, M. C. F., & Martins, C. C. (2021). Does ankyloglossia interfere with breastfeeding in newborns? A cross-sectional study. J Clin Transl Res, 7(2), 263-269.
Walsh, J., Links, A., Boss, E., & Tunkel, D. (2017). Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngol Head Neck Surg, 156(4), 735-740. https://doi.org/10.1177/0194599817690135
Wei, E. X., Meister, K. D., Balakrishnan, K., Cheng, A. G., & Qian, Z. J. (2023). Ankyloglossia: Clinical and Sociodemographic Predictors of Diagnosis and Management in the United States, 2004 to 2019. Otolaryngol Head Neck Surg, 169(4), 1020-1027. https://doi.org/10.1002/ohn.332
