Tongue tie is understood to be an anatomical difference with the lingual frenulum (piece of tissue connecting the tongue to the base of the mouth) leading to reduced tongue mobility / function.
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 and the subjective nature of tongue tie assessments. Furthermore, rates of tongue tie have increased exponentially over the past 20 years which has created doubt around the true prevalence of the condition.
Despite this, tongue tie is commonly associated with breastfeeding difficulties. It is often involving a frenulum that is short, tight or attached too close to the tip of the tongue leading to difficulty latching and feeding at the breast.
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 and attempt to troubleshoot via breastfeeding support methods.
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.
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 with tongue tie 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 reliance on anatomical appearance.
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. Tools for measuring breastfeeding difficulties are sometimes used alongside these tongue tie assessments.
Within the UK, NICE guidelines guide the practice of all NHS trusts and the staff therein. These guidelines do not provide instruction on the diagnosis of tongue tie; however, they do provide a guide on the surgical division of tongue tie.
The HSE in Ireland provides guidance to their staff via the Newborn Clinical Examination Handbook. Their guide includes an assessment of latch, feeding history, maternal symptoms and an oral examination. They encourage lactation consultant support for those identified with tongue tie and advise intervention by a trained professional at 2-3 weeks if feeding issues remain unresolved.
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
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
