Here’s what you need to know about tongue-tie:
- What is it exactly?
- Anterior vs posterior…
- What’s the difference?
- How does it affect feeding?
- Is it just a fad?
- What are the long term implications, if any?
Tongue-tie (TT) is a hot topic right now. It has medical professionals up in arms as to whether certain ties actually exist (e.g. posterior tongue-ties).
In this post, I’ll debunk the myths associated with TT and provide you with the most up-to-date information available so that you can make an informed decision as to what’s best for your baby.
Please note: A large portion of this post focuses on TT and its effect on breast-feeding. This is by no means a judgement of what is best for your situation. Having been through feeding difficulties with both my children, I realise the immense stress and pressure women are put under to breast-feed exclusively. My aim is to provide the most relevant and recent information for you to add to your armoury when making decisions surrounding your child’s feeding difficulties.
Bottle-fed babies (formula and expressed breast-milk) can also be affected, however it is easier to compensate around these issues with a teat, and therefore they are not as commonly diagnosed.
1. What is it exactly?
The term ‘tongue-tie’ may conjure up an image of someone anxiously lost for words…
… however, we’re talking about the kind that affects the control of the tongue in feeding, speech and oral development.
Tongue-tie, or ankyloglossia refers to a congenital ‘tying’ of tissue underneath the tongue, leading to a restriction of movement and therefore its function.
The official term for this piece of tissue is the lingual (tongue) frenulum. Usually, as we develop embryologically, this tissue is broken down and we are left with a ‘normal’ frenulum that doesn’t restrict the tongue’s movement.
For reasons that are still not fully understood however, some of us don’t receive the signal to turn on the breaking down of this tissue. This leaves varying degrees of connective tissue adhering the tongue to the floor of the mouth.
This frenulum can attach all the way at the front of the tongue ( anterior tongue-tie ), or be somewhat hidden underneath at the back ( posterior tongue tie ). I’ve provided more detail on this below.
TT affects somewhere between 4-10% of babies, with boys more commonly affected. There is a genetic component identified, with around 50% of babies with TT having a direct relative who also has it.
Some common symptoms in the breastfeeding mother include:
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Nipple pain or damage (cracked, blistered or bleeding)
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Mastitis or thrush
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Decreased milk supply, especially after the 10-14 week mark where supply switches from hormonally-driven to baby-driven
Symptoms in the baby may include:
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Poor latch / sliding off the nipple
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Clicking sound during feeding
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Long feeds &/or falling asleep
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Poor weight gain
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Colic or reflux from swallowing excess air
2. Anterior vs posterior… What’s the difference?
Classically TTs were divided into anterior (front) or posterior (back) positions.
This created some confusion, especially as to where the posterior ties are located. Some thought they were behind the tongue in the throat!
Although we are somewhat stuck with the anterior-posterior names, there now exists a grading system.
(Image courtesy of Dr Kotlow)
This is graded from 1-4, with 1 and 2 being ‘anterior’ in location, and 3 and 4 being ‘posterior’.
It is important to note that these numbers don’t relate to the SEVERITY of the tie. They merely describe the anatomical location.
To assess the effect a tie has on function, an examination by a qualified healthcare practitioner is required. This would preferably be someone who has knowledge in the area of TT, and especially the role of posterior TT on feeding. Choosing a practitioner who has a special interest in this area is ideal.
“… every anterior tongue tie has a posterior behind it…”
~ Dr Ghaheri, ENT
It is Dr Ghaheri’s opinion that behind every anterior tie there exists a posterior one, and to only address the anterior component doesn’t address the whole problem.
This is especially true in breastfeeding problems, as he goes on to state that ALL ties associated with breastfeeding difficulties have a posterior component.
Check out this short interview with Dr Ghaheri, discussing the importance of posterior TTs and their role in breast-feeding dysfunction:
3. How does it affect feeding?
First and foremost, not all breastfeeding problems are caused by a tongue-tie!!!
This is a really important message to get across, as with all advancements in medical diagnosis, there will inevitably be a period of over-diagnosis.
If you are experiencing difficulties with breast-feeding, then the first step should be to consult with a lactation consultant (LC). I recommend seeking out an international board certified lactation consultant (IBCLC) where possible. You can search for one HERE.
They can help identify:
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Problems with technique – e.g., attachment, latch, position etc.
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Problems with breasts – e.g., thrush, mastitis.
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Psychological stress on the mother – e.g., PND
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Physical limitations of the baby, making breastfeeding difficult.
– such as tight neck muscles (wry neck or torticollis) resulting from birth trauma or intrauterine constraint.
This is where an assessment by a qualified manual healthcare practitioner can be extremely beneficial. Choosing one with a special interest and knowledge in the area of tongue-tie is a bonus. They can identify if the problem is largely from a stiff neck or jaw muscles, or more likely a tongue-tie and refer accordingly.
Onto the feeding stuff…
Optimal breastfeeding depends on the baby being able to generate a ‘vacuum’ inside their mouth, effectively ‘drawing’ the milk out with an up and down motion of the tongue.
Check out the video attached to THIS ARTICLE for a great visual of how this ‘vacuum’ motion works.
For this to happen, there needs to be an adequate depth of latch (nipple at the back of baby’s mouth) AND mobility of the tongue.
It starts to become obvious then that a tie affecting the mobility of the tongue AND the ability to open the mouth widely and flange the lips could potentially have an adverse effect on feeding.
4. Is it just a fad?
“As is the case with any new paradigm shift in medicine, the initial response is almost always one of conservatism and doubt”
~ Dr Ghaheri, ENT
I can understand why many practitioners are wary of the growing number of TT diagnoses.
As discussed above, relatively new evidence surrounding the mechanics of BF (i.e., up and down motion of the tongue creating a vacuum), has led to a much-needed paradigm shift away from only focusing on the role of anterior tongue ties in feeding.
Let’s examine some other reasons why diagnosis *seems* more common:
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More mums are breastfeeding, therefore more TT problems are being identified.
– Simply put, there are more women breastfeeding now compared with recent times. Starting in the 1950s when infant formula became popularised, the number of breastfeeding women plummeted. Prior to the 50s, it was commonplace for midwives to snip an obvious TT (anterior or type 1 or 2) shortly after birth.
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There is more knowledge surrounding the diagnosis and management of TTs – especially posterior TTs.
– Gradually, word is spreading about the importance of proper diagnosis and early intervention to improve breastfeeding outcomes. This is largely due I think to the social media effect.
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As with the above, more parents are doing their own research:
– This is usually due to being repeatedly told that everything ‘looks right’, despite continuing to experience pain and difficulty surrounding breastfeeding.
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Genetics
– TT is more prevalent in males, and shows an autosomal dominant pattern of inheritance. This means that if ONE of the parents carries the dominant gene, then the child has a 50% chance of inheriting it.
– This also means that if a gene is being passed on through generations, then there will naturally be an increase in babies with that gene as time progresses.
Unfortunately to date, the majority of research investigating TTs and breastfeeding have focused on the easier-to-see and therefore diagnose, anterior TT (class 1 or 2).
In 2013, O’Callahan et al. investigated the outcomes of TT release in 300 babies with promising outcomes:
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64% of mothers experienced improvement in nipple pain after one week.
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Approximately 50% of mothers reported improved latch following one week.
Perhaps the most important aspect of this study was that 84% of babies had a posterior TT (class 3 or 4) treated. As we now know, this is the most important in relation to breastfeeding mechanics. It is also the most poorly understood by most healthcare practitioners giving advice on feeding mechanics.
Thankfully this is gradually changing…
5. What are the long term implications?
As we’ve discussed, in infants with no tongue restriction present, normal breastfeeding can occur. This encourages a broad pressure on the baby’s palate which, over time, has huge implications for their future orofacial development:
- The teeth develop with adequate spacing, preventing overcrowding and malocclusion (Peres et. al, 2015).
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A broad palate encourages optimal nasal development.
– a non-optimal palate development involves a high-palate, which creates a ‘buckling’ stress on the nasal septum sitting atop. This can create a domino-effect of mouth-breathing (due to not enough room to breathe nasally) and sleep apnoea.
There is some evidence to suggest that TTs can affect speech and language development. The most commonly affected sounds are R, S, L, Z, D, CH, TH and SH. These are often more noticeable in words using a combination of the above.
As the research is inconclusive at present, it is best to seek the advice of a speech pathologist who has experience in this area.
Disclaimer: This is for educational purposes only
This is for your education only. It is in no way intended to replicate or replace expert assessment and guidance from a healthcare professional qualified to diagnose and treat TT.
And I’d go one step further…
Don’t just go to any health professional… go to one who has a special interest in the assessment and treatment of babies with tongue-tie … or even better, someone who is passionate about providing the best care possible during a time of immense difficulty and confusion.
I’m sure you understand that I disclaim any and all responsibility for anything that you do as a result of reading this post. I don’t know your family’s medical history or physical state … and by reading this post you agree with this and accept 100% responsibility for your actions.
Summary
In this post I’ve explained what tongue-tie is and how there has traditionally been a lot of confusion surrounding its existence and effect on successful feeding.
I’ve outlined the classification of anterior vs posterior TTs, and the newer, more accurate 1 to 4 grading of anatomical location. I mentioned that these grades are purely based upon location and not severity of the tie.
Here are more highlights from this post:
1. Every anterior (grade 1 or 2) tie has a posterior tie (grade 3 or 4) behind it.
2. If the posterior component isn’t addressed, then the likelihood of successful improvement in feeding is greatly reduced.
3. Not all breastfeeding problems are caused by a TT! It is imperative to seek qualified lactation support prior to having a TT treated. It is also vital to follow-up with an IBCLC following any TT treatment to ensure the best outcome possible.
4. TT diagnosis is not ‘just a fad’. There are many reasons (discussed above) why it is becoming more common. Having said this, it is important to note that over-diagnosis can be a problem initially. As per no. 3, a thorough assessment by a qualified healthcare practitioner is essential.
5. We are only just beginning to understand the potential long term implications of undiagnosed TT, including orofacial development and speech and language impairment. As education and research surrounding TT improves, we should hopefully get some more conclusive answers as to their role in the above.
I welcome your comments or questions in the comment section below … but please realise that I can’t provide professional advice in this context.
References
O’Callahan, C, et al. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology 77 (2013) 827–832
Peres KG, Cascaes AM, Nascimento GG, Victora CG. Effect of breastfeeding on malocclusions: a systemic review and meta-analysis. Acta Paediatrica. 2015; 104: 54-61.
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