The Truth about Tongue Ties

Tongue ties are such a vast, controversial, and often misunderstood topic that we brought in pediatric otolaryngologist (ENT) surgeon Dr. Elise Graham to help us wade through the topic. She is also a mom to two boys with a complex breastfeeding journey of her own, which has brought her to shine a postpartum lens onto her field that she admits can gain from providing more support to patients, especially as information about tongue ties can vary greatly and specialized support can be hard to find. In addition to being a pediatric surgeon, Dr. Graham is also working towards becoming a certified lactation consultant (IBCLC) and earning a fellowship through the Academy of Breastfeeding Medicine, which is why we’re very excited to have her guide us through the evidence-based truth about tongue ties!

Basic Oral Anatomy

Infant airways are actually designed differently than adult airways! The main differences allow babies to breathe through their nose while they nurse - an evolutionary trait to optimize breastfeeding. Tune in to the podcast for more details around the anatomical differences!

But one key player in breastfeeding is the tongue - it cups the nipple at the junction of the soft and hard palate, and needs to have some movement from down to up to hold the nipple in place, as well as to cup it on the sides, creating no airway in the oral cavity. 

The oral (lingual) frenulum is a fold of tissues or band below the tongue that is formed because the tongue elevates. So when the tongue lifts up, there's a fold of the tissues underneath, of varying thickness. This can possibly - but does not necessarily - lead to issues with breastfeeding due to obstructing the tongue’s capability to latch onto the breast, as well as other purported issues later in development. But diagnosis is tricky and evidence suggests that in reality, not a lot of issues can definitely be traced back to a “tongue tie,” or problematically short or “strong” lingual frenulum, and the procedure for correcting it is not necessarily a minor or negligible one without side-effects, as we discuss below.

How are tongue ties diagnosed?

There are multiple tools and classification schemes that are used to diagnose tongue ties. Classification schemes tend to be less helpful because they rely on a description on how the tongue looks, and less so on how it is functioning. Assessment tools, such as the Tabby Tool or the Bristol Tongue-tie Assessment Tool (BTAT), are validated tools that look at the way the tongue moves, how the tongue tip looks when the tongue elevates, where the frenulum is attached on the lower gum line, and how it elevates on the side. 

But it’s important to know that there is not a lot of good consensus around the best methods for diagnosis. It is also interesting to note that the number of diagnoses has increased dramatically in the last few years. In the US, it was found that between the years of 1997 and 2012, diagnosis of tongue-ties upon discharge of newborns from the hospital had gone up 800%, and another 100% in a follow up study four years later from 2012-2016. Such trends may be attributed to the waxing and waning of general knowledge, popularity, and therefore desire to optimize the success of breastfeeding. But it could also be correlated to general information - and often misinformation - spread through social media that led to the increased adoption of frenectomies (clipping of the tongue tie), as well as financial incentives for medical providers to suggest the procedure.

How are tongue ties treated?

Although often positioned as such, clipping of tongue ties is not a minor procedure, and in the case of complications it can be rather devastating and traumatic for your newborn.  

Frenectomy, frenotomy and frenuloplasty are three terms you may hear with slightly different implications which all essentially achieve the same thing: a release of the tongue tie though a minor surgical procedure. Main ways that this is done about include with sharp scissors or a laser, but each carry their potential side effects or complications, including:

1. Bleeding: often minor but cases have been reported of babies going into shock due to blood loss and needing IV fluids for resuscitation
2. Nerve Injury: the tongue contains a lot of tiny nerves which can be affected
3. Laser procedure carries a risk of thermal injury
4. Infection
5. Oral Aversion
6. Breast Refusal 
7. Dehydration

Should you do it?

You may have heard or read about many different benefits of tongue tie removals or clipping, including for improving speech pathology, sleep apnea, or reflux. But an amalgamation of studies have found that the best evidence for tongue tie release is for breastfeeding, especially in that it provides a significant improvement in maternal pain. The evidence does not support removing a tongue tie as beneficial for any other purpose. As with any other condition, we would also recommend therapy or other forms of support before turning toward a more invasive, surgical solution.

We hope that this helps you understand the often confusing world of tongue ties a little bit better! We’ve linked some resources below - and as always please speak to your healthcare provider if you have any further questions.

• Academy of Breastfeeding Medicine Protocols: https://www.bfmed.org/protocols 
• JAMA Otolaryngology - Head & Neck Surgery: What Is a Tongue Tie?
• IG: Dr. Elise Graham @elisegmd