Tongue tie (also known as ankyloglossia) is when the lingual frenulum (piece of skin connecting the tongue to the base of the mouth) is short, tight or attached in the wrong place. It can lead to reduced tongue mobility and function.
Whilst many cases of tongue tie are asymptomatic, the primary complication associated with tongue tie is breastfeeding difficulties. Babies with restrictive oral ties may struggle creating the necessary latch and tongue movement required to feed at the breast. In extreme instances some can impact oral development and speech.
The issue of tongue tie attracts speculation due to the lack of definitive characteristics and diagnostic parameters. Furthermore, rates of tongue tie have increased exponentially over the past 20 years which has created doubt around the true prevalence of the condition.
In this post we will discuss what the literature says in terms of tongue tie definitions, characteristics, prevalence, diagnostics and treatment.
What is tongue tie?
Fairly recently a group of Otolarynologists (ENT doctors) met to create an official definition for TT. They agreed on the following: ‘condition of limited tongue mobility caused by a restrictive lingual frenulum.’ However, studies published after this still acknowledge wide variations in definitions used within practice.
Tongue ties can be classified into two main groups: anterior and posterior ties.
Anterior ties are when the frenulum attaches close to or at the tip of the tongue.
Posterior ties are when the frenulum attaches to the back portion of the tongue in a way that causes restriction, some also classify submucosal tethering of the tongue a posterior tie.
Beyond anterior and posterior tongue tie are other variations of restrictions of oral ties. Lip ties, or lip frenulum tethering, is when the piece of skin attaching the top lip to the upper gum line is restrictive in some way, while a cheek tie refers to a buccal frenulum that causes restriction. However, research into these forms of oral ties is very limited.
How does it impact breastfeeding?
Tongue tie can 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 an impactful tongue tie.
However, not all babies with tongue tie will 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.
How is tongue tie diagnosed?
Alongside the issue of a consistent definition, the lack of consistent diagnostics for tongue tie is a problem.
Many papers have been published containing proposed assessments for tongue tie. These include various classification systems and questionnaires based on measurements of the frenulum and characteristics of the frenulum and tongue. 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.
Conclusions
There is a reported lack of consistency across the definition and diagnosis of tongue ties. Since the 90’s, rates of tongue tie cases and the surgical division of tongue ties have increased dramatically.
Not all babies with tongue tie have problems breastfeeding and not all babies who struggle with breastfeeding have tongue tie. If you suspect your baby has a restrictive tongue tie, reach out to a lactation consultant or your midwife for support and guidance.
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
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
