“Does my baby have a tongue, lip, or buccal (cheek) tie?”
The diagnosis of “tongue tie” has skyrocketed in recent years along with new types of oral ties that are being blamed for breastfeeding problems, namely “posterior tongue ties” and “buccal ties.”[1][2] There has been a dramatic rise in tongue tie surgeries (frenotomies) as a result. A tongue tie is a tightness or shortness in the membrane under the tongue (lingual frenulum), causing poor mobility of the tongue. Often babies with tongue ties will present with a notch in the center of their tongues showing where the tissue is being pulled taut.
Since the rise in tongue tie surgeries, many experts have raised concern that they are being overdiagnosed and overtreated, and that normal lingual and labial frenula with no apparent functional impairments are being categorized as pathological (or medically problematic) “ties.”[3][4] The first and most important way of addressing oral variations is to ensure ideal positioning and latch. There is some evidence that breastfeeding pain can be reduced after clipping an anterior tongue tie (when the frenulum is attached close to the tip of the tongue, restricting elevation and extension)—but it is not strong evidence.[5]
If all else has been tried, it is worth getting your baby’s lingual frenulum evaluated by your pediatrician, and if necessary, referred to the appropriate provider for treatment. A pediatric ENT or pediatric dentist recommended by your pediatrician would be the next step.
Be wary of “preferred providers” or “tie-savvy” providers that may be recommended by non–medical doctors; for example, a lactation consultant who suspects a tongue tie should refer parents back to their pediatrician, who is your baby’s personal doctor and most familiar with your baby’s total health history. Anyone who states they “specialize in ties”—while they may be very passionate about the topic—may not be following the current established scientific evidence.
With any evaluation or treatment, especially when it may involve cutting into healthy tissue, it is important to consider the risks vs. benefits. Since any surgery has risks, it should therefore be supported by a strong body of evidence, which is severely lacking in the case of oral ties.
The risks of tongue tie surgery, particularly so-called posterior tongue ties (which is a more dubious diagnosis),[6] are excessive bleeding, damage to nerves and submandibular ducts, reattachment of the frenulum, and oral aversion. Rare but serious risks of the procedure are airway obstruction, serious infection of the tissue within the jaw called Ludwig’s angina, and dangerously low blood pressure from excessive bleeding.[7]
If lasers rather than scissors are used, there is a risk of burning the surrounding tissue. In addition, some practitioners recommend stretching the wound after the procedure multiple times a day, which is very painful, can impair wound healing, cause scar tissue, and can create oral aversions that can make breastfeeding difficulties worse—and there is no scientific evidence to support this practice.
There is absolutely no evidence that supports clipping labial frenula (lip “ties”) to solve breastfeeding problems; nor is there any evidence that posterior tongue ties or buccal ties even exist.[8] Beware of practitioners or resources claiming that clipping tongue ties, lip ties, or other ties can prevent cavities, speech disorders, breathing disorders, or other potential future problems, as there is no evidence supporting these theories.
Some people might argue that the lack of evidence does not mean these oral ties are not problematic, because maybe the evidence just hasn’t been collected yet. However, when a surgery, drug, or procedure is being recommended, the burden of proof is on those who recommend the intervention to provide evidence that the benefits are greater than the risks. We recommend proceeding with caution and always discussing the matter with your pediatrician.
You may also hear recommendations for chiropractic, craniosacral therapy, myofascial release, or “bodywork” when you are looking for solutions to latch problems. There is simply quality evidence that any of these practices have an effect on a baby’s latch, nor have safety and effectiveness been sufficiently evaluated; health insurance does not typically cover these experimental interventions. In fact, chiropractic treatment should never be recommended for infants or children due to the risks of serious complications.[9]
If you suspect your baby may have a physical issue contributing to the latch problems, your pediatrician will evaluate your baby and if necessary, recommend an evidence based professional such as a licensed speech–language pathologist, physical therapist, or pediatric occupational feeding therapist. If you are not satisfied with the outcome of that discussion, a second opinion may be warranted, but consider also the possibility that for complex issues like breastfeeding problems, there are few “quick fixes.”
Basic breastfeeding management for an ideal position, latch, and milk transfer, and basic medical care to address nipple pain and other maternal factors, are the tried-and-true strategies for comfortable and effective breastfeeding.
To learn more about this topic, read the Fed Is Best book available on paperback, e-book, and audiobook.
References
- “Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012 – Jonathan Walsh, Anne Links, Emily Boss, David Tunkel, 2017,” accessed August 7, 2021, https://journals.sagepub.com/doi/10.1177/0194599817690135.
- Morgan Cautero, Rachel, “Why So Many Babies Are Getting Their Tongues Clipped,” The Atlantic, March 12, 2019, https://www.theatlantic.com/family/archive/2019/03/breast-feeding-and-tongue-tie/584503/.
- Mills, Nikki et al., “What Is a Tongue Tie? Defining the Anatomy of the in-Situ Lingual Frenulum,” Clinical Anatomy (New York, N.Y.) 32, no. 6 (September 2019): 749–61, https://doi.org/10.1002/ca.23343.
- Gilliland, Alison M., Bunik, Maya and O’Connor, Mary E., “Pediatricians’ Concerns about Ankyloglossia and Breastfeeding,” Pediatrics 146, no. 1 MeetingAbstract (July 1, 2020): 124, https://doi.org/10.1542/peds.146.1_MeetingAbstract.124.
- O’Shea, Joyce E. et al., “Frenotomy for Tongue-Tie in Newborn Infants,” The Cochrane Database of Systematic Reviews 3 (March 11, 2017): CD011065, https://doi.org/10.1002/14651858.CD011065.pub2.
- Fraser L, Benzie S, Montgomery J. Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain. BMJ. 2020;371:m3928. Published 2020 Nov 26. doi:10.1136/bmj.m3928
- Solis-Pazmino, Paola et al., “Major Complications after Tongue-Tie Release: A Case Report and Systematic Review,” International Journal of Pediatric Otorhinolaryngology 138 (November 2020): 110356, https://doi.org/10.1016/j.ijporl.2020.110356.
- Shah S, Allen P, Walker R, Rosen-Carole C, McKenna Benoit MK. Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia. Laryngoscope. 2021 May;131(5):E1701-E1706. doi: 10.1002/lary.29140.
- Vohra, Sunita et al., “Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review,” Pediatrics 119, no. 1 (January 2007): e275–283, https://doi.org/10.1542/peds.2006-1392.