Why Is Tongue Tie So Controversial?
By: Leigh Anne O'Connor
Tags: Babies, Tongue Tie, Ibclc, Breastfeeding, Parenting

Why Is Tongue Tie So Controversial?

An IBCLC’s perspective

There are many myths around tongue tie and many, many discussions among lactation professionals and parents alike.

As an International Board Certified Lactation Consultant (IBCLC) I work with families who are typically having challenges getting their babies fed. One common cause for breastfeeding challenges is tethered oral tissue. These tethers can be under the tongue (tongue tie), under the upper lip (lip tie) or along the cheeks (buccal tie). Sometimes the tongue is so tight a baby is unable to latch onto a breast. Other times the baby may be able to latch but only onto the tip of the nipple causing damage and inability to remove enough milk to satisfy the baby’s needs. Sometimes there can be some moderate pain but the baby is able to get milk. In many of these cases the milk comes in and the baby basically rides the wave of the the flowing milk for the first few weeks and no one notices a problem until around twelve to sixteen weeks when the baby’s weight gain slows or even stops.

Sometimes the tongue tied baby refuses a bottle and there is no pain. This is typically because when a baby is tongue tied the roof of the mouth, the hard palate, is unusually arched. This is because when the baby was growing in utero the tongue’s limited mobility created this arch. Because a baby’s suck reflex is stimulated by contact with the roof of the mouth the breast tissue is supple enough to make that contact which triggers the baby to suck whereas a bottle nipple may not stimulate this reflex because it does not reach the palate.

Tongue tie is not black and white. It presents differently and often at different times in a person’s life. Breastfeeding is not taught as a matter fo course in medical schools. When it is taught it is often as a single lecture. The very people who are in contact with and educating new parents, obstetricians and pediatricians, have limited education on breastfeeding. When it is not going well, if the patients are lucky and the physicians are humble enough, they may refer to an IBCLC. However, they often default to bottle feeding.

When it comes to the subject of frenotomy, the procedure which releases the tethered oral tissue with by laser or surgical scissors or scalpel, there is great controversy. Read blogs and talk to parents about their experience with tongue tie release and you will hear many charged stories with various outcomes.

As an IBCLC in private practice for nearly twenty years I have seen my share of breastfeeding challenges and many, many tongue tied babies. So where does the controversy come from?

I bought a book in published 1931 titled Diseases of the Tongue. On page 17 begins a section called Tongue-tie: Anchyloglossia.

Here is a section from that chapter:

Infants vary very much in the degree of development of the tongue at birth, as they do later and teething and talking. The tip of the tongue is relatively very short, the frenum appearing almost to join the tip, yet the child can move the tongue between the gums in very soon protruded bit between the lips. In mentally backward children this development of the free portion of the tongue may be likewise delayed, also in a child who is backward in teething and beginning to talk. Hence arose the hoary superstition as to “tongue-tie” handed down from ancient times by midwives, who not only tore the frenum with dirty fingernails, but in addition, stripped up the tongue. There was a thus brought about sepsis stomatitis, nasopharyngitis, and a rash which could be mistaken for syphilis. The tongue so stripped up fell back and cause asphyxia by “tongue swallowing.” Hemorrhage has been set up and has proved fatal by a wound whether of the ranine artery or of the sublingual artery. There followed an inevitable scar, and the tongue then really became fixed in this condition of anchyloglossia. A midwife who interferes nowadays in any way with the baby’s frenum should be punished.

The midwives were demonized and the tongue tied individuals were assumed to be unintelligent. This book was published at a time in history when obstetrics was taking over midwifery and the formula industry was taking off.

When a tongue is too tethered to the floor of the mouth the appropriate amount of tissue has to be released to allow for proper movement of the tongue to be able to remove milk from the breast. The tongue needs mobility. How much to release depends on the elasticity of the tongue and the elasticity of the breast tissue.

The provider releasing the tissue needs to release enough to allow for full function of the tongue. Additionally, because this surgery is simple and does not require stitches it is important that there is follow up with the dyad to ensure the baby is able to appropriately remove milk from the breasts and that the parent is comfortable.

A common complaint that is made is that the tongue tie was released but it did not help the feeding issues. This may be because A) not enough tissue was released and/or B) the ties healed back together. This is very frustrating for new parents to have a procedure performed on their baby and have little to no resolution of the problems they were seeking to remedy.

The tongue should be able to extend beyond the bottom lips. Restricted range of motion is one indicator of a tongue the. However, there can be other causes of a restricted tongue. If a baby has torticollis, tightness in the neck, or molding of the head due to vacuum extraction, forceps or in utero positions, this can mimic a tongue tie. This is because the muscle stiffness creates tension which does not allow for full range of motion of the tongue. Sometimes a baby like this will be sent for a frenotomy, there is an incision in the floor of the mouth but the tension remains and the baby still is unable to use their tongue fully. This adds to the narrative that frenomoy is over diagnosed and does not work.

My approach is to look at the big picture. I check the tongue, I feel the suck, I palpate for a lingual frenulum, I look under the lip, I sweep my finger between the cheeks. I look at the baby, does the baby have a flat head on one side? Can the baby turn equally left and right:? Does the baby favor one side over the other?

Sometimes the baby has both a tongue tie and torticollis. If there is clearly visible body asymmetry I like to address this first because sometimes, releasing the body tension allows for full extension of the tongue and allows for the mouth to open.

If there is a visible tight frenulum I do recommend having it released.

There are consequences of having a tongue tie that extend beyond breastfeeding. This little piece of tissue can cause digestive problems, speech problems, eating problems, neck tension, sleep apnea.

I recall a baby I saw whose mouth was so tight I could not get my finger in his mouth. It was as if he had jaws of steel. His mom’s nipples were very sore. I recommended bmouth opening exercises, craniosacral therapy and a tincture of time. He was gaining weight well and the mom was tolerating the discomfort. When he was several weeks old she texted me to ask if I knew of any good care givers.as she was transitioning back to working full time. At the end of our digital dialogue she sent a cute video of her baby. I watched and in the last three seconds or so he giggled and I caught a glimpse inside his mouth and there it was, a clear and present tongue tie. It was late, around 10:00pm, I immediately asked if I could call her. “I know the problem!”

The next morning she called one of the providers on my list and had his tongue tie released that week. She felt an immediate difference in his feedings.

WhenI see families in person, I typically weigh the baby before and after nursing to see how much milk the baby takes in. On many occasions I have had the opportunity to do these weight checks after a frenotomy. A typical outcome is that a baby can get twice as much milk in half the time compared to when they were tied.

I have been with families who have a history of tongue tie and are familiar with the consequences. I will never forget discovering a tongue tie in a baby and the mom was worried her husband would be against treating it. While I was packing up my gear her husband came home. “Honey, the baby has this piece of skin under his tongue and . . “ Before she could finish her sentence he replied, “I had that, they cut it out when I got braces, let’s do it now so we don’t have to pay for orthodontia.”

Some families choose to leave the tongue as is. It isn’t always impossible to breastfeed a tongue tied baby. These babies typically tire out quickly so they have to be fed in short bursts very often. Supplementing with pumped milk or formula is a solution that many people will choose.

One mom had an incomplete frenotomy and her baby couldn’t latch onto her breasts. When I informed her that her baby was tongue tied she got angry, told me that her baby had latched onto her sister’s breast and that it was an issue with her breasts that were the reason her baby could not feed. She refused to pay for my services. This baby had a tongue tie you could see across the room.

It is challenging and confusing for parents to navigate the conflicting information they receive. I may be the only person informing them that their baby would benefit from releasing the tissue. Sometimes people tell me they are going ask their pediatrician what they think. Depending on who the doctor is I know how the conversion will go.

I keep sharing information and educating as many people as I can and helping one family at a time make an informed decision and support them in their choices.