Tongue ties are being blamed on social media for a slew of woes affecting infants—from nipple pain to poor napping to speech issues—but many experts agree that the rise in diagnosis and treatment is being led by consumer demand rather than by hard science.
Tongue tie, or ankyloglossia (AG), is a congenital condition in which an abnormally short frenulum restricts the tongue’s ability to function properly. A lip tie is an unusually tight labial frenulum, which keeps the upper lip tethered to the gum line. Tongue and lip ties often occur in tandem, are more common in boys than girls, and tend to run in families.
Wood block of a physician performing a frenectomy, dated 1679.
© Wood block courtesy of Dr. Messner
The diagnosis and treatment of AG is not new, said Anna Messner, MD, a professor at Baylor College of Medicine and division chief of otolaryngology/head and neck surgery at Texas Children’s Hospital in Houston. “There are wood cuts showing a physician cutting a newborn’s frenulum dating back to 1679” (right). However, the treatment became less common as women turned away from breastfeeding in favor of formula and bottle feeding around the middle of the last century. In the last quarter century, the pendulum has swung back in favor of breastfeeding and, with that, an increase in the number of women seeking help with nursing issues.
“For many women, breastfeeding can be extremely painful for the first few weeks,” Dr. Messner said. Successful breastfeeding requires proper technique, in which the tip of the nipple hits the roof of the mouth and creates a vacuum on the breast. This differs from compressing the nipple, which effectively squeezes the milk out rather than sucking. “The tongue is a powerful muscle, but it can’t suck and draw milk out of the breast if it’s not fully underneath the nipple,” said Julie Wei, MD, division chief of otolaryngology in the department of surgery at Nemours Children’s Health System in Orlando, Fla.
In some infants with limited tongue mobility, AG is associated with significant breastfeeding issues—including painful nipples, damaged nipples, poor milk transfer, low milk supply, early cessation of breastfeeding, and failure to thrive (JAMA Otolaryngol Head Neck Surg. 2017;143:1032–1039). “With all the health benefits associated with breastfeeding, this issue [of AG] has become more important to mothers,” said Karthik Balakrishnan, MD, MPH, associate professor in the division of pediatric otolaryngology at the Mayo Clinic in Rochester, Minn. “Social media both facilitates and exacerbates the concerns of mothers and has been a big driver in the increase in diagnosis and treatment of AG,” he added. This has led mothers to seek help from lactation consultants in the first weeks of breastfeeding. Lactation consultants often then recommend a referral for tongue tie diagnosis and treatment (BMC Pregnancy Childbirth. 2017;17:373).
Considerable controversy surrounds this condition, however. Otolaryngologists, oral surgeons, pediatricians, speech therapists, and lactation consultants often have differing opinions regarding the definition, clinical significance, need for surgical intervention, and timing of treatment of ankyloglossia.
The incidence of AG is a subject of debate because of different definitions for tongue tie. —Anna Messner, MD
How Common Is AG?
“The incidence of AG is a subject of debate because of different definitions for tongue tie,” said Dr. Messner. The definition is generally divided into two classifications: anterior (Type 1 and Type 2) and posterior (Type 3 and Type 4). “With the recent inclusion of posterior tongue tie, there has been an overdiagnosis of ties in some areas of the country, leading to babies having procedures that are not really necessary,” she said.
Among newborn infants in a hospital setting, the incidence of AG has been reported to range between 4% and 11%, she noted (Cochrane Database Syst Rev. 2017;3:CD011065). In children older than 6 years of age, the incidence is much lower—between 2% and 3%.
The rates of diagnosis in hospital births increased three-fold in Canada from 2008 to 2013 and 10-fold in the United States from 1997 to 2012, Dr. Balakrishnan said (Paediatr Child Health. 2017;22:382–386). “There is no public heath reason to explain the increase, only an increase in awareness and diagnosis.”
The data on the benefits of treating tongue tie are very weak. … There are no large, well-controlled studies; we need more standardization on the definitions and how to measure outcomes. —Karthik Balakrishnan, MD, MPH
Diagnosis and Treatment
Many issues can contribute to feeding issues in an infant. Therefore, a careful exam of the newborn or infant is needed to diagnose tongue or lip tie, as well as to rule out more serious issues that might affect feeding, including airway issues, neurologic issues, and hypotonia, among others, said Dr. Balakrishnan.
Dr. Carter’s operative set up for frenotomy.
© Courtesy Dr. Carter
“It is normal for everyone to have a ‘tie,’ or frenulum. However, not all clinicians know what a tongue or lip tie looks like. Doctors may not check under the tongue and therefore miss even the most obvious tongue ties,” Dr. Wei said. To evaluate for tongue tie, “I use my clean finger to “sweep” under the tongue. If I palpate a ridge or I can clearly see the excessive frenulum limiting tongue movement [anterior tongue tie classification 1 and 2], I am more willing to recommend release,” Dr. Wei said.
To look for lip tie, Dr. Wei everts the upper lip to see if the natural upper frenulum comes down and “wraps around” the alveolar ridge. “If it’s too thick, broad, and, specifically in children who have teeth, if the thick band is between the gap of both central incisors, it may be reasonable to consider releasing it only if it interferes with brushing teeth or causes pain. If not, especially in babies without teeth, there is not enough evidence to support release to ‘improve’ nursing,” Dr. Wei said.
The research on whether or not frenectomy is an effective treatment has yielded mixed results. One report found that there is a “small body of evidence that frenotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain” (Pediatrics. 2015;135:e1458–1466). However, “with small, short term studies with inconsistent methodology, strength of the evidence is low to insufficient,” the authors concluded.
Treatment Options
For newborns, frenectomy can be performed in the office without anesthesia or sedation. Dr. Wei performs an in-office procedure using a sterile scissor and silver nitrate sticks to stop the bleeding, if needed; no sutures are needed.
Lasers are more commonly used by dentists, who may charge $800 or more to treat a tongue tie, Dr. Messner noted. But the use of lasers can be dangerous. “As a pediatric otolaryngologist, I have seen burn injuries as a result of laser therapy; therefore, I would personally not use lasers on any newborn,” Dr. Wei said. Once an infant is older than six months, it is more difficult to perform a frenectomy in the office.
For toddlers and school-aged children, lingual frenotomy is generally performed under brief mask general anesthesia. “Having the child under sedation allows me to be precise, release as much as necessary, and place a few dissolvable stitches to bring together the edges of the mucosa instead of waiting for that raw area to heal by secondary intention and risk scar band reforming,” Dr. Wei said.
There are some downsides to the procedures. There are rare incidences of persistent bleeding, damage to the salivary ducts, or oral aversion due to pain in the baby’s mouth. “That is why many otolaryngologists are opposed to lasers. Nipping [the tie] with the scissor is kinder and likely to have fewer complications,” Dr. Messner said.
One thing that many professionals appear to agree on is the need for more research. “The data on the benefits of treating tongue tie are very weak. Much is being talked about in this area and there is a lot of controversy, yet there are no large, well-controlled studies; we need more standardization on the definitions and how to measure outcomes,” Dr. Balakrishnan said.
“Each surgeon must rely on their experience, knowledge, [and] careful exam, and discuss with the family what’s truly reasonable and if that were their own child, would they ‘cut’ anything,” Dr. Wei said.
To address the controversy, the American Academy of Otolaryngology–Head and Neck Surgery is producing a consensus report to be released at the annual meeting in New Orleans on September 15, 2019. The American Academy of Pediatrics is also working on a consensus statement.
Nikki Kean is a freelance medical writer based in New Jersey.
Key Points
- Otolaryngologists, oral surgeons, pediatricians, speech therapists, and lactation consultants often have differing opinions regarding the definition, clinical significance, and need for surgical intervention of ankyloglossia.
- There are no large, well-controlled studies on the benefits of treating tongue tie.
A Speech Pathologist Talks about Ankyloglossia
April Johnson, MA, CCC-SLP, a supervisor and speech-language pathologist and co-director of the Pediatric Voice and Swallowing Clinic at Stanford Children’s Health in Palo Alto, Calif., talked to ENTtoday about tongue ties.
ENTtoday: How common are speech-related issues among children with tongue ties?
Johnson: This is a difficult question to answer because there is a lack of comparative data on this subject. Studies show great variability in speech disorder prevalence among children, and the American Speech and Hearing Association has reported that 2.3% to 24.6% of school-aged children were estimated to have speech delay or speech sound disorders. Of the children diagnosed with a speech sound disorder, there are no data on the prevalence of AG within this population.
There are a few studies that claim that tongue tie release improved articulation in patients with AG. Because there are no standardized measures to evaluate the need for release, many practitioners, including physicians and speech language pathologists, look at lingual mobility tasks, such as lingual protrusion, as well as parent report of a speech disorder, to make a decision regarding release. However, there is no evidence that reduced ability to protrude the tongue and to lateralize the tongue tip to the molars will affect a patient’s ability to produce consonants.
ENTtoday: When would you recommend treatment?
Johnson: I look at tongue mobility for functional tasks, such as clearing food residue from the cheeks and teeth. For speech, I use standardized testing with an articulation test as well as informal measures to test overall speech intelligibility in conversation. I look for the child’s ability to produce alveolar consonants, which are produced with the anterior portion of the tongue. Even in cases of AG, most children I’ve seen do not have difficulty producing these sounds.
It’s important to provide a differential diagnosis because there are many reasons why a speech sound disorder may exist, including a motor speech disorder, an articulation delay, or a phonological processing delay. These diagnoses require different treatment methods, and I would always start with speech therapy targeting the sound errors and the child’s ability to produce accurate productions prior to recommending a surgery to release the frenulum, if that is a concern. Ultimately, the decision to perform a surgical release is based on the physician’s recommendation.
Pearls & Pitfalls for In-Office Frenotomy
John Carter, MD, section head of pediatric otolaryngology–head and neck surgery at Ochsner Health Systems in New Orleans, recommends the following for releasing a tongue tie:
- You can typically perform in-office frenotomy until an infant is old enough to bite your finger (approximately six months of age).
- Don’t do the procedure in the office on:
- infants on anticoagulants or aspirin;
- infants who can’t tolerate anemia (i.e. congenital heart defects, BPD); or
- infants who have difficulty managing their secretions.
- Hemostatic gauze is a good way to stop bleeding that oxymetazoline or neosynephrine will not.
- Silver nitrate is not good solution to stop bleeding, as it will often burn the infant’s upper aerodigestive tract.
- Oral sucrose is sufficient for perioperative anesthesia.
- It is OK to let the infant breastfeed right after the procedure, and helps to calm her down, which slows bleeding.
Items in operative set-up:
- Iris scissor
- Groove director
- Sucrose vial
- Hemostatic gauze
- Oxymetazoline
- Gauze