Untying Tongue Ties: What they are and what to do about them
Written by: Qamar Halat, Speech-Language Pathology Student
Tongue-tie surgeries have become more common in recent years. In fact, Canadian surveys have found that the frequency of this surgery became four times more common between 2002 and 2014, and this frequency continues to rise as surgical procedures continue to improve and as awareness increases (Messner et al., 2020). Yet, one might wonder, is this surgery always warranted? Are there any benefits to this procedure? And what are tongue ties, anyway? These questions will be answered below to help untangle this topic.
What are tongue-ties?
Before looking into some of the available evidence, it is important to begin with some background information. A tongue-tie, also known as ankyloglossia, is a physical condition where the tissue under the tongue, the lingual frenulum, is short and thick, causing it to connect the tongue too tightly to the floor of the mouth (Walsh & Tunkel, 2017). The cause of this phenomenon is not always known, but it can run in families or can be caused by other conditions that impact the mouth such as cleft palate (Healthwise, 2020). The incidence of tongue-ties ranges from 0.1% to 12.11% and seems to increase each year (Messner et al., 2020; Walsh & Tunkel, 2017). This is because there is no standard understanding of a tongue-tie. According to the Canadian Paediatric Society (CPS) position statement, there is no consistent definition nor any clear diagnostic criteria for tongue-ties which causes additional confusion when it comes to diagnosis and treatment guidelines (Rowan-Legg, 2015). Although there are multiple methods available to classify tongue-ties, they are used inconsistently and the method varies between practitioners (Walsh & Tunkel, 2017).
What can be done for a tongue tie?
For children diagnosed with a tongue-tie that is impacting their skills, a doctor may either decide to monitor the child and determine if any next steps are warranted or they may recommend a frenectomy. This is a quick minor procedure that may be done using surgical scissors or laser to cut the frenulum and allow the tongue to move more freely. As with any procedure, there are potential complications such as infections, bleeding, swelling, and pain when feeding (Hale et al., 2019). The Canadian Paediatric Society position statement indicates that based on current evidence, a frenectomy cannot be recommended for all infants with a tongue-tie (Rowan-Legg, 2015). One study found that of 115 infants who were referred to a clinic for a tongue-tie surgery 62.6% of these ended up not needing to undergo the surgery after a team feeding assessment was completed (Caloway et. al., 2019). Instead, many of these parents were offered strategies and feedback to assist them with breastfeeding.
What impacts does a tongue-tie have on my child?
Tongue-ties could potentially impact breastfeeding and speech. However, as with the definition of the condition, there is no consensus on whether tongue-ties have an impact on either of these despite several studies being completed in this area.
With breastfeeding, the tongue needs to be able to move forward and upward to create a seal and put enough pressure to stimulate the release of milk. When a child has difficulties moving their tongue, they will try to compensate by using their jaw and lips which can cause pain for the one breastfeeding the child (Glauser, 2019). After a frenectomy, the theory is that a child will be able to begin to regain mobility of their tongue and will no longer need to use compensatory strategies. Yet, in one study, researchers found that 56% of children who were diagnosed with a tongue-tie were still able to feed with no difficulties (Rowan-Legg, 2015). Many studies have come to the same conclusion. Another researcher indicates that while a frenectomy can have positive impacts, they found that some mothers demonstrated a placebo effect when they believed their child received the procedure (Brookes & Bowley, 2014). However, they also found that perception of feeding and pain scores by some mothers whose children did undergo the surgery were improved. An expert panel of medical professionals did reach the consensus that pain and poor latch can be caused by a tongue-tie, but they can also be caused by other things even when a tongue-tie is visible (Messner et. al, 2020).
In speech, the tongue plays a vital role. The tongue tip needs to be able to move in a variety of directions including to the roof of the mouth for sounds like “l” in “lake” and forward for sound like “th” in “think.” Just as with breastfeeding, there is conflicting evidence as to whether a tongue-tie has an impact on a child’s ability to produce speech sounds. An expert panel concluded that tongue-ties do not typically affect speech and many sounds that need tongue tip mobility can be made with restriction (Messner et. al, 2020). On the other hand, one study found that children with tongue-ties produced twice as many articulation, or speech sound, errors than their peers who had undergone the surgery (Brookes & Bowley, 2014). Another study found that there is not only a connection between speech sound production and tongue ties but also a connection with speech delays (Baxter et al., 2020). In their study, they noticed that half of their patients said at least one new word after their procedure, with some using the word on the same day. However, both of these studies have multiple limitations, such as small sample sizes, lack of descriptions of terms, and lack of blinding, and this is the case for many of the studies available on this topic.
Overall, the evidence on whether a frenectomy is warranted when a child has a tongue-tie is limited and conflicting and whether the surgery has positive effects on the child is also not fully understood.
So, what should I do if I suspect my child has a tongue-tie?
If you are experiencing any symptoms while breastfeeding or suspecting your child is having any difficulties with feeding or speech and you can see, or you suspect, that your child has a tongue-tie, it would be a good idea to see your family physician. An assessment should be completed by an interdisciplinary team to ensure that it is thorough and that any difficulties are not caused by something else before determining which next steps are warranted (Caloway et. al., 2019). Even when a tongue-tie is present, it may not have any functional impacts on the child’s ability to breastfeed or to speak as demonstrated by the evidence described above. Thus, comprehensive assessments are important to ensure that the child will not undergo undue harm if the tongue-tie is not impacting their abilities.
There are many professionals qualified to diagnose a tongue-tie, including Ear, Nose, and Throat doctors (ENT), and family physicians. If you are observing or experiencing difficulties with breastfeeding, speak to your family physician. Your family physician will be able to determine next steps. One of these may be an assessment by a feeding team which can include a speech-language pathologist, an occupational therapist, a dietitian, and a lactation consultant. If you are concerned about speech development, reach out to a speech-language pathologist for additional support.
Baxter, R., Merkel-Walsh, R., Baxter, B. S., Lashley, A., & Rendell, N. R. (2020). Functional improvements of speech, feeding, and sleep after lingual frenectomy Tongue-Tie release: A prospective cohort study. Clinical Pediatrics, 59(9–10), 885–892. https://doi.org/10.1177/0009922820928055
Brookes, A., & Bowley, D. M. (2014). Tongue tie: The evidence for frenotomy. Early Human Development, 90(11), 765–768. https://doi.org/10.1016/j.earlhumdev.2014.08.021
Caloway, C., Hersh, C. J., Baars, R., Sally, S., Diercks, G., & Hartnick, C. J. (2019). Association of feeding evaluation with frenotomy rates in infants with breastfeeding difficulties. JAMA Otolaryngology–Head & Neck Surgery, 145(9), 817. https://doi.org/10.1001/jamaoto.2019.1696
Glauser, W. (2019, November 25). Are too many babies getting tongue tie surgery? Retrieved from https://www.todaysparent.com/baby/breastfeeding/are-too-many-babies-getting-tongue-tie-surgery/
Hale, M., Mills, N., Edmonds, L., Dawes, P., Dickson, N., Barker, D., & Wheeler, B. J. (2019). Complications following frenotomy for ankyloglossia: A 24‐month prospective new zealand paediatric surveillance unit study. Journal of Paediatrics and Child Health, 56(4), 557–562. https://doi.org/10.1111/jpc.14682
Healthwise. (2020, May 27). Tongue-Tie. Retrieved from https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=hw183100
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. Otolaryngology–Head and Neck Surgery, 162(5), 597–611. https://doi.org/10.1177/0194599820915457
Rowan-Legg, A. (2015). Ankyloglossia and breastfeeding. Paediatrics & Child Health, 16(4), 222. https://doi.org/10.1093/pch/16.4.222
Walsh, J., & Tunkel, D. (2017). Diagnosis and treatment of ankyloglossia in newborns and infants. JAMA Otolaryngology–Head & Neck Surgery, 143(10), 1032-1039. https://doi.org/10.1001/jamaoto.2017.0948