I commonly hear people say, “You must clip a tongue tie or your child will not breastfeed, will have issues with speech, not eat, and end up with complications.” The evidence is not there. Let’s discuss.
Tongue tie and lip tie. To clip or not to clip?
The diagnosis and surgical treatment of tongue tie has increased 10-fold between 1997 and 2012 in the United States, and 3-fold between 2008 and 2013 in Canada. The likely explanation is due to increased awareness and assessment, not to an evolutionary change of producing more babies with this variant. Lip ties are also being noted more frequently, also in large part due to increased awareness of the entity.
There is a lot of division when it comes to a tongue tie.
Lactation consultants, pediatricians, feeding therapists, dentists, ENTs, and speech therapists all have their opinions. Some in the community are extremely opinionated to say that every tongue tie/lip tie in newborn age should be clipped—and this is simply not true. The reality remains that some children MAY develop issues with speech, breastfeeding, and feeding, but to blame it SOLELY on tongue ties is not fair. It may be correlation but not causation.
Causation explicitly applies to cases where action A causes outcome B. In this case, not clipping your baby’s tongue WILL lead to issues down the line. But we see 1,000s of children with tongue tie and maybe 10 will go on to have some speech/eating/issue…so do should we do a release for everyone?
What does the data say?
A study published in JAMA Otolaryngology-Head and Neck Surgery investigated a group of infants referred to an otolaryngology practice for tongue tie release surgery, aiming to assess how many of these procedures are actually necessary, and whether or not there are alternative options. The study, based at the Massachusetts Eye and Ear Infirmary and the Massachusetts General Hospital, both in Boston, looked at over 100 babies referred to an otolaryngology surgeon for surgical repair of a tongue tie. The average patient age was 34 days old. All patients were enrolled in a multidisciplinary feeding evaluation by speech and language pathologists. Prior to going ahead with surgery, families were offered techniques to improve quality of breastfeeding. Following this program, over 60% of infants referred for surgery of the tongue or lip fold did not need it.
So, what to do?
When we decide on an intervention for children we think are there poor outcomes if we don’t intervene across the board? If we saw a large amount of children having issues with their tongue ties, we would be recommending a release. But we’re not. We need to look at function over appearance. This is key. Is this causing true issues that can’t be explained for other reasons? If so then yes we do a release (or clipping).
A tongue tie can come in different types
- Class 1 ties are attached on the very tip of the tongue. This would be considered an anterior tongue tie. The appearance of the tongue tip often resembles a heart shape when elevated. These are the ones that most people think of when they talk about tongue ties.
- Class 2 ties are a little further behind the tip of the tongue about 2-4 mm and attache on or just behind the alveolar ridge (jaw bone). They also fall under the classification of anterior tongue tie.
- Class 3 ties are closer to the base of the tongue and attach to the mid-tongue and the middle of the floor of the mouth. These ties are generally tighter and less elastic.
- Class 4 ties are the most commonly missed ties. The front and sides of the tongue elevate, but the mid tongue can not. These are also known as posterior tongue ties and must be felt to be diagnosed. It’s very thick and inelastic.
Ankyloglossia or tongue ties effect 4-10% of the population. But it doesn’t mean all go on to have issues. The most important thing we need to know in the newborn period—is this effecting a baby’s latch? If you are having any pain or difficult latching, I do agree we need to evaluate for ties. The tie can effect the mobility of the tongue—the inability to elevate rather than protrude is the most important quality for nursing.
If the tongue tie is causing problems, It should be clipped. It can cause an ineffective latch, inadequate milk transfer, nipple pain which makes the breastfeeding experience miserable. But not all babies and their mothers will have this issue. So, case by case basis and close monitoring with Peds/LC.
Will your baby develop feeding or speech issues?
Not exactly. We see many kids with tongue ties without issues. So we watch for function. The difficulties in articulation for individuals with ankyloglossia are evident for consonants and sounds like /s/, /z/, /t/, /d/, /l/, /sh/, /ch/, /th/, and /dg/, and it is especially difficult to roll an r. Because parents often do not report speech issues accurately, an evaluation by a speech-language pathologist trained in assessing tongue-ties is recommended to assess for speech or language errors prior to recommending a tongue-tie release.
In terms of dental/oral development—data is limited. Evaluation by a dentist is important. A lip tie can cause a gap in front teeth but treatment is not recommended based on appearance alone. Treatment may not close this gap, and function is way more important. Also the tie doesn’t cause more cavities—but hygiene is important to get around that area.
What to do if you are concerned about a tongue tie
- Have your Pediatrician take a look. If you want a second opinion see your dentist, ENT or oral surgeon. I am a big believer in second opinions for surgical procedures where it’s elective AKA you are deciding if you want to proceed.
- If breastfeeding, talk to a lactation consultant for an eval and see if other positioning helps or if there are other reasons for an inadequate latch.
- In the newborn period, if the latch is not impacted, have a conversation with your Pediatrician. Most will mention no need to do a release. If your parent heart feels you want to, you can. But it’s not necessary. Otherwise, we monitor for any possible issues.
- If your child is older and having issues with speech or feeding, it’s important for it to be a team effort. Speak with your Pediatrician, speech therapist, and/or feeding therapist BEFORE laser procedure. We want to see if there’s another reason before going first to a surgical procedure.
Why not clip every tongue tie?
- These procedures carry risk of infection, bleeding, and longer term scarring and nerve damage. We have to see if the benefit outweighs risk.
- The obsession with ties when there may be other issues. When deciding to do a procedure, we should always err on doing what is necessary. Releasing ties without trying other interventions is not the way to proceed.
- You shouldn’t have to be paying $1,000 of dollars out of pocket. There are many shady practices doing this saying that your child needs this or they will end up with major complications and this is not completely true.
- A child is born with it. Just like tonsils. Do we excise all tonsils? No, only if it causes problems. Do we take out everyone’s appendix? No only if it causes problems. Same applies here. Function matters over appearance.
- We commonly want a reason as parents/therapists/etc. I think about this in just how this is occurring more in developed countries. We have kids in other countries who have tongue ties that never get released. They learn to adapt to their tongue tie or lip tie.