Tongue Tie

By Dr Ola Basson, Ear, Nose and Throat (ENT) Specialist, FCS ORL (SA) (2002), MBChB Cape Town (1994)

One would think that breast feeding your baby is the most “natural” thing in the world, but for many new mums it is a process fraught with difficulty. Often anxious and exhausted, mothers battle to get their babies to latch, feeding hurts, babies tire and lose weight, everyone sleeps poorly. Advice is freely given from all quarters, and invariably “tongue tie” is blamed, or at least receives a mention.

What is tongue tie?

The medical term is ankyloglossia, and it refers to the restriction of normal tongue movement by the attachment of the underside of the tongue to the floor of the mouth by the lingual frenulum. You can see your own frenulum in the mirror when you touch the tip of your tongue to your palate – it is the vertical band of tissue in the midline. During embryonic development, it holds the tongue in position; and around the 12^th week in utero, it should then be resorbed, much like a tadpole’s tail. The process is not always complete, and a band that is too short, too thick, too inelastic, or too high up the tongue can lead to problems with breastfeeding, speech development, and oral hygiene (think of trying to clear food from crevices in your mouth without being able to reach them with your tongue).

The first step in diagnosing tongue-tie is to think of it first. Poor latching, prolonged feeding times, clicking sounds, or pain and nipple damage can indicate tongue tie. While it may be obvious to see when baby cries, with the tip of the tongue making an “upside-down heart”, there are variants that can be trickier to diagnose. The posterior tongue tie, also known as submucosal (under the surface) can only be diagnosed on palpation. Other tissues in the mouth can cause similar restriction of normal movement – lip-tie and cheek-tie. It is important to emphasise that these can be present without causing any problems or needing treatment.

In toddlers, “fussy eating” or speech difficulties can be indicative of tongue tie. The tongue is composed of different muscles involved in feeding, speech, and swallowing. Good function and muscle rest position provides a mould for correct growth and development of the dental arches and facial development.

Treatment

The early diagnosis is most often made by the paediatrician or the lactation consultant. Non-surgical management can involve different breast-feeding positions or nipple shields, but dividing the frenulum – frenotomy – is a quick and easy procedure that can be performed in the rooms without the need for general anaesthesia. A small amount of local anaesthetic is applied, and the frenulum is divided with a pair of scissors. The procedure typically results in minimal bleeding. While the trauma and pain can be likened to biting one’s tongue, and is obviously upsetting for baby (and parents!) for a short time, it results in immediate improvement in tongue mobility. If the diagnosis has been delayed, the procedure is then done under a short general anaesthetic as a “day case”. This is usually only necessary after the age of 12 months. An alternative tool is a laser.

A frenuloplasty is a more extensive procedure, and is performed under general anaesthesia. This involves the release of the frenulum and stitching the incision in a way to prevent re-attachment. It is considered for particularly thick frenulums, or when scarring after a previous frenotomy has resulted in a recurrence of tongue tie.

Post-procedure care by parents is important to prevent wound scarring and re-adhesion. Stretches and exercises need to be performed at least three times a day for at least two weeks or until healing. Ideally, the lactation consultant should be seen within 24 hours of the release.

Pre-hab and re-hab

Is frenotomy then the solution to tongue ties? Some argue that tongue ties are over-diagnosed and overtreated, while others emphasize the benefits of early intervention. In his book “Tongue Tied”, Dr Richard Baxter uses the analogy of one’s first pair of running shoes having their laces tied together. You can still run in them, but you are going to be slower and fall often. Once the laces are untied, you can run unhindered, but will benefit from training and coaching over time. Hence the importance of lactation support for babies, and speech and myofunctional therapy for older patients (physiotherapy to improve the function of the tongue and facial muscles). Depending on the length of time the tongue was “tied”, compensatory patterns would have been developed, and now correct movements have to be learned to feed, or chew and talk.

Angela Buck is a Cape Town based physiotherapist and breastfeeding consultant who specialises in oral motor dysfunction and pre/post-frenectomy treatments. She prescribes “pre-hab” before the release – training the baby’s tongue to strengthen it and improve co-ordination before the procedure; and thereafter doing similar exercises to optimise tongue function and feeding. The rehab post release also decreases the likelihood of formation of scar tissue.

While tongue tie treatment should not be seen as the universal panacea for all breastfeeding, speech, and oral health issues, it definitely deserves attention.