LIP & TONGUE TIES: A HOT TOPIC!

Kellie Eason, MILK...early parenting support
​Nurse | Midwife | International Board Certified Lactation Consultant | Infant Feeding Therapist | Gentle Sleep & Settling Consultant

She collaboratively with holistic practitioners at Osteo 4 Kids & Adults in Preston, Melbourne as well as providing a home consulting service within the Northern Suburbs of Melbourne

There is much hot debate within the community about infants with lip and tongue ties.  
There is just as much of a hot debate about how to treat them too, which is why so many parents are baffled about what to do when they are told their baby may have a tongue and/or lip tie.

WHAT IS A TONGUE TIE OR A LIP TIE?
Most of us have a band of tissue in the centre and underneath our lip and tongue - this is called 'frena' (plural) or 'frenulum' (singular)

The lingual frenulum is located beneath the tongue and the labial frenum is located between the underside of the lip and gum line.

During embryonic development, the frena normally recede or shrink to allow the tongue and lip to move freely.
Normal tongue and lip movement is known to be important for feeding, oral health and speech.

Where the lingual and/or labial frenum have failed to shrink and are impairing normal tongue and lip movement, this is what is referred to as a "tongue tie" or a "Lip tie".  By looking at the pictures below,  you can see, that some babies have lip and tongue ties, some don't at all and for others it is really hard to tell...

WHY ARE LIP & TONGUE TIES SUCH A HOT TOPIC?
The reality is that tongue and/or lip ties can be really difficult to identify, because looking at a baby's mouth or looking at pictures of the mouths of babes alone, cannot tell you if they have a tongue tie or not.

​The key here, is the definition of a lip or tongue tie - which are seen as a conditions where movement of the tongue and/or lip are assessed as being limited.

Now here is where the plot thickens, as yet, there are no clear anatomical variable identified that have a direct correlation with the limitation of specific tongue movements, or improvement in any objective outcome measures following frenotomy. Consequently, major controversy still exists around when and how the frenulum is determined to be limiting movement, and when that limitation is sufficient to warrant surgical intervention. (1)

Without clear definitions and guidelines in place, here is where the controversy and confusion has begun. 

The highest standard of medical evidence requires randomised controlled trials (RCT) to ensure the highest level of objectivity and safety for medical and surgical interventions.  These trials require a groups of a minimum of 1000 study participants without medical/surgical intervention and the other group to have the intervention.  These groups are then compared to assess the differences in outcomes.

When it comes to research in the field of Paediatric Surgery & Medicine, there are often limitations on passing research proposals through ethics committees due to the unethical implications of denying one group of children treatment versus the providing the other group of treatment of which its effects are yet unknown.

In terms of research that is agreed upon, is that if an infant indeed is assessed to have a tongue tie which is contributing to breastfeeding issues such as painful latch, latching difficulties and/or low milk supply,  there is a significant improvement in that breastfeeding mother's pain score and ability to continue breastfeeding. (2) (3) 

To date, there are no RCT studies on the impact of tongue ties on bottle feeding, speech and dental health, however it is recognised that further research is needed. (1)(5)(12)

There are limited good quality studies on the impact of lip ties on breastfeeding and there is research underway into the area of sucking dynamics, bottle feeding and lip/tongue ties. (4)(5)

However, there is a lot of anecdotal evidence amongst various health professionals such as specialist dental surgeons, ENT surgeons, IBCLC's and Speech Pathologists with regard to the assessments and treatment of tongue and lip ties.  

We cannot forget that anectodal evidence is still just as important, as it comes from years if not decades of experience with patients.

When it comes down to undergraduate and post graduate clinical education (ie. for most health professionals including Nurses, Midwives, Maternal & Child Health Nurses, GP's, Paediatrician's and IBCLC's) does not cover topics such as:

• Tongue and lip ties
• Breast and Bottle feeding
• The dynamics of sucking and swallowing
• Speech & language development
• Dental health

​HOW DO I KNOW IF MY BABY HAS A TONGUE OR LIP TIE?
It is known that tongue ties can cause issues with:

• Breastfeeding
• Feeding
• Speech
• Sleep

Common infant related concerns associated with tongue tie can include, painful and prolonged breastfeeding duration, poor stimulation of maternal milk production, reflux, slow weight gain and gassiness. (6)

Progression to eating solids can elicit symptoms such as food refusal, "picky eating", gagging, coughing after eating,  spitting out food and having to manually clear baby's mouth of food. (6)

Speech related concerns include, speech delays, unintelligible speech, stuttering and difficulty with clear pronunciations of the 'R, L, S, SH, TH, and Z sounds'. (6)

Tongue ties can impact from infancy, as it may impact on the frequent waking.  Where the tongue and or shortened jaw causes partial closure of the airway, the brain is stimulated to wake frequently to enable oxygen delivery to the brain.  The ongoing impact of this is the difficulty to engage in deep restful sleep. (6)

So far, it is obvious to see that more research is needed in the area of Tongue & Lip Ties. This is exactly why parents will receive mixed opinions about whether their child 'does or doesn't have a lip or tongue tie' and why their child 'should or shouldn't have it treated'.  If you put yourself in the shoes of the clinician, you can easily understand why you will get this kind of advice.  After all, we want we think is best and safest for your child, based with the evidence and experience that we have at hand. 

In my clinical experience, 100% of the time, parental intuition always serves best.  Mums always know when something is "not quite right" with their child. 

In my clinical experience, about 70% of parents will listen to what they are told, leaving it at that, only to regret down the track that they didn't follow their gut sooner.

In my clinical experience, about 30% of parents, will turn into FBI agents - they will not give up until they find an answer in seeking several professional opinions and researching articles,  forums & social media groups for guidance.

Most of the time, if your baby's tongue tie is obvious, you will be referred for treatment.
If your baby's tongue tie is less obvious, you need to be in that 30% group of FBI parents where you have to do your homework and find the help you need.  

If you are uncertain about the advice you are given by a health care provider, it is important that you ask for a referral to one that can assist you, who is more experienced, even if it is for a second opinion.

WHAT DO I DO, IF I SUSPECT MY BABY HAS A TONGUE OR LIP TIE?
In doing your research, you need to find a health practitioner that is highly recommended that can help you.  
Most of the time, word of mouth is your best recommendation, but note it isn't always your best recommendation.

These websites have access to providers that can help:
https://www.lcanz.org/find-a-lactation-consultant/
ankyloglossiabodyworkers.com
International Affiliation of Tongue Tie Professionals

WHAT CAN I DO TO ENSURE MY BABY IS ASSESSED BY THE SAFEST PROVIDER?
There are a few questions you need to ask:
1. What is your clinical background
Ideally, you want a provider that has Specialty Training and ongoing experience in Paediatrics.
This is to ensure your provider has experience with a great deal of sensitivity to the unique needs of children.
It may seem obvious me mentioning this, but the field of Paediatrics is indeed a speciality of its own - children have unique health care needs that are entirely different to those of adults.  Unless you have training and experience in Paediatrics, the level of care is not going to be at an optimal standard for your child.

2. How many babies do you see in your practice with tongue and lip ties?
When a clinician consults a large proportion of infants with lip and tongue ties, it is going to give the clinician greater expertise due to greater exposure. I wouldn't expect most clinicians to identify that they have seen over 100 babies that have tongue and/or lip ties with complex feeding issues, but at least demonstrate that it is not a rarity in their practice and that they are confident in the clinical needs and research associated with mother/baby pairs affected by tongue and/or lip ties. They should also be able to refer you to an IBCLC or Infant Feeding Therapist that they work with.

3. What kind of professional development do you regularly undertake in the area of tongue and lip ties?
If a clinician has a special interest in caring for children with lip and tongue ties, they will attain specialty courses and conferences in the area of tongue and lip ties, as well as reading regular journal articles on the same topic.

This means that provider has a special interest and is likely to have more knowledge about lip and tongue ties than he or she otherwise would have.

4. What kind of care do you offer to support babies with tongue and lip ties?
Infant's who have tongue and lip ties with complex feeding problems,  need special care and attention.
To ensure the best outcomes, pre surgical treatment is needed along with post surgical rehabilitation.
This will often involve bodywork such as Chiropractic, Osteopathic or Physiotherapy treatment, also support with an IBCLC or Infant feeding Therapist who can provide oromyofunctional therapy.

As for myself, as well as being a Nurse, Midwife and IBCLC, I am trained in Infant Feeding Therapy which involves Oromyofunctional Therapy for infants. I am also trained in Infant Sleep & Settling as well as Infant and Maternal Mental Health. This enables to application of therapeutic techniques such as massage, exercises and techniques to enable improved infant feeding.  It also enables the application of sleep and settling strategies for infants and parents that are struggling to sleep.  Which is super common with infants that are affected by lip and tongue ties.  It enables me the ability to apply holistic care in context of the individual needs of the mum and baby to ensure the best outcome possible for them.

The body needs preparation prior to surgery as well as conditioning to ensure endurance for the procedure and recovery period.  Infants have a lower pain threshold than adults and need preparation to adjust to oral stretches and exercises to improve its range of existing function. After any tongue/lip tie release procedures that take place, tiny babies need support to adapt to their changed oral function to ensure that it functions at it's best whilst recovering. It takes a minimum of 4 months for full healing and recovery following tongue and lip tie related procedures.

This therapy also applies to infants that don't under go tongue/lip tie release surgery.  In addition to bodywork, it may faciliate the a reduction in the need for in infants that need any surgical procedures for tongue and lip ties.  I have had many babies that have been able to avoid needing the procedure with therapy alone.

I provide parents with tools to faciliate at home therapeutic exercises to optimise recovery and their child's development. 

WHAT CAN I DO, TO ENSURE THAT MY CHILD IS ABLE TO AVOID UNNECESSARY INTERVENTION?
For starters, it is really important to know, that tongue tie or lip tie surgery is not the only option and it should not necessarily be the first option in treating feeding issues associated with lip or tongue ties.  Treating tongue and lip ties with surgery is an elective procedure as it is not a life threatening condition and is one that can be managed without surgery.  

Many infants progress into adulthood with lip and tongue ties without any problems at all.  

I myself had my tongue tie surgery at the age of 44 and didn't realise I had any problems until I gained experience in the field and started realising some symptoms which were causing me issues.  I have met parents that didn't realise they had tongue ties until they saw me with their own babies. 

The most important recommendation I can make, is for you to engage with an IBCLC or Infant Feeding Therapist that is highly knowledgeable and experienced in this area.  They can have a chat to you about what your concerns are, assess your baby's feeding, do a clinical examination of your baby, and facilitates an action plan designed to get you and your baby back on track.

IBCLC's  can offer you alternative feeding options and strategies to optimise your situation without treatment. 

Also engaging with a bodyworker such as an appropriately qualified and experienced Paediatric Osteopath or Chiropractor will facilitate preventing your child going through any unnecessary interventions.

October 2019, saw the release of a large scale independent review into Chiropractic Treatment for patients under the age of 12 years.  The independent panel review was undertaken by Safer Care Victoria, a body of Victoria's Tertiary Paediatric Neurological & Orthopaedic Surgeons, Paediatricians, Chiropractors, Physiotherapist, Chief Medical Officer and consumers. Out of 21,874 public submissions, it found there were:

• • 0 reports of harm to children under the age of 12, including infants
  • 99.7% participants reported satisfaction with the chiropractic care of their children
  • 21,474 out of 21,800 (98%) of respondents reported improvements in their child's health and wellbeing with Chiropractic
  • Over 95% reported they were appreciative of the information provided by their child's chiropractor with regard to risks Vs benefits of treatment and information provided by the chiropractor 

Your child's bodyworker will assess the function of your child's body - if there are tight areas of the body such as the head, neck, pelvis, this can cause collateral strain to the muscles supporting the mouth. (8,9,10)

By alleviating these collateral strains, the mouth can work at its best.  If your child's mouth is able to work at its best without causing problems associated with the tongue/lip ties, the likelihood of them not needing lip or tongue tie surgery is far greater.

If despite the bodywork your child still needs the lip or tongue tie surgery, you have commenced the preoperative treatment.  You have commenced preparing your child for surgery.  It is not uncommon for a tongue or lip tie to become more prominent after having bodywork, which means in this case, it is more obvious for the surgeon to cut the tied tissue more effectively, meaning less trauma a better surgical result and better recovery for your baby.

A lot of the time when I engage my work with a bodyworker, we collaboratively track the progress of the mother and baby to our treatment and can work out if our treatments alone are not enough for your baby. In a nutshell, we can work out within 2-3 sessions if this is indeed the case.

WHAT ARE SOME LINKS THAT CAN GIVE ME FURTHER EVIDENCE BASED INFORMATION ABOUT TONGUE & LIP TIES?
https://www.lcanz.org/find-a-lactation-consultant/
ankyloglossiabodyworkers.com
www.drghaheri.com/blog
​tonguetie.net

SOURCES
1. Mills, N; Pransky, S; Geddes, D & Mirjalili S  Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Clinical Anatomy  2019, Vol. 32(6): 749-761

2. Hogan, M; Westcott, C & Griffiths, M Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005 May-Jun;41(5-6):246-50

3.  Billington, J; Yardley, I & Upadhaya, M. Long-term efficacy of a tongue tie service in improving breast feeding rates: A prospective study. J Pediatr Surg. 2018 Feb;53(2):286-288

4. Minion, C.. Ankyloglossia and the Breastfeeding Infant: Assessment and Intervention. Adv Neonatal Care. 2016 Apr;16(2):108-13

5. Chinnadurai, S; Francis D; Epstein, R; Morad, A; Kohanim, S & McPheeters, M.  Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review. Pediatrics. 2015 Jun;135(6):e1467-74. doi: 10.1542/peds.2015-0660. Epub 2015 May 4.

6. https://dentalsleeppractice.com/case-report/tongue-ties-and-sleep-issues-and-more/

7.Quraishy, K.; Feeding in the NICU: A Perspective from a Craniosacral Therapist. Neonatal Netw. 2016;35(2):105-7

8. Gray, C​.;.20+ Years of Infant Craniosacral Therapy Practice.  Midwifery Today Int Midwife. 2015 Winter;(116):16-9

9.Herzhaft-Le Roy J, et al Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants' Biomechanical Sucking Difficulties. . J Hum Lact. 2016.

10. Effectiveness of craniosacral therapy in the treatment of infantile colic. A randomized controlled trial.
Castejón-Castejón M, et al. Complement Ther Med. 2019.

11. Guan L., Collet JP.,  Yuskiv, N., Skippen, P., Brant, R., Kissoon, N. The effect of massage therapy on autonomic activity in critically ill children. Evid Based Complement Alternat Med. 2014;2014:656750. 

12. Walsh, J & McKenna Benoit, M. Ankyloglossia and other oral ties Otolaryngologists Clin North Am 2019 Oct;52(5):795-811.

13. Patel, P., Wu, D., Schwartz, Z & Rosenfeld, R. Upper lip frenotomy for neonatal breastfeeding problems.  Int J Pediatr Otorhinolaryngol. 2019 Sep;124:190-192