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Kellie Eason RN, RM, IBCLCKellie is a Nurse, Midwife and International Board Certified Lactation Consultant in private practice, with over 25 years experience. She has a special interest in providing personalised support for families with complex infant feeding issues. Kellie works collaboratively with holistic practitioners at Osteo 4 Kids & Adults in Preston, Melbourne as well as providing FaceTime & Skype Consultations & home consulting services within the Northern Suburbs of Melbourne. WHAT IS ARE TONGUE & LIP TIES? A band of tissue called the 'frenum' (plural frena) that is usually in the center and underside of the tongue connecting to the floor of the mouth which is restricting the normal movement of the tongue. Frenum that is usually located underneath the center of the lip, which is leading toward the upper gum. The frenum located beneath the lip which restricts normal lip movement of is referred to as a 'lip tie'. During embryonic development, tissue of the frena, is meant to shrink away. A lot of the evidence points to there being a genetic component as to why the affected frena do not shrink away. Hence, it is common for tongue and/or lip ties to be shared in families. WHAT SYMPTOMS CAN TONGUE & LIP TIES CAUSE?
WHAT DOES THE LITERATURE SAY ABOUT TONGUE & LIP TIES? It is agreed that the assessment of a tongue or lip tie should be based on function alone and just its appearance. The limitations on tongue and lip movement is crucial to the diagnosis and in the decision made to proceed to tongue/lip tie surgery. The major controversy in the surgical treatment of tongue ties that exists, is the fact that there are no clear variables which define how and when movement of the frenum is restricted and when that restriction is sufficient to warrant surgical intervention. There have been no studies done into the effect of lip ties on breastfeeding, bottle feeding, speech and dental development. The vast majority of the research is focused on tongue ties and breastfeeding. Breastfeeding Most studies report a statistically significant improvement in painful latch and continuation of breastfeeding due to this. Following this, the baby and mother, benefits of from breastfeeding alone due to its many health benefits. Ultrasound studies have demonstrated normal tongue movement and abnormal tongue movements. It is known that the tongue is meant to remain in close contact and cupped to the breast, raise and then lower to "pull" the milk from the breast. When infants are tongue tied, the tongue cannot lift and extract milk from the breast. The jaw is seen to make deep excursions or movements in compensation for the tongue that is restricted. Bottle feeding Dr. Bobby Ghaheri ENT has some research in progress, observing the oral mechanics in bottle feeding. This is needed to progress lip & tongue tie research for bottle fed and breastfed infants. He has conducted a pilot study into the impact of lip ties on breastfeeding and has found Apart from this, there are no documented studies with regard to the impact on bottle fed infants and tongue and/or lip ties. Speech There is no direct research to date, linking tongue or lip tie with speech impairment. However it is known that tongue restriction can make it difficult to pronounce the following letters 'R, S, L, Z, D, CH, TH, and SH' Putting these sounds together can also be difficult for some. Studies have demonstrated some improvement in speech function following a frenotomy, yet most research fails to demonstrate an obvious benefit of the procedure in relation to speech. Dental Upper lip ties can cause cavities to the 2 central upper teeth (upper central incisors). Food can be trapped within this area or painful toothbrushing leading to toothbrushing refusal can lead to cavities. Tongue tie can contribute to decay of the molars (back typically happen in the setting of tongue tie (this is because tongue is unable to be swept back to clean the molars). WHY IS THE TOPIC OF LIP & TONGUE TIES CONTROVERSIAL? 1. The Medical profession relies on the highest quality of evidence which is difficult to attain in the area of Tongue and Lip Ties. In order to make assessments and clinical decisions regarding tongue and lip ties, clinicians need to have training and experience in the:
The above mentioned topics are not covered routinely in the study fields of:
2. More research is needed to:
As health professionals, we only want what is best and safest care for our patients with. We use the best of our knowledge in caring for families, using our experience and the research that we have on hand at the time. Considering these factors, it is understandable why there is often conflicting advice given and why this is so controversial. The true prevalence, incidence and long term outcomes for infants with treated Vs untreated tongue and lip ties is not known due to the fact that there is no universal method for assessing and treating tongue ties. Many areas within medicine and surgery are based on research in addition with anecdotal evidence. This, in conjunction with experience, knowledge of anatomy and physiology, is often what is relied upon within this field. WHAT ARE OUR TREATMENT OPTIONS? Conservative treatment
With this in mind, babies develop sucking habits from early on in utero. This combined with physical contraints from birth and lying in utero, can place additional tension on the muscles coneected to and surrounding the tongue. These muscles are located around the face, head, neck, jaw and collar bone. Seek the support of an IBCLC, Infant Feeding Therapist of Paediatric Speech Pathologist or Occupational Therapist to assess and facilitate your baby's feeding skills and provide you the advice and support you will need to faciliate breast and/or bottle feeding. You are should be provided take home exercises to help support your child's feeding development. This treatment often done in conjunction with bodywork (ie. physiotherapy, osteopathy, chiropractic). Sucking and swallowing is a dynamic and highly complex physiological process. Where intraoral restrictions occur, it takes a team of health workers to faciliate the best outcomes. Bodyworkers are trained to assess the involvement of the nerves, muscles and joints involved in feeding. Their gentle and proven safe techniques are aimed at restoring body function to normal in facilitating natural free movement of these structures. Mobilising the structures connected to the tight tongue and lip, enables improved range of motion for better sucking and swallowing. Again, there is limited research in this area specifically linked with tongue ties. It is important that this treatment is not working on the tongue or lip ties, but the compensations caused by the tongue and lip ties. Surgical treatment For best outcomes, conservative treatment recommended prior to surgical treatment and during post surgery period. Surgical treatment for young babies involves either a Frenectomy or Frenotomy.
In terms of Frenectomy Vs Frenotomy/Frenulotomy, it has been identified that no one procedure is better than the other. It is totally dependent on the experience and quality of procedure performed by the clinician. In my clinical experience of over 25 years, I have yet to see a lip and tongue tie be effectively released via frenotomy, but have seen better outcomes with frenectomies and correct post surgical rehabilitative care. Over the last 5 years, I have cared for over 4000 infants that have undergone a either frenotomy or frenectomy procedures alone. HOW CAN I BEST HELP MY BABY? Do your homework - if you suspect your baby has a tongue and/or lip tie and you are advised otherwise, seek a second opinion Make sure you find a suitably qualified and experienced team caring for your baby. These will include your IBCLC, Bodyworker, who will be able to refer you to a suitably qualified Surgeon if needed. I have come across far too many cases whereby infants have a surgical procedure for lip and/or tongue ties without a feeding assessment and without the correct preparations prior to the procedure. It is really important to be mindful that surgical treatment for tongue and lip ties alone, is not the ultimate "fix" for their infants feeding issues. With surgery alone, it can take from 2-6 weeks for your baby's feeding to improve. Other considerations to be mindful of is that without the correct preliminary assessments, the procedure may not work achieve the desired effect and that this means that their child has endured a surgical procedure which wasn't necessary to begin with. Whilst mother's know their babies, it is important not to consult Dr. Google or non qualified health 'experts' for advice about complex feeding issues. There is a reason as to why we have gained our qualifications, ongoing professional development and experience. And it is us that you need to seek your advice and referrals from. WHAT KIND OF SUPPORT DO YOU PROVIDE FAMILIES? With 25 years experience as a Nurse/Midwife and 15 years as an IBCLC, I have supported over 4000 families with children affected by tongue and/or lip ties. I have a strong network of similar colleagues around Australia. With an additional background in Oral Myofunctional Therapy, Infant Feeding Therapy, Infant & Maternal Mental health, Family & Child Health - I provide conservative treatment, pre surgical and post surgical therapy. I also support with sleep & settling difficulties in infants. I provide parents with a take home action plan to facilitate optimal outcomes such as a holistic package of take home exercises, massage, feeding and activities. It also includes feeding and routine support. On average, I see families for an initial consultation and for 2-3 review appointments thereafter. More complex feeding issues obviously need more consultation and may be referred to a suitably qualified Paediatric Speech Therapist. My aim of care is always to restore the family to a normal and healthy family life as soon as possible. Because when families are facing complex feeding issues, they are also facing significant amounts of stress. I provide consultations within my clinic in the Northern Suburbs of Melbourne, I also provide local in home consultation and Skype/FaceTime Consultation as well. I find that this model of care supports the dynamics involved and provides the best outcomes. In my experience, well trained providers work in a similar fashion. From my clinical experience, a majority of the families experience positive outcomes. Those that don't are those that have not sought advise and support from the appropriate professionals. Commonly I have noted a practitioner's referral has been sought without a feeding assessment, then proceeding to surgical intervention without addressing the root cause of their infant's feeding issues. WHERE TO FIND OTHER PROVIDERS To access suitably qualified & experienced providers, check out these links: tonguetieprofessionals.org/directory/ www.lcanz.org/find-a-lactation-consultant/ www.ankyloglossiabodyworkers.com/provider-list.html#INT REFERENCES USED 1. Mills, N., Pransky., Geddes, D., Mirjalili, S. What is a tongue tie? Defining the anatomy of the in‐situ lingual frenulum, Clinical Anatomy 2019 Vol 32 (6) 749-761 2. tonguetieprofessionals.org/directory/ 3. www.lcanz.org/find-a-lactation-consultant/ 4. www.ankyloglossiabodyworkers.com/provider-list.html#INT 5.www.bettersafercare.vic.gov.au/reports-and-publications/chiropractic-spinal-manipulation-of-children-under-12 6. dentalsleeppractice.com/case-report/tongue-ties-and-sleep-issues-and-more/ 7. drghaheri.squarespace.com/blog/ 8. blog.asha.org/2015/03/10/just-flip-the-lip-the-upper-lip-tie-and-feeding-challenges/ 9.www.drghaheri.com/blog/2014/3/13/it-takes-a-team-to-improve-breastfeeding-after-a-tongue-tie-procedure |
Kellie EasonNurse, Midwife, Lactation Consultant, Infant Feeding Therapist, Birth and Parenting Educator, Gentle Sleep & Settling Consultant 
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