Can we talk about tongue ties a minute?

What IS a tongue tie? You know that little string (sometimes prominent, sometimes hidden back further) under your tongue? That is called a frenulum and everyone has one, although some are shorter and/or tighter than others. It's technically a fold made up of mucous membrane tissues and sometimes fascia (a band of connective tissue that surrounds muscles). Comfortable and effective breastfeeding is dependent on the tongue being able to do its job and move well. If that frenulum is too tight/restrictive, mothers who nurse can experience painful nipples and baby can have trouble removing her available milk (so baby loses weight and over time milk supply decreases).

Tongue ties have been written about for as long as people have been writing. They say midwives used to keep one fingernail sharp to "clip" it after delivery. Nowadays, ENTs or pediatricians or pediatric dentists can laser or clip the frenulum, thereby releasing the tongue so it can move better (less pain to mother, better milk transferring from breast to baby's mouth). So why is this so controversial? Why do some lactation consultants say baby is tongue tied and the pediatrician says "no"? Why can't we all agree on assessment of this issue? Well—insert deep breath here—it's complicated. There exists today NO standardized method or tool that everyone uses for evaluating and diagnosing tongue ties. Sometimes it's a "no brainer" when the frenulum is really close to the tip of the tongue, but other times it's not so clear cut. There are MANY issues that are involved in mother's pain and baby's weight gain, so a thorough evaluation is needed to see what the true cause may be for the breastfeeding woes. As a lactation consultant (LC), my job is to do an evaluation and see what positioning/latching techniques we can try to improve the situation, but if nothing is working the next step is to refer for further evaluation. LCs cannot diagnose a tongue tie but we can certainly describe what we see and make next step recommendations. Sometimes that means an ENT/dentist, and sometimes that means bodywork to work on any musculoskeletal restrictions around the tongue/jaw/head/neck that might be causing tightness/restriction in the suck. There are some great practitioners out there (osteopathic manipulative medicine doctors, pediatric chiropractors, pediatric speech/language/feeding therapists, physical therapists, craniosacral therapists, etc.) doing some non-invasive work and seeing good results (either with or without a clip/laser procedure). When I cannot seem to help a mother/baby's situation, I strive to reach out to take an interdisciplinary approach if parents are interested. But what parents need to know (and deserve to know) is that there is not a lot of gold-standard quality research on ANY treatment modality. And these treatments cost money, sometimes a lot of money. Parents need to decide for themselves what feels right for their baby. Because truth is, sometimes clipping the tongue works and sometimes it doesn't…and worst case scenario, it makes the breastfeeding situation worse. We as LCs (myself included) can say anecdotally we typically see positive results when a tongue tie is corrected, but I will admit that my recommendation is from case studies and my personal experience (and some less-than-perfectly designed research). And as painful as it is to admit and live with, I have missed some tongue restrictions, and mothers have the procedure to clip/laser it and report improvement—and for those cases, I feel horrible and like I have been punched in the gut. But I also feel that way if I recommended a procedure and it made the issue worse. I'll admit I'm a bit gun-shy and tend to take a more conservative approach because of the responsibility I bear for what I say/recommend. Throughout my career I have seen trends come and go, and it's a bit disturbing to me to know that in the US there has been an increase of 866% over the last decade for diagnoses and treatment (frenotomies) of tongue ties. That makes me pause, and wonder if we shouldn't take a more nuanced look at things. Definitely some babies need a surgical procedure, but I'm not convinced it's as common as what the Internet would lead us to believe.

But one thing for sure I wish for Christmas….for everyone (LCs, pediatricians, ENTs, dentists, etc.) to all get on board with the same assessment and treatment options for parents so they are not left confused and suffering, wondering what to do next.