March 20, 2015

Does Tongue Tie Cause Breastfeeding Difficulties and Speech Problems?

Although there is both objective and subjective evidence that tongue tie contributes to breastfeeding difficulties and speech problems, when it comes to quality evidence-based research, the data is a bit lacking. And because of this sparseness, tongue tie release is actually considered a controversial topic with both supporters and detractors (personally, I am a supporter of this procedure). Among the detractors, tongue tie release is considered unusual and unnecessary... even bizarre.

To reiterate, personally I am a supporter of this procedure but it is worthwhile to understand where naysayers are coming from. 

So what data is out there currently?

The Holy Bible contains a passage that loosely could be interpreted to suggest tongue tie release:
"And looking up to heaven, he sighed, and saith unto him, Ephphatha, that is, Be opened. And straightway his ears were opened and the string of his tongue was loosened, and he spoke plain." (Mark 7:34-35) [link]
Tongue tie release was considered controversial in ancient history with Aristotle (3rd century BC) and Paul of Aegina (7th century AD) being supportive, but Celus (1st century AD) and Galen (2nd century AD) arguing against. Even in the middle ages, the benefit of tongue tie release was controversial among midwives (who used their fingernail to cut the tongue tie) and surgeons (who used surgical instruments).

This controversy continues even into modern times. In the year 2000, in perhaps the largest survey of lactation consultants (n=350), speech language pathologists (n=400), ENTs (n=423), and pediatricians (n=425),
"69% of lactation consultants, but a minority of physician respondents, believe tongue-tie is frequently associated with feeding problems. 60% of ENTs, 50% of speech pathologists, but only 23% of pediatricians believe tongue-tie is at least sometimes associated with speech difficulties. 67% of ENTs versus 21% of pediatricians believe tongue-tie is at least sometimes associated with social/mechanical issues. Surgery is recommended at least sometimes for feeding, speech, and social/mechanical issues by 53, 74, and 69% of ENTs, respectively, but by only 21%, 29%, and 19% of pediatricians." [link]
In terms of actual evidence-based research, only 20 studies were identified in a pubmed literature search summarized in a meta-analysis published in 2013.
"Of those, 15 studies were observational and 5 were randomized controlled trials. Tongue-tie division provided objective improvements in the following: LATCH scores (3 studies); SF-MPQ index (2 studies); IBFAT (1 study); milk production and feeding characteristics (3 studies); and infant weight gain (1 study). Subjective improvements were also noted in maternal perception of breastfeeding (14 studies) and maternal pain scores (4 studies). No definitive improvements in speech function were reported. The only significant adverse events were recurrent tongue-ties that required repeat procedures." (Abbreviations: IBFAT: infant breastfeeding assessment tool; LATCH: latch, audible swallowing, type of nipple, comfort, and hold; SF-MPQ: short-form McGill pain questionnaire.) [link]
The meta-analysis went on to conclude that:
Ankyloglossia is a well-tolerated procedure that provides objective and subjective benefits in breastfeeding; however, there was a limited number of studies available with quality evidence. There are no significant data to suggest a causative association between ankyloglossia and speech articulation problems. Aspects of ankyloglossia that would benefit from further research are described, and recommendations for tongue-tie release candidacy criteria are provided... [procedure should be performed only] in newborns with significant ankyloglossia and associated breastfeeding problems who have failed conservative management 

Just because quality data is lacking does not mean tongue tie release should not be performed. In fact,  definitive research may not be possible given bias would be nearly impossible to eliminate. Parents and doctors will have preconceived notions of the kinds of pathology tongue tie may cause and understandably, parents can't help but desire a certain course of action rather than put their child into a randomized research situation. Even the intervention itself cannot be blinded as it will be clear to all which child underwent a tongue tie release or not.

The only truly unbiased participant in any future research attempted is probably the innocent child himself who has no preconceived notions beyond signals the parents may send.

Alternatively, more objective testing may need to be utilized to determine effectiveness or not. For example, breastfeeding improvement based on ultrasound measurements can be further developed and used as an objective test.

In the end, it takes a considered evaluation by all who is caring for the infant and ultimately, the parents need to decide whether tongue tie release is worth pursuing or not. From a parental perspective, what may be the most frustrating part of tongue tie evaluation is the potentially radically divergent opinions that may be proffered by lactation consultants, pediatricians, speech language pathologist, and ENTs.

I should also mention that even adults get tongue tie release performed due to symptoms felt secondary to an immobile tongue.

The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):635-46. doi: 10.1016/j.ijporl.2013.03.008. Epub 2013 Mar 26.

Much Ado about Nothing: Two Millenia of Controversy on Tongue-Tie. Neonatology 2010;97:83–89

Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol 2000; 54: 123–131.

Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul;122(1):e188-94. doi: 10.1542/peds.2007-2553. Epub 2008 Jun 23.

Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7. doi: 10.1016/j.earlhumdev.2007.12.008. Epub 2008 Feb 11.

Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties? J Fam Pract. 2015 February;64(2):126-127.

Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie. Comparative Effectiveness Review Number 149

Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review. Pediatrics. 2015 May 4. pii: peds.2015-0660. [Epub ahead of print]

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

1 comment:

Unknown said...

I am a practising midwife with over thirty years experience in the community. I have seen so many distraught mothers with sore nipples and unsatisfied babies. Within hours of release of the tongue tie they suckle beautifully. Satisfied mum. Satisfied baby.That is even with only moderate tongue tie. However I would like to point out that due to the way midwives now learn about breastfeeding techniques,they are not taught how to handle mild dysfunctional latching from tongue tie or receeding jaw. In the initial stages of breastfeeding in such infants, the chin must be held forward by the mothers hand in order to facilitate a better latch.As a newly qualified midwife , checking the babies mouth for tongue tie was never taught as part of th initial exam. I have no reason to believe that that has changed up to 2014. As a hospital based midwife for 20yrs, I never checked for tongue tie. It was only pointed out to me on community by an experienced community midwife. Now it forms part of the newborn first check for me,so it is documented in case there is subsequent feeding problems. As an addendum I would like to say that i have been marrried to a man with tongue tie, who is now 60yrs old and although I would never have said he had speech problems, I used to call him "Mr. malaprop" and we would laugh, until the day he told me that when he hears a word and goes on to speak it he thinks it sounds like the word he heard. French kissing inability. Therefore the tongue is not doing the job it was intended to do and he is marginally handicapped.He has now gone on to have a stroke and that has made a difference to his ability to regain his speech as the muscles have lost their strength, and he is combanting the tongue tie as well. So yes Yes Yes to release of the tongue tie.What harm can it do,apart from the strain on the NHS. Then let's have more private clinics doing it. If i was in hospital practice I would make it my mission to ensue that all newborns were checked for suspect tongue tie at the newborn exam and on admission to the ward.

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