Feeling Tongue Tied: Informed Decision-Making Regarding Tongue Ties and Associated Surgeries

Written by: Dana Pagliuco M.S. CCC-SLP, Spaulding Outpatient Center for Children in Lexington

There seems to be disagreement in the medical community about the decision to surgically intervene when a tongue tie has been identified. Tongue tie release surgeries (called frenectomies) can be performed by an oral surgeon, otolaryngologist (ENT), or a plastic surgeon. This procedure can be done with or without anesthesia utilizing a traditional scalpel or a carbon dioxide (Co2) laser. Despite how easy it has become to perform this surgery, parents can get conflicting reports on when to clip a tongue tie, or whether to clip at all.

The appropriate medical terminology for a tongue tie is known as ankyloglossia and is used to describe a restricted lingual frenulum that anchors the tongue to the floor of the mouth, causing restrictions in the tongue’s movement and range of motion (Morris & Klein, 2000). Sometimes the frenulum is restricted all the way to the tip of the tongue, and sometimes the restriction is somewhat further back, known as a posterior tongue tie. Tongue ties can often be identified by a heart shaped appearance of the tongue when an infant or child attempts to protrude their tongue forward.  More severe tongue ties that reach towards the tongue tip will often be identified during breast feeding. In breast feeding, the infant’s tongue must protrude forward in order to obtain a latch on the nipple. Sometimes children with posterior tongue ties are able to breastfeed adequately, and the tongue tie is not identified until later, when the child is exposed to solid foods. In children who are bottle-fed exclusively, both posterior and anterior tongue ties may go unnoticed.

When a tongue-tie negatively effects the ability for a child to breast-feed, often that can be reason enough to justify a frenectomy. Research indicates many positive objective and subjective outcomes for both infants and mothers during breastfeeding following a frenectomy. This includes better scores on objective measures assessing infant latch, maternal pain, infant feeding characteristics and infant weight gain. Subjectively, mothers reported improvements in their perception of breastfeeding and a reduction in pain (Web, Hao, & Hong, 2013). In infants who are bottle fed or who are still able to breast-feed relatively well, the decision to release a tongue tie can feel less obvious.

There is a misconception that a tongue-tie will cause problems with a child’s speech intelligibility, or that a child may not be able to speak because of a restricted lingual frenulum. Despite this common belief, there is no evidence in the scientific literature that ankyloglossia typically causes speech impairments. On the contrary, several authors, even from decades ago, have disputed the belief that there is a strong causal relationship (Wallace, 1963; Block, 1968; Catlin & De Haan, 1971; Wright, 1995; Agarwal & Raina, 2003). A more recent systematic review of the literature spanning from 1966 to 2012 concluded that no definitive improvements in speech function were reported in individuals post-surgery, suggesting there is not a causative association between ankyloglossia and speech articulation problems (Web, Hao, & Hong, 2013). This is likely because the tongue does not require its full range of motion to produce speech sounds, and therefore restrictions that limit the tongue’s movement will not have serious consequences on speech production.

Where varying degrees of ankyloglossia can negatively affect function is in the domain of feeding. In individuals where a tongue tie was missed in infancy, we may begin to see difficulties occur in a child’s ability to manage more complex solid textures. Your tongue is very involved in the process of eating and swallowing and successful eating does require unrestricted access of your tongue. During feeding, the tongue must be able to move food to the molars for chewing, collect chewed food from the teeth to gather it into a ball (known as a bolus), propel that bolus to the back of the mouth for swallowing, and use the tongue tip to collect any food that has fallen between the surfaces of the gums and cheeks. Think about how far your tongue must reach to collect a pesky popcorn kernel stuck behind your top left molar. Now contrast that movement with where your tongue is positioned to say the word “cat”, and you can observe how a tongue tie may not affect speech, but can greatly affect feeding.

When a tongue tie goes unnoticed in an infant or toddler, feeding may become an unpleasant experience for both child and parent. The child may develop maladaptive strategies to compensate for their structural impairment. Even after a tongue tie is released in later infancy or toddlerhood, a child may need direct feeding intervention to re-learn feeding skills. Another unintended consequence is that children with unidentified tongue ties may begin to refuse foods they know they can’t manage.  A desperate parent may resort to forceful feeding techniques when weight loss or reduced weight gain are identified during pediatrician visits. This can quickly snowball into a psychological feeding disorder that may persist even after a frenectomy is recommended months or years later.

Decisions regarding a tongue tie release should not be “a one size fits all” approach. These decisions should be based on the consultation of many medical professionals including dentists, ENTs, speech language pathologists, and pediatricians to name a few. While this continues to be an area of debate within the medical community there are a few key points from scientific literature to help inform your decision making:

• Providers and parents should not expect significant changes in speech production following a frenectomy. Desired improvements in verbal speech should not be a driving factor in the decision for a tongue tie release.

• Research has shown objective and subjective improvements in breast feeding for both mother and child following a frenectomy.

• When a child demonstrates difficulty advancing to solid textures or food refusal, a child should be evaluated for the presence of a tongue tie as a potential contributing factor.

If you suspect a tongue tie, or any other impairment, is impacting your child’s feeding abilities, a comprehensive feeding evaluation may be indicated. Please contact the Spaulding Outpatient Center for Children in Lexington team for a multidisciplinary feeding evaluation.

References

Kummer, A. 2005. Ankyloglossia: To Clip or Not to Clip? That’s the Question. ASHA Leader, 10 (17), 6-30.

Morris, S., & Klein, M. 2000. Pre-Feeding Skills-Second Edition. Austin, Texas: Pro-ed.

Web, A., Hao, W., & Hong, P. 2013. The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 7 (5), 635-636.