Zooming in on Tongue Tie with Focus on Whole Body Function

Allyson Wessells, PT, IBCLC

Tongue tie (aka, ankyloglossia, oral restriction) has been in the news lately but is something we have been assessing, addressing and learning about for years as practicing International Board Certified Lactation Consultants (IBCLCs) at Nurture. Some families that seek our care want to know if there are oral restrictions present with a need for further evaluation and procedural release (aka, oral tie release, frenotomy, frenectomy); while others are adamant about avoiding any procedure regardless of the presence of a possibly offending oral restriction.

What is the Nurture approach?

First, we prioritize and recommend optimizing maternal/infant feeding posture and positioning, latch function and overall breastfeeding qualities (frequency, duration, breastmilk supply to name a few) ideally before anyone considers consultation with a provider skilled to perform oral tie releases. Whether working with a newborn or a months old baby, allowing the body to grow and unwind from often restricted uterine positioning and strenuous birthing journeys (or, in the case of many older infants, months of compensatory/asymmetrical movement) is essential in our experience. We strive to help infants with whole-body movement and reflexive function before recommending further assessment with a provider to release what may be restrictive anatomical tissue. Sometimes, optimizing this movement is all that is necessary to achieve functional feeding, whether at breast or bottle. It is always the best place to begin the journey toward considering procedural release which does then often lead to functional breastfeeding in our clinical experience. Per respondents to our own practice survey sent to all clients at one year, the majority of clients that had tongue tie release in combination with IBCLC care go on to breastfeed at least one year.

Second, it is important to know that we are unable to officially diagnose the presence of oral restrictions (aka, tongue, lip cheek/buccal ties). But, as IBCLCs, we maintain clinical competency as established by the International Board of Lactation Consultant Examiners (IBLCE) to assess oral anatomy, neurological responses and reflexes.⁸ This can include use of palpation skills to determine anatomical attachment sites on the underside of the tongue and at the mandible (jaw bone), observing tongue appearance, and assessing tongue motion upward/outward and to each side. We, most importantly, zoom out to look at an infant’s entire body to note any movement patterns at head/neck/back/pelvis/hips that may be problematic because of or in the presence of oral restrictions. Afterall, the tongue is a component of whole-body movement with indirect fascial connections from the neck to the tip of the toes. The tongue is ultimately attached to and a part of the whole body, and interdependent with the whole body as related to function. Abnormal body movement can affect tongue movement, and abnormal tongue movement can affect whole body movement.

With this in mind, we have a written Nurture Protocol and Decision-Making Tree in place to standardize what we do, optimize movement with care before referral to a release provider, and refine movement with care after any releases until family goals are achieved to the best degree possible. This protocol is informed by years of clinical experience as well as published practice guidelines with the International Consortium or oral Ankylofrenula Professionals.

What do the highest level of research design studies within the last 5 years say about tongue tie care and procedures?

Recent systematic reviews suggest that tongue tie is associated with breastfeeding challenges and adversely affects maternal well-being.³ Collaboration with lactation consultants and other healthcare professionals who can provide holistic approaches to address breastfeeding challenges as related to tongue tie is recommended and helps with decision making.^2,7 Ultimately, infant frenotomy has been shown to be effective in improving maternal pain, breastfeeding self-efficacy, and symptoms of reflux.^1,4,5,11 While research comparing the instruments used for the procedure is limited, some studies show that laser frenectomy presents a series of advantages.^9,12 This is consistent with our experience. However, our experience also tells us that while the surgical method is important, it is second to the skill of a provider in understanding whole body connections, recognizing best timing for release based on whole body function, and performing the procedure in a precise but complete fashion with a diamond shaped wound that heals well with movement focused care in the days after the procedure. With regard to lip and buccal ties, there is limited research, but in our clinical experience, releasing these restrictions has also been observed to be helpful in some cases.

And, that is the ultimate conclusion…each case is unique and we approach each as individually yet evidence informed as possible. Nurture Columbus has co-owners with backgrounds in public health and physical therapy, each informing our overall protocol and practice. We recognize the public health call to empower families to breastfeed, and understand the structure function relationship that is required for successful breastfeeding. Never is this relationship more obvious than in a newborn baby or growing infant becoming proficient in the first movement milestone of feeding. Optimizing the structure function relationship as related to the biological norm of breastfeeding only improves on each across the lifespan. Afterall, breastfeeding duration enhances structure as a natural palate expander, is associated with less need for orthodontia later in life, and has been shown to be associated with better motor function through adolescence.^10,6

As the bones grow, the surrounding anatomy must be compatible and the muscles must be able to freely move the bones. Tongue tie sometimes interferes with this compatibility, and may not even be an assessed component of functional challenge until time and growth have revealed it to be. Regardless, as we zoom in on tongue ties and other oral restrictions, whole body movement must be a concurrent focus before and after any procedural release. At Nurture, we look forward to new research, especially on breastfeeding outcomes at one year, to inform our clinical approach as we are entrusted to help inform new families during a most vulnerable, exhilarating, and emotional phase of life.

References

1. Bruney, T. L., Scime, N. V., Madubueze, A., & Chaput, K. H. (2022). Systematic review of the evidence for resolution of common breastfeeding problems-Ankyloglossia (Tongue Tie). Acta paediatrica (Oslo, Norway : 1992), 111(5), 940–947. https://doi.org/10.1111/apa.16289
2. Carnino, J. M., Walia, A. S., Lara, F. R., Mwaura, A. M., & Levi, J. R. (2023). The effect of frenectomy for tongue-tie, lip-tie, or cheek-tie on breastfeeding outcomes: A systematic review of articles over time and suggestions for management. International journal of pediatric otorhinolaryngology, 171, 111638. https://doi.org/10.1016/j.ijporl.2023.111638
3. Cordray, H., Mahendran, G. N., Tey, C. S., Nemeth, J., Sutcliffe, A., Ingram, J., & Raol, N. (2023). Severity and prevalence of ankyloglossia-associated breastfeeding symptoms: A systematic review and meta-analysis. Acta paediatrica (Oslo, Norway : 1992), 112(3), 347–357. https://doi.org/10.1111/apa.16609
4. Cordray, H., Raol, N., Mahendran, G. N., Tey, C. S., Nemeth, J., Sutcliffe, A., Ingram, J., & Sharp, W. G. (2024). Quantitative impact of frenotomy on breastfeeding: a systematic review and meta-analysis. Pediatric research, 95(1), 34–42. https://doi.org/10.1038/s41390-023-02784-y
5. Ghaheri BA, Lincoln D, Mai TNT, Mace JC. Objective Improvement After Frenotomy for Posterior Tongue-Tie: A Prospective Randomized Trial. Otolaryngology–Head and Neck Surgery. 2022;166(5):976-984. doi:10.1177/01945998211039784
6. Grace, T, Oddy, W, Bulsara, Hands, B. (2017). Breastfeeding and motor development: A longitudinal cohort study. Human Movement Science, 51, 9-16.
7. Guinot, F., Carranza, N., Ferrés-Amat, E., Carranza, M., & Veloso, A. (2022). Tongue-tie: incidence and outcomes in breastfeeding after lingual frenotomy in 2333 newborns. The Journal of clinical pediatric dentistry, 46(6), 33–39. https://doi.org/10.22514/jocpd.2022.023
8. International Board of Lactation Consultant Examiners https://iblce.org/about-iblce/bylaws-iblce-documents
9. Lebret C, Garot E, Amorim Pereira M, Fricain JC, Catros S, Fénelon M (2021) Perioperative outcomes of frenectomy using laser versus conventional surgery: A systematic review. J Oral Med Oral Surg 27:3. https://doi.org/10.1051/mbcb/2021010
10. Sánchez-Molins, M., Grau Carbó, J., Lischeid Gaig, C., & Ustrell Torrent, J. M. (2010). Comparative study of the craniofacial growth depending on the type of lactation received. European journal of paediatric dentistry, 11(2), 87–92.
11. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A. Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study. Clin Oral Investig. 2021 Jun;25(6):3431-3439. doi: 10.1007/s00784-020-03665-y. Epub 2020 Dec 14.
12. Tancredi S, De Angelis P, Marra M, Lopez MA, Manicone PF, Passarelli PC, Romeo A, Grassi R, D’Addona A. Clinical Comparison of Diode Laser Assisted “v-Shape Frenectomy” and Conventional Surgical Method as Treatment of Ankyloglossia. Healthcare (Basel). 2022 Jan 4;10(1):89. doi: 10.3390/healthcare10010089. PMID: 35052254; PMCID: PMC8775129.

Books to consider for further information:

Bebee, R. Fit to be Tied: A Visual Resource for Parents. 1^st ed.; 2023.

Baxter R, Agarwal R, Musso M, et al. Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. 1^st ed. Alabama Tongue-Tie Center; 2018.

About the author: 

Allyson Wessells is a physical therapist and International Board Certified Lactation Consultant (IBCLC) with Nurture Columbus, in Columbus, Ohio.  As a PT and IBCLC, she focuses on optimizing nourishment and growth for lifelong health. Other services include presentations emphasizing the importance of breastfeeding and infant neurodevelopment as foundations for preventive healthcare.