It’s uttered in hushed tones during mommy-and-me yoga classes and at Montessori-school drop-offs, discussed ad nauseam in breastfeeding support groups and on parenting message boards.
It’s called tongue tie, and it’s everywhere. In online mom groups, it’s blamed for all sorts of parenting woes. Baby isn’t gaining weight, or won’t take a bottle? Have you tried checking for ties? Kid won’t nap? It’s probably related to tongue tie. Baby have a rash? Check under the tongue!
Tongue tie, or ankyloglossia, is characterized by an overly tight lingual frenulum, the cord of tissue that anchors the tongue to the bottom of the mouth. It occurs in 4 to 11 percent of newborns. A lip tie—a related condition—is an unusually tight labial frenulum, the piece of tissue that keeps the upper lip tethered close to the gum line. Tongue and lip ties often occur in tandem.
To breastfeed effectively, babies need to create negative pressure (in a word, a vacuum) on the breast. This differs from the compression that some babies with limited tongue mobility use, effectively squeezing the milk out rather than sucking.
This compression can be painful for mothers, and breastfeeding pain can compound the stress of the exhausting first weeks of parenting. And cases of severe tongue tie have been linked to issues such as failure to gain weight.
But the tongue-tie madness in pediatricians’ offices, lactation rooms, and online groups has some researchers wondering whether people are all twisted up over nothing.
Moms might start worrying about tongue tie when breastfeeding fails to be the peaceful bonding experience they envisioned, when they’re dealing with cracked nipples and the pain of trying to nurse a baby who can’t latch properly.
They might call a local lactation consultant to help. If the consultant suspects a tongue tie, she’ll typically refer mom and baby to a pediatric dentist or an otolaryngologist (an ear, nose, and throat doctor), who will perform a procedure to “clip” the stringlike piece of tissue underneath the tongue. In some cases, the child’s pediatrician is not involved in the decision.
The procedure, called a frenotomy, frenulotomy, or tongue-tie revision, is a relatively straightforward one. A doctor or dentist holds the baby’s tongue taut toward the roof of his mouth and cuts the lingual frenulum to “release” it, usually with a laser or sterile scissors. This allows for greater range of motion for the tongue, provided the frenulum doesn’t reattach.
During the procedure, the baby will be restrained with a swaddle, but there’s no need for general anesthesia (just a topical numbing), and the risk of possible complications—bleeding, infection, damage to the tongue or salivary glands, reattachment, or airway compromise—is low. Babies tend to be quite young when the procedure is performed, typically less than three months old. As medical procedures go, it’s quick and easy. And the results can be immediate. After a frenotomy, some babies have an improved latch, which makes breastfeeding less painful for mothers.
While the popularity of frenotomies has exploded in recent years, many medical professionals and researchers say it’s not totally clear whether they address the issues they’re supposed to—or whether a lot of babies are having an unnecessary procedure.
My son has both a tongue and lip tie, as diagnosed by a lactation consultant shortly after his birth. After helping my newborn son latch, she spent the next 20 minutes telling my husband and I that we needed to take him to a pediatric dentist immediately to have his tongue tie lasered, or he would never latch properly, would have trouble eating, would need braces and probably develop a speech impediment, and could develop craniofacial issues or sleep apnea.
After his feed, the consultant weighed my son, and was astonished to find that he ate three ounces in 12 minutes—a huge amount for a four-day-old. My husband and I talked it over and decided that if our son didn’t have issues eating, and the pain of breastfeeding went away, then we would forgo the lasering. Plus, our pediatrician was unconcerned about it.
We also noticed something: We both had tongue and lip ties, yet neither one of us had experienced the issues the lactation consultant was describing. I was an early talker, never needed braces, and didn’t have any of the sleep-related issues often attributed to tongue tie. While I could plainly see the cords of tissue under my baby’s tongue and between his upper lip and gum line, he was feeding just fine. And the initial pain I had breastfeeding him gradually started to fade away.
So why was my lactation consultant insisting that I fix my baby’s tongue tie when he was breastfeeding successfully?
I’m not imagining the extreme popularity of tongue-tie diagnosis. One 2017 study found an 834 percent increase in reported diagnoses of tongue tie in babies from 1997 to 2012, and an 866 percent increase in frenotomies during that time. And those are just inpatient numbers: babies who had tongue-tie revisions shortly after birth, before even leaving the hospital. It doesn’t include babies who get an outpatient procedure later in life.
This increase is fairly incredible by any standard, and the actual numbers are likely even higher, according to Jonathan Walsh, an assistant pediatric-otolaryngology professor at Johns Hopkins School of Medicine and an author of the 2017 study. Many parents seek tongue-tie treatment for their babies in the weeks and months following birth, after experiencing difficulty breastfeeding.
The frenulum frenzy is in large part attributable to the recent renewed emphasis on breastfeeding. “We’re seeing [tongue-tie diagnoses and revisions] more now because of the stress women are putting on themselves to breastfeed,” says Adva Buzi, an attending physician in the division of otolaryngology at Children’s Hospital of Philadelphia (CHOP).
According to the most recent Breastfeeding Report Card from the Centers for Disease Control and Prevention, 83.2 percent of mothers in the U.S. in 2015 started off breastfeeding their babies, while 57.6 percent were still breastfeeding at six months. According to 2007 data, 75 percent of new mothers started off breastfeeding their infants, while only 43 percent were still doing so at six months.
“Today, people are trying to find reasons why it isn’t working, whereas in the past, if it didn’t work, people just went to formula and it was fine,” Buzi says.
Today, women face pressure to breastfeed from the moment their babies are born. Yet, they might not be taught about proper latching, or the fact that—unsurprisingly—attaching a tiny suction machine to your nipples for hours each day can be painful. Instead of working through the natural learning curve, parents might look for a problem they can fix to make it better. Enter tongue tie.
“As a new mother, you can’t go to any parenting- or breastfeeding-support website that isn’t describing [tongue tie] as the predominant reason your child is having difficulty or why breastfeeding is painful,” Walsh says.
I took a breastfeeding course before giving birth. It showed 1980s-era videos of new moms breastfeeding topless in the hospital and taught me how to latch a stuffed animal onto my clothed breast, but it failed to inform me that breastfeeding can be extremely painful at first.
I can still remember the annoying, singsongy refrain: If it hurts, you’re doing it wrong. Guess what? It really, really hurts, just like several other aspects of expelling a human being from your body.
In some cases, a frenotomy makes sense—it’s a safe procedure that’s unlikely to harm a baby long term, and it might help with certain issues. For instance, some studies have shown that a frenotomy can help with reflux, because when babies aren’t latching properly, they tend to swallow more air, which can make reflux worse.
But many researchers say there’s no good evidence that an untreated tongue tie will lead to bad outcomes down the line—or that a frenotomy will help with the breastfeeding relationship in the short term.
“There are probably children who could benefit from [a frenotomy]. But we don’t have great criteria to determine who those children are,” says Karthik Balakrishnan, a pediatric-otolaryngology professor at Mayo Clinic Children’s Center.
The long-term risks of an untreated tongue tie are likely overstated for the child, especially in mom groups. “Long-term effects are very unpredictable, and depend on how bad the tie is,” Walsh says. “The lack of good data is one reason there is so much disagreement within the medical and dental community. Some of the research demonstrates contradictory findings.” For example, some studies show an association between dental misalignment and the severity of tongue tie, while others do not.
Buzi says that when she sees patients, she focuses on whether a tongue tie is giving a child problems in the present, not hypothetical future issues. “It’s never about, Oh my God, they are going to have issues in the future with speech, because we don’t know that for sure at all,” she says.
“I would have a lot of concern with somebody talking to the parent of a six-month-old or four-month-old and saying, ‘I can tell you that this short frenulum is going to interfere with their speech development,’” adds Jennifer R. Burstein, the manager of speech-language pathology at CHOP. “There is no research basis for that.”
While the long-term effects of a tongue tie are unclear, so too is parents’ more immediate concern—its effects on breastfeeding. Some research shows that a frenotomy could help babies breastfeed better. One study of 237 mothers and babies found that the average breast-milk intake increased by 155 percent post-frenotomy. The researchers also write that frenotomies appeared to improve both the quality and duration of the breastfeeding relationship, helping with maternal nipple pain and giving mothers more confidence in their ability to breastfeed.
But much of the research on the subject relies on mothers self-reporting the effect a frenotomy had on breastfeeding, which is highly subjective. In short, moms might see a change post-frenotomy because they want to.
“If you’re a mom that has put her child through this procedure because you thought it was the right thing to do, you might be more inclined to look upon the outcome favorably,” explains Balakrishnan. “You might say, ‘Well, it still hurts, but my kid is feeding better.’ Whether it’s a real effect or a placebo effect, I don’t think that matters.”
“When a baby has difficulty latching while breastfeeding or even to bottles, I think it’s totally reasonable to attempt a frenotomy,” Buzi says. “In the end, the frenotomy is a very safe procedure. The risk is low … but I have no way of determining whether it’s going to make a huge difference.”
It’s not frenotomy or bust. The presence of a tongue tie doesn’t in and of itself mean that breastfeeding will be difficult. “It’s never what the frenulum looks like. It’s how it behaves and what level of function to require before any intervention, if necessary,” says Linda Derbyshire, a certified lactation consultant in Philadelphia. “There are many babies that look to have a suspicious-looking frenulum, but it may have elasticity and be able to function. In that case, you wouldn’t recommend treatment, because there would be no reason.”
One study estimated that 40 to 75 percent of babies with tongue tie will eventually breastfeed successfully without intervention. This same study also found that while frenotomies were likely to improve maternal nipple pain, they were not found to help infants with breastfeeding.
Derbyshire suggests strength-building mouth exercises as a precursor to surgical intervention. These include rubbing babies’ gums to get them to extend their tongue or move it side to side, getting babies to suck on a clean finger to work on the sides of the tongue, even working with the back of the tongue, helping them to master the swallowing motion.
A weak suck, which limits a baby’s ability to efficiently elicit milk from the breast, could also be to blame for breastfeeding troubles, she notes. It can lead to all sorts of other issues, from failure to gain weight to reflux, which is why Derbyshire advocates for rehab exercises before a frenotomy.
But perhaps the most serious concern when it comes to a tongue-tie fix is that it might be masking something else. An errant tongue-tie diagnosis can obscure a more serious issue, says Paul Bahn, a pediatric dentist based in Philadelphia, who regularly performs tongue-tie revisions. A premature frenotomy could cause parents and providers to miss another problem, such as torticollis (a condition in which a baby’s head tilts to one side), congenital issues, even a cardiac issue, he says.
For example, if a baby has a cardiac problem, she’s not going to breastfeed well, because she gets tired more easily than a baby with a healthy heart, Bahn explains. This can present similarly to a baby who is having issues feeding because of an overly tight lingual frenulum.
“I know [tongue tie] is a hot-button topic, and I think many folks try to make it an absolute issue or black and white. It’s not,” Bahn says. “I try to focus more on the here and now and what the current issues are with the [breastfeeding relationship], and not muddy the mess with all the what ifs and could bes in the future.”
There is a gap between the (muddled, developing) scientific understanding of tongue tie and the popular understanding. Falling into that gap might be babies who simply don’t need the procedure, but are getting it anyway.
“We are probably doing too many procedures on infants that don’t need it,” Walsh says. “Until we have a better way to identify [the babies who need frenotomies and those who do not], we are stuck in a limbo of not wanting to withhold a procedure from an infant who probably needs it to foster and encourage breastfeeding, while inevitably doing more procedures than need to be done.”
Research from 2007 suggests that only 10 percent of pediatricians think tongue ties affect breastfeeding, compared with 30 percent of ENTs and nearly 70 percent of lactation consultants. So new parents might be left with very different impressions of the seriousness of their baby’s tongue tie, depending on whom they’re getting their advice from.
“If you’re a new mother and you’re not sure what is going on, then you’re going to be inclined to believe [a lactation consultant] and go with their advice,” Balakrishnan says. “It’s like taking your car to the shop. If the mechanic says, ‘I think it’s your head gasket,’ unless you’re a mechanic, you’re going to say, ‘Okay, let’s fix it.’”