Tongue Tie in Babies: How Ankyloglossia Affects Breastfeeding & Other Concerns

By: Maya Bunik, MD, MPH, FAAP & Peggy Kelley, MD, FACS, FAAP Breast milk offers the best possible nutrition for growing babies. But as many parents of newborns will tell you, nursing can be a challenge sometimes—especially at the beginning. Infants sometimes have trouble latching on to the nipple. This can cause pain for the breastfeeding parent, mixed with concern about whether the baby is getting enough milk. Tongue tie (ankyloglossia) has been gaining attention as a possible cause of breastfeeding issues. However, experts worry that tongue tie is being overdiagnosed—leading to unneeded surgeries as other causes of nursing challenges are overlooked. For the clinical report, "Identification and Management of Ankyloglossia and its Effect on Breastfeeding in Infants," the American Academy of Pediatrics (AAP) reviewed the latest research on tongue tie. We looked not only at breastfeeding concerns, but other health issues as well. Here's what parents need to know. In children with tongue tie, the band of tissue connecting the tongue to the floor of their mouth is unusually short or tight. This can limit the tongue's range of motion. An estimated 4% to 10% of newborns have tongue tie. Although the condition has long been thought to cause breastfeeding issues, research hasn't shown a clear link. Even so, tongue-tie release surgeries, called frenotomy, jumped by 110% since 2012 and has continued to climb since then. This has sparked controversy among child health providers and families. The trend may be fueled by other worries, too. For example, parents may hear that failing to correct tongue tie early will cause speech, sleep and dental problems later in life. Child health care providers—from breastfeeding experts to ear, nose and throat doctors (otolaryngologists) to pediatric dentists, lactation specialists and primary care doctors—often use different standards to evaluate tongue tie and decide whether to recommend surgery. With far too few studies of tongue tie in nursing infants, we don't have clear evidence to prove that surgery consistently helps. But research does show that: Less than half of all infants with physical signs of tongue tie have trouble nursing. In fact, one U.S. study of 115 babies referred for tongue-tie surgery found that 63% did not need the procedure to solve nursing issues. A muscle under the baby's tongue can stretch and lengthen with continued feeding, possibly solving nursing issues. Healthy nursing might also depend on movements in the middle of a baby's tongue. This makes the tip of the tongue less important (and surgery less effective). This finding comes from a newer study using advanced imaging to show milk flow in infants' mouths. Although more studies are needed to confirm the role tongue tie plays in nursing, research does show that a tongue-tie release can relieve nipple discomfort—at least in the short term. When a baby’s tongue does not extend beyond the gums, the nursing parent may experience pain during breastfeeding. Since nursing pain can be severe—and even cause parents to give up on breastfeeding—the procedure may be helpful for many infants and families. If you've heard your infant will need surgery now to prevent serious problems down the road, here are key facts to know: Tongue tie will NOT delay your child's speech development. It might change the way they form words (articulation), because kids who can't easily touch their tongues to the roof of the mouth may have trouble making "t," "d," "n," "l," "s," "z" or "r" sounds. If this happens, a speech therapist can evaluate your child and suggest the best course of treatment, which may include speech therapy. There's no evidence that a tongue-tie release surgery will improve dental health or prevent sleep apnea later in life. These health issues have complex causes, so surgery alone cannot protect your child from conditions that might (or might not) appear years from now. Claims that frenotomy can improve reflux, fussiness, bedwetting and other issues also are not evidence-based. Surgery to correct lip ties or cheek ties will not improve breastfeeding, even though lip-tie surgery is often paired with tongue-tie surgery. The bands that connect a baby's lips and cheeks to the inside of their mouth aren't directly involved in latching or sucking, so these procedures are not useful. Breastfeeding issues have many possible causes, which also means there are many solutions. To help ensure the correct diagnosis and treatment, your baby's pediatrician or other primary care provider should coordinate care in a team approach that includes lactation coaches and feeding therapists with surgeons and others. Coordinated care provides a chance to study what's happening, test out different approaches and provide close follow-up for continued concerns. It helps prevent misdiagnosis and unnecessary tongue-tie procedures, which can worsen feeding issues, interfere with function later in life and create extra medical expenses for families. Nursing newborns with possible signs of tongue tie should be closely monitored in the first few days of life. Doctors and lactation specialists can do a careful exam that tests the baby's sucking reflex and looks at tongue movement and coordination. They can gauge the baby's ability to take milk in by comparing pre-feeding and post-feeding weights. Closely observing a feeding session can provide more insights before surgery is recommended. As testing moves forward, parents whose baby has tongue-tie should get plenty of support. This includes follow-up care to monitor their child's feeding, weight gain and overall wellness. When breastfeeding does not improve after the release procedure, it is important to investigate other causes. Tongue-tie surgery can be performed by pediatric dentists, otolaryngologists, pediatricians trained in the procedure and other qualified health care providers. It is best to look for a provider who can bill insurance. There is concern that asking for out-of-pocket payment leads to health inequities. Frenotomy is usually an in-office procedure that is brief and done without general anesthesia. Providers may use sterile instruments or a laser (both work equally well; no evidence supports laser cutting over clipping with surgical scissors, the most common method). Infants do cry and fuss during the procedure, but the process takes just minutes. After a short observation period, babies can head home to rest. Over-the-counter pain relievers for infants can ease post-surgical discomfort. As with any surgery, parents must watch for bleeding or pain that persists, but long-term complications are rare. Post-surgical stretches and exercises have not been proven to help infants recover from tongue-tie surgery. In fact, they may even cause babies to temporarily draw back from nursing. Without evidence that they help, the AAP does not recommend these exercises after tongue-tie surgery. The AAP supports new research to develop a simpler and more consistent way to diagnose tongue tie in newborns and infants, and clear guidelines for when tongue-tie surgery is needed. Studying longer-term outcomes will confirm the possible benefits of surgery, helping parents feel more confident in agreeing to the procedure—or choosing to skip it. AAP Addresses Rise in Tongue-Tie Diagnoses for Breastfeeding Concerns Breastfeeding: AAP Policy Explained How to Tell if Your Nursing Baby Is Getting Enough Milk Why Breastfeeding Parents Need More Support Warning Signs of Breastfeeding Problems Maya Bunik, MD, MPH, FAAP, is a Professor of Pediatrics at University of Colorado Denver School of Medicine and Associate Chief Medical Officer of Ambulatory at Children's Hospital Colorado. Dr. Bunik is Chair of the American Academy of Pediatrics (AAP) Section on Breastfeeding and author of the AAP book, Breastfeeding Telephone Triage and Advice, which is distributed to U.S. hospitals as part of the WHO Baby Friendly Health Initiative. Peggy Kelley, MD, FACS, FAAP, is the Clinical Director of Pediatric Otolaryngology at Providence St. Vincent Medical Center in Portland, Oregon, and is an Executive Board member of the AAP Section of Otolaryngology, Head and Neck Surgery. Images courtesy of Maya Bunik, MD, MPH, FABM, FAAP, and Peggy Kelley, MD, FAAP