Ties: cheeks, lips and tongues
Have you been told your baby isn't feeding well because of a cheek, lip or tongue tie? It's common these days for new moms to hear that their baby has a tongue tie. More and more I'm even hearing about lip and cheek ties, so I wanted to talk about what they are and when they should be treated.
I’m updating this September 2024 because the AAP recently shared Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report. See the bottom of the original post for details of that.
What are cheek, lip, or tongue ties?
If you lift your upper lip, you will probably see a flap of tissue (frenulum) connecting your lip to your upper gums. There's a similar flap of tissue under your tongue. Many people also have a noticeable flap connecting their checks to their gums.
Since most of us have these flaps, it goes without saying that most of the time they do not cause problems. Simply seeing one in your newborn or child does NOT mean they need to be cut or lasered. Their function should be evaluated to decide if they need to be addressed.
These ties are often blamed for causing breastfeeding and speech problems. I've even seen recent social media posts blaming ties on gross motor and fine motor developmental delays. There is NO evidence to support developmental delays due to tongue, lip or cheek ties.
With the increasing breastfeeding rates in recent years, more parents are told that their baby's frenulum should be clipped.
I have seen many mothers who feel the benefit of an improved latch with less pain after a tight tongue tie is released. This is one of my favorite procedures to do when it is indicated because it is relatively low risk and has potentially great benefits to support breastfeeding. But I have also told many parents that it is not recommended to do a procedure to clip the tie when the tongue functions normally - the frenulum attachment does not seem to be related to the breastfeeding problem. Some physicians and dentists are known to clip every frenulum they see. This is not good practice, but it can be hard for parents to know if a procedure is really indicated or if the clinician simply can get paid to do a procedure. As you'll see below, even the experts have trouble agreeing as to when procedures should be done sometimes.
There are some firm recommendations against certain tie releases though (to be discussed below). For example, I have never seen benefit from lip or cheek releases. These are often done with a laser in a dental office without my knowledge.
PLEASE talk to your pediatrician prior to any elective procedure. We can help assess the need and discuss risks and benefits.
Consensus statement
In April 2020 a panel of otolaryngologists (ENTs = ear nose and throat specialists) published a consensus statement about the treatment of ties. This passed under my radar at the time due to my being overwhelmed learning about COVID19 and I just recently found it.
There were several issues that the panel of experts were not able to agree upon because there is limited data, but they were able to make recommendations on when to release ties - and when it's best to leave them alone.
I'll summarize it below after giving a few definitions to make this easier:
ankyloglossia - tongue tie
frenulum - a piece of tissue that helps to anchor a mobile body part
buccal - cheek
labial - lip
frenotomy or frenulotomy - clipping of the frenulum (the tissue that ties)
frenectomy - removal of the frenulum (often confused with frenotomy)
frenuloplasty - an incision of the frenulum with a rearrangement of the tissue
interincisor diastema - wide space between top teeth
Tongue ties
The definition of tongue tie (ankyloglossia) that was agreed upon in this panel is a “condition of limited tongue mobility caused by a restrictive lingual frenulum.”
They were not able to come to a consensus regarding the definition of anterior versus posterior tongue ties due to lack of consistent data.
The panel was also unable to come to an agreement on the best rating scale for ankyloglossia. Some of the systems are based solely on the look and attachment location of the frenulum, but others assess functionality. (As mentioned above, I am in the camp that believes functionality matters most.)
How common is tongue tie?
The panel found a wide range of incidence of tongue tie, from 2.8% to 10.7% of the population. The number of infants diagnosed with tongue tie is rising in recent years. This does not mean that it is becoming more common, only that it is being diagnosed more.
They found that in some communities infants are over diagnosed with tongue tie and undergo unnecessary procedures.
Several factors were proposed that may contribute to more children being diagnosed in recent years. This list includes:
An increased focus on the benefits of breastfeeding.
An increased awareness that ankyloglossia can negatively affect breastfeeding.
The number of lactation consultants who identify infants with possible ankyloglossia has increased.
Social media posts and websites related to tongue-tie.
An increase in the number of medical practitioners, particularly dentists, who treat ankyloglossia.
What about sleep apnea?
It has been suggested that tongue tie can lead to an altered jaw shape over time and contribute to sleep apnea if not corrected.
The consensus statement offers the argument that if the tie holds the tongue towards the front of the mouth, it is less likely to fall back during sleep and obstruct the airway. The tie might actually help to prevent apnea and serve a benefit if not released.
They do not recommend frenotomy to prevent sleep apnea.
What about future speech issues?
The panel found that in infants with little or no tongue mobility restriction, frenotomy does not prevent future feeding or speech disorders.
They do not recommend frenotomy to prevent future speech issues.
How is breastfeeding best supported?
There are many factors that impact breastfeeding and it is obvious that addressing only one potential issue is not going to improve breastfeeding rates.
They reviewed a couple large studies that looked at breastfeeding rates with and without frenotomy when breastfeeding support was given. Frenotomy rates decreased without sacrificing successful breastfeeding when effective support was given.
In other words: many of the frenotomies were not necessary.
What is necessary is supporting the breastfeeding mother and baby.
For those infants with breastfeeding challenges, the most commonly associated symptoms of ankyloglossia include nipple pain with nursing, irritation of the nipple skin, and shallow/poor latch. Other considerations should include prematurity, abnormal facial structure, neurologic or cardiac disorders and upper airway obstruction leading to difficulty feeding. Working with a lactation consultant is essential to see if breastfeeding support without a procedure can address the issues.
Maternal factors that should be considered include discomfort during the first few weeks of breastfeeding, maternal nipple anatomy, poor positioning or support at breast, maternal milk supply and breast infection.
Planning the frenotomy
An optimal time at which to do a frenotomy was not found. It should be done only after time to evaluate and assist breastfeeding techniques has been completed. Ideally the release should be done in the first month of life if an infant has a tongue tie that restricts tongue movement and affects breastfeeding.
Discussion of risks and benefits
Complications of frenotomy should be discussed prior to having parents consent to the procedure. These complications may include:
bleeding
airway obstruction
injury to salivary structures
oral aversion (resisting eating)
scarring
no improvement with breastfeeding
Non-surgical options to frenotomy should be offered. These include:
working with a lactation consultant
working with a speech-language specialist
observation
Frenotomy procedure recommendations
There was no preference of type of frenotomy, such as laser vs clip with scissors. Both seem to be well tolerated but the laser is typically more expensive.
There is no indication for either topical or injectable anesthetic for infant frenotomies.
Oral sucrose (sugar) is often used for painful procedures in infants and can be used for frenotomies. Breastmilk may be used instead. Optimal timing of sucrose (or breastmilk) is unknown. (I personally prefer to have the infant breastfeed immediately after the procedure and most babies don't show signs of pain or distress during the procedure, with or without sucrose.)
There is no preference to where frenotomies should occur (clinic vs operating room). A clinic is much less expensive than an operating room.
No post-procedural routine is recommended. Some people have recommended massage or tongue stretches. These have not been found to be beneficial.
Summary of the AAP’s “Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report”
Anatomy versus function
Anatomic variations of the lingual frenulum do not necessarily lead to difficulties with breastfeeding. Fewer than half of infants with physical findings consistent with ankyloglossia (“tongue tie”) had difficulty breastfeeding in studies.
They did not find evidence to support releasing lip or cheek ties and suggest that when done, it may be for the financial gain of the person doing the procedure, not to help breastfeeding.
When considering treatments for “poor feeding” it is important to consider causes of ineffective latch and reasons newborns fail to gain appropriate weight. None of the tools proposed to evaluate the severity of tie have been validated. Important aspects to review may include:
A review of the prenatal course, including medications used, breastfeeding history, breast surgeries, breast and nipple anatomy, and family history
Infant feeding history including any abnormal features (coughing, choking, color change, bilious emesis, early tiring) and/or breastfeeding difficulties (nipple pain, nipple trauma, long feeding times, difficulty staying attached to the breast)
Physical examination with special attention to:
Notable physical features, especially cleft palate or small or recessed jaw
Assessment of tongue movement and coordination as well as suck reflex
Ability of the tongue to move over the gums and how it can lift with an open jaw
Assessment of milk transfer using pre- and post- feeding weights
Lactation assistance to observe a feeding session
Weight pattern since birth
Note: sucking blisters are a normal finding and do not indicate need for a procedure
Types of treatments for tongue-tie
The most common approach to infant frenotomy is scissor clipping of the frenulum. The scissors technique has not been reported to have complications and usually does not require anesthetic or sutures in the newborn infant.
Recently there has been a marked increase in the use of laser for frenotomy. There is no data on the use of laser versus clipping for frenotomy in the newborn period. Scissor procedures may be preferred due to the increased cost of the laser and no benefit of the more expensive procedure.
Stretching exercises following a frenotomy has not been shown to help and is associated with problems, such as oral aversion, so should not be done.
Other treatments supported by some health care professionals include physical therapy, craniosacral therapy, or myofascial therapies. These treatments are not well studied to understand any potential benefits and often require out-of-pocket costs for families.
Benefits and Drawbacks of Frenotomy for Symptomatic Ankyloglossia in Infants
Potential benefits of frenotomy include a decrease in maternal nipple pain during breastfeeding and a potential improvement in the infant's ability to breastfeed. Decreasing nipple pain can be an important factor in helping mothers continue breastfeeding.
Drawbacks of frenotomy include the risks associated with any surgical procedure, such as bleeding and infection. There is also the risk of performing a frenotomy on an infant who does not actually need one due to overdiagnosis.
Alternative treatments for breastfeeding difficulties include:
Lactation Support: Breastfeeding mothers and infants benefit from working with a lactation specialist, especially when an infant exhibits feeding difficulties or poor weight gain. Many breastfeeding challenges can be effectively addressed with proper lactation support.
Observation and Monitoring: For infants with the appearance of a tongue tie who are not experiencing breastfeeding problems, watchful waiting and monitoring their feeding patterns is a reasonable approach.
Addressing Underlying Issues: Problems with breastfeeding occur from a variety of factors, including maternal factors (breast anatomy, nipple pain, previous breast surgeries), infant factors (prematurity, oral anatomy, suckling ability), and feeding history (latch difficulties, milk transfer, infant weight gain). Working with feeding specialists to address the underlying issue is important.
Managing breastfeeding difficulties often necessitates a multidisciplinary approach. This collaborative effort may involve lactation specialists, feeding therapists, surgeons, and pediatricians working together to determine the best course of action for each family.
When a tongue looks like a heart, the function and movement of the tongue should be assessed to determine if the frenulum limits movement.
What about older kids?
Most of the literature on tongue ties focuses on infants, but in older children there are concerns for speech problems, dental issues, mechanical limitations (inability to lick an ice cream cone or French kiss), and social implications (insecurity due to the look of their tongue).
The consensus group concluded that ankyloglossia does not typically affect speech despite common beliefs. Since there is no method to predict which children with ankyloglossia will require treatment, the consensus group agreed that consultation with a speech pathologist should be done prior to frenotomy for speech concerns.
If there are dental, mechanical or social concerns, there is no maximum age at which a frenotomy should be performed.
There is no ideal type of procedure that is preferred in older children, though they are more likely to require anesthesia compared to infants.
Cheek ties
There is no reason to release cheek ties to help with breastfeeding. The consensus of the panel was to recommend against releasing buccal ties.
Why is it done? I suspect because it is a procedure that pays well.
Why isn't it recommended? The buccal frenulum helps to attach the cheek to the gums. Studies show that the breastfeeding latch can be assisted if there is support added to the cheek - it increases the suction during feeding. Releasing the attachment would do the opposite of what you need.
Don't have your baby's cheek ties "repaired" - it may do more harm than good.
Lip ties
There is little evidence that lip ties contribute significantly to infant feeding problems and the consensus statement suggests that lip ties are over diagnosed and treated in some communities.
A common concern among parents is that the lip tie will cause a wide space between teeth (interincisor diastema). This has not been shown to be a definitive correlation. In fact, studies show that as teeth come in, scarring from a lip tie release may actually worsen the positioning of the teeth.
It is not recommended to perform a lip tie release to prevent future tooth spacing issues and there is no firm evidence that it helps breastfeeding.
In summary
Tongue tie can lead to breastfeeding issues, but proper assessment should be completed prior to deciding if it should be released or not. While frenotomies have overall low risk, they are not risk free, so non-surgical options should be considered in addition to surgical release. Frenotomies should not be done to prevent future speech issues.
Lip ties are not generally associated with breastfeeding problems. If they are suspected, working with a lactation consultant to improve latch should be done prior to consideration of a release. Frenotomy of the lip tie might increase scarring and future dental problems.
Cheek ties should not be released. Release of these ties might worsen breastfeeding technique.
