Note: This blog discusses tongue ties specifically. A discussion about lip ties can be found here.

Here is my recommendation for care of the infant suspected to have a tongue tie:

Suspect a tongue tie –> Full feeding assessment and HATLFF by IBCLC –> Referral to revision provider for evaluation if infant fails HATLFF –> Follow up with IBCLC including wound care, suck exercises, and bodywork

I divide my career (so far) as an IBCLC into four phases to date:

Phase one: 2009-c. 2012

I knew about and could easily identify classic, anterior tongue ties. I would refer the mothers to have their babies’ mouths evaluated, but often had doctors or dentists refuse to perform the frenotomy on the baby. I was not comfortable with, familiar with, or educated about posterior tongue ties or upper lip ties at this point. (Most of the evidence around posterior ties and upper lip ties came into the landscape in 2013). It wasn’t part of the curriculum when I became a lactation consultant in 2009 and it wasn’t widely accepted or talked about amongst IBCLCs yet.

I had a fair number of breastfeeding cases that I couldn’t fix and I didn’t know why.

Phase two: 2012-mid 2015

I became more aware of posterior ties and upper lip ties and I connected with a team of Ear Nose and Throat (ENT) doctors locally who were offering to revise them. I developed an excellent working relationship with one doctor in particular who did an excellent job of revising mouths. The procedure was getting covered by insurance, the doctor was reliably revising what I sent to him if he agreed with my findings, and I was able to resolve more breastfeeding issues than before. This ENT used scissors to do the procedure, not a laser. Although scissors work, there was a good deal more re-healing going on. Mouth tissue heals to itself quickly, so in order to keep the benefits of the procedure, parents had to perform “active wound management.” Another way to describe this is that parents had to keep the wound open as it tried to heal since it needed to heal from the inside out. I was able to fix many more breastfeeding issues, but the re-healing was an issue.

Phase three: mid 2015-early 2017

I joined forces with a few area dentists who are masters of laser dentistry. Now, frenulums could be revised with seemingly less pain and less reattachment. So, which is better: laser or scissors? Either work well, as long as they are done completely and by a really skilled provider. In our area, I began exclusively referring to the providers who use laser. The process of identifying, referring, and revising tongue and lip ties became smooth and seamless.

Phase four: early 2017- current

The tongue tie debate is getting hotter and more controversial than ever before. There are some professionals who are very confident that all tongue ties, lip ties and bucchal ties should be revised. There are others that are voicing concern about the trend to revise so quickly and so completely.

The debate has made me take a hard look at how I practice and what recommendations I give to breastfeeding families. I personally took a lot of time to slow down and review the quality evidence available, the opinions of professionals I trust, and my own personal past practice.

So where do I find myself? Smack dab in the middle (no surprise there!).

I will never take revision of oral tissues lightly, for we are electively changing these baby’s bodies. I do believe, however, that revision of tongue and lip ties is making breastfeeding possible for a significant number of moms and babies who otherwise would have struggled with a whole host of issues for the duration of however long they can tolerate their troublesome breastfeeding relationship. As many of us know, mothers don’t just breastfeed or not breastfeed; they suffer for weeks or months in the middle of those extremes.

As Alison Hazelbaker puts it in her most recent publication, Color Atlas of Infant Tongue -Tie and Lip-Tie Laser Frenectomy, “Unfortunately, the fervor over tongue-tie diagnosis and treatment has outstripped the evidence, engendering over diagnosis and corresponding, and perhaps appropriate, backlash from the medical community.”

So, in the year 2017, I have come to the following conclusion:

We must take every mother’s concern that her baby has a tongue tie and/or lip tie seriously, for what she is truly saying is, “I need help with breastfeeding.” If we don’t take her seriously, she is much more likely to go straight to the revision provider without getting the breastfeeding support she needs before and after.

We must encourage every mother to see a trusted IBCLC before revision to have a more thorough evaluation of all the contributing breastfeeding issues. Revising tongue and/or lip tie very rarely magically fixes all breastfeeding issues and the post revision care can often be stressful and alarming for mothers.  They need quality lactation care and support before and after the procedure.

There is a lot of information about this topic on the Internet. It is not my intention in this blog to have all the answers about tongue and lip tie, nor is it my intention to make the argument for or against revision. It is your responsibility to educate yourself as much as possible if your child has a tongue tie. It is my intention in this blog to make you aware of what I see as the current state of affairs in the tongue tie debate and report how I practice personally.

Below is a list of sites where you can read more about this. All of these sites are from reputable professionals who are respected in their fields. Remember, whenever you are “researching” online, be sure to ask yourself: Is this APOS? (Applicable, Professional, Opinion or fact, Sensible)

Laurence Kotlow, DDS
Bobby Ghaheri, MD
Paul Bahn, DDS 
Dr. Pamela Douglas
Protocol from the Academy of Breastfeeding Medicine
From the American Academy of Pediatrics (2/7/17)

What is the best way to identify if there is a tongue-tie?

However much I would like to simply rely on my “discerning eyes and fingers,” I also believe as a healthcare provider that we need standardized and reliable tools to confirm our subjective findings. There are more than a half dozen tools and techniques around to identify the presence and impact of a tongue tie in infants. There is, however, only one validated tool: The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF). The Academy of Breastfeeding Medicine endorses the use of this tool for the identification of infant tongue ties and I now use it to score every baby I see in my lactation office.

The HATLFF is a superior tool because it assesses not just how the tongue looks, but also how it works!  I have found that using the HATLFF helps me to identify exactly which oral movements the baby is unable to perform properly so that I can customize my post revision suck training exercises. For instance, if baby is unable to fully extend her tongue before revision, I know to teach mom tongue extension exercises to practice before and after the revision to help baby learn this newfound skill.

I complete the full HATLFF in my office, but the short version of the HATLFF is most reliable for those who do not perform these regularly.

Does the evidence support revising tongue ties?
Cochrane Library published a 2017 systematic review of the available randomized control studies and concluded the following: “In an infant with tongue-tie and feeding difficulties, surgical release of the tongue-tie does not consistently improve infant feeding but is likely to improve maternal nipple pain. Further research is needed to clarify and confirm this effect.”

However, they note, “The quality of the evidence is very low to moderate because overall only a small number of studies have looked at this condition, the total number of babies included in these studies was low and some studies could have been better designed.”

Bottom line: There is confirmation that revising tongue ties helps with nipple pain, but we need better research to prove that it improves breastfeeding outcomes.

In the meantime, what are we to do?

Here is my recommendation for care of the infant suspected to have a tongue tie:

Suspect a tongue tie –> Full feeding assessment and HATLFF by IBCLC –> Referral to revision provider for evaluation if infant fails HATLFF –> Follow up with IBCLC including wound care, suck exercises, and bodywork

Suspect a tongue-tie?

The suspicion of tongue tie usually comes from one of two places. First, from a provider who assesses the baby in the first days of life. The pediatrician, nurse, midwife, or lactation consultant may identify the tongue as being “tight.” Mom may be told that there is a tongue tie or that the tie is there, but it “isn’t too bad” or “probably won’t cause problems.” This quick assessment by the healthcare provider is often done by “look and feel,” but not with a validated tool (aka not with the HATLFF).

More often, moms are diagnosing their baby’s tongue tie based upon what they are finding online. This is often driven by her feeling that breastfeeding is not okay. This is most likely and most often stemming from nipple pain, but also from difficulty latching, and/or baby’s excessive gassiness, fussiness, or poor weight gain. I am not dismissing the practice of solving your own problems with the Internet. As moms, we are our children’s best advocate. “Don’t Google it” no longer applies. We Google and we fall down the online wormhole until we find answers to help our children.

Once the suspicion is there, this is when things start to go awry.

Mothers go to their pediatricians and report their suspicion. How does the pediatrician respond? Often, it is one of four ways:

  1. Frustration at the “new tongue tie craze” causes them to dismiss the mother’s concerns entirely (I’d like to think this never happens, but it does happen).
  2. Quick visual assessment of the baby’s mouth shows no tongue tie and dismissal of mom’s concerns.
  3. If the pediatrician agrees with the mother’s diagnosis, he may directly refer to a revision provider.
  4. Referral to a trusted IBCLC to address the breastfeeding symptoms that mother is experiencing.

Choices 1 & 2 may lead a mother to self seek a revision provider without first seeing an IBCLC. Choice 3 may lead to a revision of the tongue tie, but leaves the mother without the breastfeeding support she desperately needs. Choice 4 is what pediatricians ought to do, but I am not sure how often this is truly happening.

If a mother presents with a suspicion of tongue tie, the provider should hear, “I am having difficulty breastfeeding” and mom should be referred to an IBCLC.

Rather than simply “looking” to see if there is a tongue tie, I encourage mothers or providers to use the appearance section and just the first three function items of the HATLFF (extension, lateralization, and lift) since this has been shown to be the most reliable. I think that completing the long-form HATLFF takes the experience of practicing on dozens of babies before mastering it. Without this experience, the findings are less reliable.

Full feeding assessment and HATLFF by IBCLC

It is my job as the IBCLC to see the whole picture, not just the tongue. Tongue tie almost never exists in a vacuum of breastfeeding problems. Or, rather, the tongue ties that don’t cause breastfeeding problems aren’t a problem and tongue ties that do cause problems cause a whole host of problems.

I feel it pertinent to remind everyone that a baby’s mouth must fit onto two particular nipples. We cannot only look to the baby’s mouth for answers to breastfeeding difficulties, we must also look at maternal anatomy. Pediatricians are often not well suited for this task due to limitations in time and expertise. An IBCLC, on the other hand, is masterful at assessing maternal anatomy in addition to evaluating the infant’s feeding needs.

It is the role of the IBCLC to

  • Address the mother’s suspicion of tongue tie and decrease self-seeking of revision, which may be unnecessary.
  • Communicate her findings with the infant’s pediatrician.
  • Refer the mother to a known and trusted revision provider (Dentist, ENT, oral surgeon, etc.).
  • Treat underlying breastfeeding issues, such as low milk supply, nipple trauma, or infant’s poor weight gain, to name a few.
  • Provide support, education, and anticipatory guidance before, during, and after the revision procedure.
  • Provide follow-up shortly after the visit, including addressing all persistent breastfeeding issues, infant suck relearning, strengthening through tummy time, and emotional support.

It is not the role of the IBCLC to

  • Diagnose tongue tie. The IBCLC simply identifies limitations in oral range of motion. It is the revision provider who officially diagnoses tongue tie.
  • Tell the family what she thinks they should do or make false promises that a revision will fix everything.

If the infant fails the HATLFF, the IBCLC should refer to a trusted revision provider for evaluation and potential treatment.

After evaluation with the revision provider, follow up with IBCLC is critical.

Reference List