If you’re a new parent who spends time in Facebook breastfeeding groups, no doubt you’ve come across the topic of ties.
Perhaps you are experiencing breastfeeding challenges and you’ve asked such groups for help.
Subsequently, it might have been suggested your baby has ties, and you should see someone who is ‘tie-savvy’ from the group’s provider list.
There is a problem, however, which is dividing professionals and parents alike.
When it comes to tie releases, Dr. David McIntosh, a paediatric ENT surgeon, believes that too many inappropriate ones and not enough appropriate ones are being done.
So, what now?
What Are Ties?
‘Ties’ is a collective term used to describe tongue-ties, upper lip-ties and buccal ties. All of these are related to connective tissue that restricts movement in the mouth and causes functional problems.
Definitions of tongue-tie vary, but it’s generally agreed a tongue-tie exists when the lingual frenulum (the connective tissue under the tongue) restricts tongue movement in a way that negatively affects function.
Upper lip-ties occur when the frenulum underneath the upper lip, known as the labial frenulum, is deemed to have caused a functional problem.
Buccal ties occur when frenula underneath the cheek are deemed to have caused a functional problem.
The prevalence of tongue-tie appears to fall between 4% and 10%. Inconsistencies in diagnostic criteria most likely contribute to variation in estimates.
Broadly and simply speaking, some tongue-ties are obvious – where the frenulum attaches close to the tip of the tongue. These are referred to as ‘classic’ or ‘anterior’ tongue-ties.
Other possible tongue-ties are less obvious, and can be referred to as ‘posterior’ tongue-ties.
Few would argue against there being genuine indications for releasing a tongue-tie. When a tongue-tie causes a functional problem, releasing it can help improve function. A tongue-tie release is a surgical procedure, performed either by scissors or laser.
The question is this: are too many supposed tongue-ties and other ties being released?
Health Professionals Concerned About Over-Treatment Of Ties
Many health professionals are concerned that too many ties are being released; that is, some professionals are performing too many unnecessary surgical procedures on babies.
Karen Palmer, a neonatal nurse (for 10 years), midwife (for 22 years) and an International Board Certified Lactation Consultant (IBCLC) for 23 years, indicates she “fought hard 10 years ago to get simple tongue-ties simply cut, to allow more effective, pain free feeding where necessary”.
She adds, “A few years back we had never heard of these things and other ways were found to manage breastfeeding issues and support mothers. Now, surgery has become the default position. The wide variation of IBCLC practice with no discernible improvement in breastfeeding rates tells a story”.
Heather Harris, a midwife (for 46 years) and an IBCLC (for 25 years) is also concerned tongue-ties, upper lip-ties and buccal ties “appear to have become a mainstream intervention for any breastfeeding or perceived breastfeeding problem.” According to her, “Surgical intervention seems to be the first ‘go to’ option whenever there is a breastfeeding issue”.
Anne Cullen, is another IBCLC who is concerned about the number of ties being released. She says, “I have huge concerns that there are some professionals that release far too many tongues. The increase I have seen in lip and buccal releases over the past two years has me very worried”.
Holly Tickner, a speech pathologist who has specialised in the area of paediatric feeding difficulties for over a decade, believes “the pendulum has swung too far in each direction. Probably fifteen or twenty years ago tongue-ties were being missed and not being diagnosed. The science behind breastfeeding and tongue-tie has come a long way in recent years and we know a lot more about it now than back then. But at the moment the pendulum is swinging a little too far to the other end”.
Holly is concerned about “the current trend of having surgery for oral ties without a functional assessment first. A functional assessment takes into account what the tongue and mouth look like, as well as how they work”.
In Holly’s opinion, it’s not enough “just to have a physical examination of the mouth”. Holly meets “far too many older babies and children who have had oral surgery done first before trying anything else, and often the parent has been led to believe that it will provide a quick fix, and instead the parents have seen no changes (or worse yet, the surgery has caused new problems)”.
There is also a concern some parents are obtaining inaccurate information related to ties from tongue-tie and breastfeeding peer support groups on Facebook.
The Research On Breastfeeding And Ties
A tongue-tie can negatively affect breastfeeding. For example, a tongue-tie might reduce how well a baby can remove milk from the breast and it might increase the risk of nipple pain and damage.
The latest systematic review on the topic of tongue-ties and breastfeeding concluded:
“Frenotomy [the name of the surgical procedure to release a tongue-tie] reduced breastfeeding mothers’ nipple pain in the short term. Investigators did not find a consistent positive effect on infant breastfeeding. Researchers reported no serious complications, but the total number of infants studied was small. The small number of trials, along with methodological shortcomings, limits the certainty of these findings. Further randomised controlled trials of high methodological quality are necessary to determine the effects of frenotomy”.
There have been no systematic reviews undertaken about any possible effect upper lip-ties or buccal ties might have on breastfeeding, due to significant lack of evidence.
There is negligible evidence with regard to breastfeeding and upper lip-tie, and zero evidence with regard to breastfeeding and buccal ties.
Karen thinks anterior tongue-ties “can negatively impact breastfeeding and the effects can be seen in the early days and weeks”. However, she feels “posterior tongue-tie diagnosis can be subjective”. In Karen’s opinion, upper lip or buccal ties don’t affect breastfeeding at all.
Similarly, Heather believes “anterior tongue-ties can (but do not always) impact negatively on breastfeeding, as the tethered tongue may not be able to draw the breast far enough into the mouth to effectively extract milk, resulting in poor milk transfer and potential nipple trauma”.
However, Heather feels the “upper lip frenulum is a normal part of infant oral anatomy and should never be interfered with at this age – if ever”.
She continues: “The belief that the top lip needs to be flanged to enable a good latch is erroneous and demonstrates a poor understanding of normal breastfeeding attachment”. Furthermore she believes that buccal ties have nothing to do with breastfeeding.
Anne says she has “personally never seen a lip-tie or buccal tie that needs releasing due to a breastfeeding problem”.
What Should You Do If You Believe Ties Are Affecting Breastfeeding?
If parents are concerned about whether ties might be affecting breastfeeding, Karen suggests they first contact their primary practitioner (nurse, midwife or GP) for a holistic assessment of their baby.
From there, Karen suggests a referral to an IBCLC for further assessment if necessary. She feels “IBCLCs definitely need to be part of that team, to sit and observe a feed first and foremost, but other factors from pregnancy, birth and the neonatal time need to be taken into account”.
Karen indicates she is “always aware that many medical issues present first as feeding problems so therefore a thorough assessment is required before a specific road is gone down”.
If Heather believes a tongue-tie is interfering with breastfeeding, she feels the most appropriate line of referral is to a medical practitioner who has extensive experience in, assessment of, and safe division of anterior tongue-ties.
She adds she “would never refer to a dentist or speech pathologist or ‘body worker’ for such an issue at this early age”. She adds that with regard to upper lip-ties there’s “no such thing, so I would never refer anywhere; same with buccal ties”.
According to Anne, if parents are concerned their baby has a tie, “Mothers should always consult an IBCLC first to work on latching and positioning”.
In terms of diagnosing ties, Anne says she prefers “a team approach – I’d like to see a certified lactation consultant working in conjunction with an ENT or other paediatric medical specialist”.
She thinks “any feeding problem needs to be looked at holistically so that we can identify the root of the feeding problem. Feeding problems can even be related to a mother’s state of wellbeing and the support around her; they are often not problems that can just be solved with a ‘quick fix’ tie release”.
Heather, Karen and Anne all agree that if a tongue-tie isn’t obviously contributing to any current functional problem, it shouldn’t be released pre-emptively.
Karen says, “A baby has a lot of growing and developing to happen first. There is no harm in a ‘wait and see’ approach.”
Likewise, Heather says, “If there are no obvious problems I can see no advantage in a surgical intervention. Ain’t broke, don’t fix it”.
Anne says “There is never any justification for performing a preventative release on a baby.”
There is certainly a lot of confusion, speculation and conjecture surrounding the topic of ties. For parents who are concerned about their baby possibly having a tie, it can be very difficult to try to navigate their way through it, and make sense of it all.
The truth is we don’t fully understand the topic of ties. More quality research is needed, but this will take time.
If you’re worried your child might have a tie, it’s best to seek advice from the appropriate health professional – e.g. lactation consultant for breastfeeding issues, speech pathologist for speech issues, specialist paediatric dentist for dental issues, and ENT surgeon for breathing issues etc.
Ultimately, if you’re having problems with breastfeeding, please do seek help from a qualified lactation consultant. Get second or third opinions if you need or want to.
Just don’t suffer in silence.
