‘Ties’ are a hot topic. ‘Ties’ is the collective name given to tongue, upper lip, and buccal (cheek) ties.

There is much controversy surrounding the topic of ‘ties’, even amongst health professionals.

Most agree that releasing an obvious and significant (‘classic’, ‘anterior’, or ‘type I and II’) tongue ties is justified, and likely to help prevent or improve various breastfeeding problems, such as latching issues.

However, the release of a less obvious (posterior, submucosal, or ‘type III, IV and V’) tongue ties, upper lip-tie, or buccal ties creates differing opinions.

What Does The Research Say About Tongue Ties?

If you are concerned that your baby might have ‘ties’, it can be very difficult trying to wade through the mixed information from various sources, and come up with a decision about what might be the best way forward.

One important factor in informed decision-making is to look critically at what the body of evidence about a particular topic says.

So, let’s look at what the overall body of evidence says with regard to ‘ties’.

The Evidence Indicates More Research Is Needed

When making a critical appraisal of the research on a topic, it’s important to look at what the body of evidence says.

This is because each individual study is only one small piece in a much bigger puzzle, and an individual study can range in quality from low to high.

Only when all the research is put together, and analysed in a systematic review, can more definitive conclusions be reached.

The most recent systematic review about the treatment of tongue-tie for breastfeeding outcomes concluded: ‘A small body of evidence suggests that frenotomy may be associated with mother-reported improvements in breastfeeding and potentially in nipple pain, but with small, short-term studies with inconsistent methodology, strength of the evidence is low to insufficient’.

There’s been no systematic review done on upper lip-ties, as very little research has been done with regard to the treatment of upper lip-tie for breastfeeding outcomes.

Only a few non-controlled studies, which have included upper lip-tie release, have been done. Such studies typically include very small numbers of babies having upper lip-tie releases, or release of upper lip-ties and tongue-ties together, making it impossible to know whether any improvements were due to the tongue-tie release, the upper lip-tie release, or both.

There are also no validated diagnostic criteria for assessing when a labial frenulum might cause a functional problem.

To date, there has been no research that has looked into the treatment of buccal ties for breastfeeding outcomes.

What about the distinction between posterior and anterior tongue-ties? What does the research indicate about this?

Good Quality Evidence Exists About Release Of Anterior Tongue-Ties

Several randomised controlled trials (RCTs) have been done, which have clearly demonstrated the effectiveness of releasing an obvious anterior tongue-tie. RCTs are studies which sit high on the hierarchy of evidence.

In these RCTs, the procedure was done, using scissors, by a skilled and qualified health professional.

To date, no RCTs have been done to evaluate outcomes after laser release of ties. Controlled studies about the efficacy of posterior tongue tie release are also lacking.

So, given the lack of research, should procedures to release upper lip ties, buccal ties, or posterior tongue ties still be done?

Well, the answer isn’t simple. But here are some things to think about:

Five Important Factors To Consider About Tongue Ties

#1: No Surgical Procedure Is Without Risk

It’s important for any parent whose baby is to undergo a tie release to be fully informed about all potential risks, such as post procedure bleeding, pain, and oral aversion.

#2: It’s Important That The Need Is Adequately Determined Prior To A Release

For a breastfeeding mother and baby, there are many factors that can contribute to the presenting breastfeeding related problem/s; tongue-tie is one of them.

It takes a skilled, experienced, and breastfeeding knowledgeable person, such as an International Board Certified Lactation Consultant (IBCLC) to make a thorough assessment.

This includes performing an oral examination, watching a breastfeed closely, and taking into account all possible differential diagnoses, to determine whether or not a release is necessary.

Unless the tongue-tie is obvious, it can take some time for the need to become apparent.

For a breastfeeding baby, a lingual frenulum is only a tongue-tie if it’s causing a clear functional problem for breastfeeding. Otherwise it’s just a normal lingual frenulum.

Likewise, unless it’s clear that an upper lip-tie, or buccal ties, in a breastfed baby, are causing a functional problem with breastfeeding, then it’s not a tie but rather a normal labial frenulum, or cheek frenula.

#3: There Is A Wide Range Of Normal Tongue Movement

There is no single, narrow definition of what makes up normal tongue movement. There is a wide range of normal tongue movement, just as there is wide variation in anterior (front part of tongue) tongue length.

#4: Laser Release Is A Significant Procedure

Laser release is a significant procedure, after which parents are commonly instructed to perform regular unpleasant stretches to the wounds, for weeks.

For these reasons, and given the lack of solid evidence for these stretches, and for ties, as detailed in this article, critical thinking and thorough assessment are paramount prior to any release taking place.

#5: The Presence Of A Labial Frenulum Underneath The Upper Lip Is Normal

There are various classification scales for labial frenulums; one is the Kotlow scale.

The title sometimes given to this scale is misleading, as it contains the word ‘tie’. Therefore it can give some people the incorrect impression that a class III or IV labial frenulum is somehow a problem.

What this scale actually shows is the normal range of insertion sites for a labial frenulum.

And, in normal cases, the majority of babies’ labial frenulums insert low down on the upper gum (class III), or even wrap around it (class IV).

It’s important to note that, for effective breastfeeding, the upper lip does not have to flange out like the lower lip in order to create a seal. It just has to rest in a neutral position.

This information should help you to make the right decision for you and your baby.

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