Thanks for sharing this! I am an IBCLC, and tongue ties are something I deal with a lot. I have personally (with my sons) seen the difference a tongue tie release can make - and not getting one can make. We opted not to get my middle son’s done (very long story) and now he is eight and dealing with sleep apnea, teeth grinding, and other airway issues we are now resolving. Would the tongue tie release have prevented all this? Impossible to say.
Professionally; I have seen the good a tongue tie release can do, and I’ve seen the bad. I’ve seen babies referred for one that did not need one and there were major issues after. I’ve also seen moms breastfeeding with so many issues, doctors telling the parents that tongue ties don’t exist, yet they give no other solution - and then the baby gets a release and there is an immediate improvement. I’ve also seen babies get them done with no negative or positive impact.
My approach is to do a thorough assessment of the oral function of the infant, and if there are issues, I typically recommend body work, suck training, etc first to see if there is improvement. If not, I refer to one of a couple providers in our area (with NO kick backs, I assure you) for further assessment and diagnosis if necessary.
I am of the belief that there are long term effects of tongue ties, but I would never recommend a release based on the potential for future symptoms - only current issues. Of course, I cannot diagnose, and I always try to give parents all the information I can to make a decision. I do believe that far too many releases are done without proper before and after care - the release is only one step.
I also believe tongue ties are over AND under diagnosed. Yes, there are some just “in it for the money” but I don’t see that - at least not within the professional circle I work with. There was a dentist that wanted me to refer to them but I didn’t love their approach as it seemed like “everyone has a tie!”
I do think it’s a very complex issue and there are families hurt from both providers who refuse to acknowledge tongue ties can cause issues as well as providers who release every frenulum they see. I often say - it is the function, not the appearance, that matters.
Thank you so much for sharing your first hand experience from the practitioner side including both sides of the discussion. I think until we have more research sharing this type of information is so important in supporting parents.
I have also personally spent thousands of dollars and many, many hours in continuing education on this topic. Not to mention the many unpaid hours I spend with these families during and after the process (to the point where I likely to a loss with these cases).
So it does get frustrating when I get pediatricians saying “she doesn’t know what she’s talking about” when it really feels like they are the ones. I really do try and have a holistic approach toward oral function issues, but there are times where all the suck training and stretches in the world won’t do a thing without a release do. It really is a complex issues, and I appreciate your measured response.
My experience with tongue ties was that most people who you think would be able to correctly diagnose a tongue tie actually aren't trained and experienced enough to do so - in my area (a major metropolitan area of 2 million with two major medical research universities), there are just two dentists who are well-known as being very experienced and trusted (meaning that they definitely have advised no release needed or wait and see plenty of times) who can diagnose and treat properly. I worked with a couple of excellent lactation consultants who were good at spotting them, but obviously couldn't do the treatment. I also found that with my son follow-up care in the form of helping release tight muscles in his neck that had developed from trying to compensate was also important. It's definitely clear that more research is needed because I feel extremely lucky to have had access to good resources and people who knew what they were doing, including a great breastfeeding support group at one of the local hospitals and online support group, but in a different metro area that would have likely been a very different story. Releasing my son's tongue and lip ties was critical to us being able to breastfeed past a year, which I'm so thankful we go to do.
Thank you so much for this thorough review. It’s really helpful to get the full picture. Was there anything in the research related to eating solids and the impact of a tongue tie? It seems a lot of the discussion is around breast-feeding and speech, but I was curious about solids. Thank you!
I appreciate you addressing tongue ties and raising awareness about them. I have Feelings (TM) about them. My daughter, now 3, started off nursing great. Then, despite nursing basically all day beginning at around 2 months, she struggled to gain weight. She spit up a LOT. We were going through all of our burp cloths every single day. Nursing did not hurt me, but I could tell something was off (she has an older brother who had no issues, so I knew what it should be like). The pediatrician thought she had reflux and wanted to put her on medicine for it. I dug into some academic research and found that reflux in breastfed babies is unlikely (like, single digit percentage likely) and that the medications increase the likelihood of brittle bones prone to breaking later in life. The pediatrician and the lactation nurse (that was not her formal job) they have in the office kept pushing supplementing with formula and me practicing various pumping methods to increase supply. That, I knew. what not the problem. And what good is more milk if she spits it up everywhere? So I went to see the actual lactation nurse at the hospital where she was born. And, while allowing my daughter to latch onto her finger, the nurse immediately diagnosed a posterior tongue tie. We began speech therapy (yes, for a 3-month old - it's just stretching exercises) to work as much of it out as we could, then she got the laser procedure. It was fast, and she immediately latched and then did not spit it up (!!!). The post-procedure stretching every 4 hours was brutal, and I don't think we stretched it as far as we could have (it's VERY hard to do this with a wailing baby at 3 am), but she started gaining weight and all was well. She has some speech issues now - normal kid stuff, like the back-of-throat sounds, and it all may be exacerbated from being a pandemic baby who didn't get a lot of exposure to other people's speech outside of our home. Nothing some speech therapy can't help.
You gave the caveat of research that is slow to catch up and not always a randomized trial (quite tough and possibly unethical in some situations here), but I also want to add that the severity of the tongue tie varies. Some are not as far back as others, and, thus, may not be a hindrance to feeding, weight gain, speech, apnea, etc. Some are quite far back; my daughter's was - she couldn't put get the tip of her tongue past her lips at 2 months old. When she born, all was fine, but as her mouth and skull grew, her tongue could not keep up. There were no negative side effects to the procedure. A dentist did it - they know mouth fascia! She also had slight lip and cheek ties, but the dentist determined they were not severe enough to impact feeding and we should do just the tongue, let things settle, and see how she was doing. We did not need to go back for any other procedures. After a lot of crying at the pediatrician's office, including when she warned me NOT to get the procedure done until my daughter gained a little weight (which made no sense to me - how was she to gain weight until she had it done?), the pediatrician afterward admitted it was the right thing to do. I felt like I was swimming upstream in a sea of MDs. It is hard to speak up and against medical professionals, but I felt like she wasn't listening. Later, my husband discussed the whole thing with an Irish friend who said that would have never taken so long to sort out in Ireland. There are more doctors of osteopathy, and they focus on function and how to solve the problem rather than American MDs who find a symptom (in this case, the spitting up) and throw a pill at it. This is an oversimplification, of course, but it does seem that pediatricians aren't taught about posterior tongue ties in med school. My daughter was born with torticollis, too, that went unaddressed for a while, and I think they're all related because all of our fascia is connected. During her anatomy scan, she had a thick neck, and there was a concern she may have one of several frightening chromosomal abnormalities (to add to the emotional turmoil, the scan was on my 35th birthday at the end of March 2020). It turned out she was just crunched in there with a squished neck; whether the tight fascia was because of the posterior tongue tie or something else, I'll never know, but, again, I assume it's all related.
If you've read this far, thanks for listening. It was all a lot at the time, and it was covid times; I was home with a 3yo and a newborn and had no family to help. I wanted to share my story so that other parents aren't afraid of the procedure if their kid really can benefit from it.
Also, I'm writing this as I bake pies for Thanksgiving, so forgive me if this stream of consciousness is messy.
Thank you so much for sharing your journey. I learned so much from your comment on other things to consider and ways we can improve the research and the services that are provided. I so appreciate the time you took to share this.
This is an amazing resource. We did the procedure when my daughter had orthodontic work but know I wonder if it was related to some of her feeding difficulties!
My 2 yo nephew had the laser procedure to release his tongue tie a week ago. He did struggle with breastfeeding but my SIL switched to formula when he was 2 mo.
My oldest did not have a good latch, and I think most of our problems were caused by that- we used a shield and then he had some oral/motor issues that led to me switching to pumping at 3 months old and to formula at 5.5 mo. He turns 7 in 6 weeks. The lactation consultants in the hospital made me very uncomfortable but they were nicer to me when I made an appointment. He was a 5.5 lb baby at birth so there was a lot of concern about him dropping too much weight, but it’s hard to believe now as he’s a high percentile kid.
My youngest (now 4) had an easier time nursing but he took 3 weeks to get back up to birth weight so they had a health visitor come to weigh him a few times. They never suggested my kids had a tongue tie but I had a lot of friends get the procedure for their infants.
Thank you so much for sharing your story. The breastfeeding path is such a difficult one and I just wish there was more access to lactation consultants who are cross trained!
That is something that I found shocking--with how common tongue ties are how few people in the pediatric world understand them. We need so much more education! Thank you for sharing your lessons learned
Thank you for this well written post on a difficult topic due to the low-quality research available to make evidence-based decisions. As a pediatrician I find that occupational therapists can help with infant feeding problems in ways that lactation consultants cannot. If breastfeeding is not improving after working with lactation but I do not think tongue tie is the cause, I will refer to OT. I do recommend (and perform) frenotomies when the tongue movement is limited, and an instant improvement is often seen when the procedure is indicated. Despite being able to do these (and making money from them) I recommend against them often because having feeding problems does not mean they are from a tongue tie. Clipping the frenulum is not going to give a quick fix if it is not the problem, regardless of what some mom friends and lactation consultants may advise. Too often I see parents who took their baby to a dentist before talking to me about the procedure and they are frustrated that the feeding didn't change after the clipping. I advise that parents talk to their pediatrician and let them assess the tongue and talk to you about breastfeeding before doing any procedure to avoid unnecessary risks.
Thanks for sharing this! I am an IBCLC, and tongue ties are something I deal with a lot. I have personally (with my sons) seen the difference a tongue tie release can make - and not getting one can make. We opted not to get my middle son’s done (very long story) and now he is eight and dealing with sleep apnea, teeth grinding, and other airway issues we are now resolving. Would the tongue tie release have prevented all this? Impossible to say.
Professionally; I have seen the good a tongue tie release can do, and I’ve seen the bad. I’ve seen babies referred for one that did not need one and there were major issues after. I’ve also seen moms breastfeeding with so many issues, doctors telling the parents that tongue ties don’t exist, yet they give no other solution - and then the baby gets a release and there is an immediate improvement. I’ve also seen babies get them done with no negative or positive impact.
My approach is to do a thorough assessment of the oral function of the infant, and if there are issues, I typically recommend body work, suck training, etc first to see if there is improvement. If not, I refer to one of a couple providers in our area (with NO kick backs, I assure you) for further assessment and diagnosis if necessary.
I am of the belief that there are long term effects of tongue ties, but I would never recommend a release based on the potential for future symptoms - only current issues. Of course, I cannot diagnose, and I always try to give parents all the information I can to make a decision. I do believe that far too many releases are done without proper before and after care - the release is only one step.
I also believe tongue ties are over AND under diagnosed. Yes, there are some just “in it for the money” but I don’t see that - at least not within the professional circle I work with. There was a dentist that wanted me to refer to them but I didn’t love their approach as it seemed like “everyone has a tie!”
I do think it’s a very complex issue and there are families hurt from both providers who refuse to acknowledge tongue ties can cause issues as well as providers who release every frenulum they see. I often say - it is the function, not the appearance, that matters.
Thank you so much for sharing your first hand experience from the practitioner side including both sides of the discussion. I think until we have more research sharing this type of information is so important in supporting parents.
I have also personally spent thousands of dollars and many, many hours in continuing education on this topic. Not to mention the many unpaid hours I spend with these families during and after the process (to the point where I likely to a loss with these cases).
So it does get frustrating when I get pediatricians saying “she doesn’t know what she’s talking about” when it really feels like they are the ones. I really do try and have a holistic approach toward oral function issues, but there are times where all the suck training and stretches in the world won’t do a thing without a release do. It really is a complex issues, and I appreciate your measured response.
My experience with tongue ties was that most people who you think would be able to correctly diagnose a tongue tie actually aren't trained and experienced enough to do so - in my area (a major metropolitan area of 2 million with two major medical research universities), there are just two dentists who are well-known as being very experienced and trusted (meaning that they definitely have advised no release needed or wait and see plenty of times) who can diagnose and treat properly. I worked with a couple of excellent lactation consultants who were good at spotting them, but obviously couldn't do the treatment. I also found that with my son follow-up care in the form of helping release tight muscles in his neck that had developed from trying to compensate was also important. It's definitely clear that more research is needed because I feel extremely lucky to have had access to good resources and people who knew what they were doing, including a great breastfeeding support group at one of the local hospitals and online support group, but in a different metro area that would have likely been a very different story. Releasing my son's tongue and lip ties was critical to us being able to breastfeed past a year, which I'm so thankful we go to do.
Thank you so much for this thorough review. It’s really helpful to get the full picture. Was there anything in the research related to eating solids and the impact of a tongue tie? It seems a lot of the discussion is around breast-feeding and speech, but I was curious about solids. Thank you!
Great question! I didn’t see any research on this topic, but will dig into it further!
Really excellent review of this complicated issue. Thank you!
You are so welcome. It is an emerging field that we need to know more about.
I appreciate you addressing tongue ties and raising awareness about them. I have Feelings (TM) about them. My daughter, now 3, started off nursing great. Then, despite nursing basically all day beginning at around 2 months, she struggled to gain weight. She spit up a LOT. We were going through all of our burp cloths every single day. Nursing did not hurt me, but I could tell something was off (she has an older brother who had no issues, so I knew what it should be like). The pediatrician thought she had reflux and wanted to put her on medicine for it. I dug into some academic research and found that reflux in breastfed babies is unlikely (like, single digit percentage likely) and that the medications increase the likelihood of brittle bones prone to breaking later in life. The pediatrician and the lactation nurse (that was not her formal job) they have in the office kept pushing supplementing with formula and me practicing various pumping methods to increase supply. That, I knew. what not the problem. And what good is more milk if she spits it up everywhere? So I went to see the actual lactation nurse at the hospital where she was born. And, while allowing my daughter to latch onto her finger, the nurse immediately diagnosed a posterior tongue tie. We began speech therapy (yes, for a 3-month old - it's just stretching exercises) to work as much of it out as we could, then she got the laser procedure. It was fast, and she immediately latched and then did not spit it up (!!!). The post-procedure stretching every 4 hours was brutal, and I don't think we stretched it as far as we could have (it's VERY hard to do this with a wailing baby at 3 am), but she started gaining weight and all was well. She has some speech issues now - normal kid stuff, like the back-of-throat sounds, and it all may be exacerbated from being a pandemic baby who didn't get a lot of exposure to other people's speech outside of our home. Nothing some speech therapy can't help.
You gave the caveat of research that is slow to catch up and not always a randomized trial (quite tough and possibly unethical in some situations here), but I also want to add that the severity of the tongue tie varies. Some are not as far back as others, and, thus, may not be a hindrance to feeding, weight gain, speech, apnea, etc. Some are quite far back; my daughter's was - she couldn't put get the tip of her tongue past her lips at 2 months old. When she born, all was fine, but as her mouth and skull grew, her tongue could not keep up. There were no negative side effects to the procedure. A dentist did it - they know mouth fascia! She also had slight lip and cheek ties, but the dentist determined they were not severe enough to impact feeding and we should do just the tongue, let things settle, and see how she was doing. We did not need to go back for any other procedures. After a lot of crying at the pediatrician's office, including when she warned me NOT to get the procedure done until my daughter gained a little weight (which made no sense to me - how was she to gain weight until she had it done?), the pediatrician afterward admitted it was the right thing to do. I felt like I was swimming upstream in a sea of MDs. It is hard to speak up and against medical professionals, but I felt like she wasn't listening. Later, my husband discussed the whole thing with an Irish friend who said that would have never taken so long to sort out in Ireland. There are more doctors of osteopathy, and they focus on function and how to solve the problem rather than American MDs who find a symptom (in this case, the spitting up) and throw a pill at it. This is an oversimplification, of course, but it does seem that pediatricians aren't taught about posterior tongue ties in med school. My daughter was born with torticollis, too, that went unaddressed for a while, and I think they're all related because all of our fascia is connected. During her anatomy scan, she had a thick neck, and there was a concern she may have one of several frightening chromosomal abnormalities (to add to the emotional turmoil, the scan was on my 35th birthday at the end of March 2020). It turned out she was just crunched in there with a squished neck; whether the tight fascia was because of the posterior tongue tie or something else, I'll never know, but, again, I assume it's all related.
If you've read this far, thanks for listening. It was all a lot at the time, and it was covid times; I was home with a 3yo and a newborn and had no family to help. I wanted to share my story so that other parents aren't afraid of the procedure if their kid really can benefit from it.
Also, I'm writing this as I bake pies for Thanksgiving, so forgive me if this stream of consciousness is messy.
Thank you so much for sharing your journey. I learned so much from your comment on other things to consider and ways we can improve the research and the services that are provided. I so appreciate the time you took to share this.
This is an amazing resource. We did the procedure when my daughter had orthodontic work but know I wonder if it was related to some of her feeding difficulties!
The research in this is so slow to come out. I was glad to pull together what is out there in one place.
My 2 yo nephew had the laser procedure to release his tongue tie a week ago. He did struggle with breastfeeding but my SIL switched to formula when he was 2 mo.
My oldest did not have a good latch, and I think most of our problems were caused by that- we used a shield and then he had some oral/motor issues that led to me switching to pumping at 3 months old and to formula at 5.5 mo. He turns 7 in 6 weeks. The lactation consultants in the hospital made me very uncomfortable but they were nicer to me when I made an appointment. He was a 5.5 lb baby at birth so there was a lot of concern about him dropping too much weight, but it’s hard to believe now as he’s a high percentile kid.
My youngest (now 4) had an easier time nursing but he took 3 weeks to get back up to birth weight so they had a health visitor come to weigh him a few times. They never suggested my kids had a tongue tie but I had a lot of friends get the procedure for their infants.
Thank you so much for sharing your story. The breastfeeding path is such a difficult one and I just wish there was more access to lactation consultants who are cross trained!
That is something that I found shocking--with how common tongue ties are how few people in the pediatric world understand them. We need so much more education! Thank you for sharing your lessons learned
Excellent review, Dr. Goodwin!
Thank you for this well written post on a difficult topic due to the low-quality research available to make evidence-based decisions. As a pediatrician I find that occupational therapists can help with infant feeding problems in ways that lactation consultants cannot. If breastfeeding is not improving after working with lactation but I do not think tongue tie is the cause, I will refer to OT. I do recommend (and perform) frenotomies when the tongue movement is limited, and an instant improvement is often seen when the procedure is indicated. Despite being able to do these (and making money from them) I recommend against them often because having feeding problems does not mean they are from a tongue tie. Clipping the frenulum is not going to give a quick fix if it is not the problem, regardless of what some mom friends and lactation consultants may advise. Too often I see parents who took their baby to a dentist before talking to me about the procedure and they are frustrated that the feeding didn't change after the clipping. I advise that parents talk to their pediatrician and let them assess the tongue and talk to you about breastfeeding before doing any procedure to avoid unnecessary risks.