Introduction

As parents, we closely observe our infants’ growth & development milestones, including their oral motor skills.

Tongue-tie can affect anyone;  it is more common in boys than girls. Tongue-tie sometimes runs in families.

Tongue tie¹/ankyloglossia, crooked or looped tongue) It is common in babies. It may not cause any problems, but if it does, treatment is available.³

Tongue tie is a condition that limits the function of a baby's tongue. When a baby’s tongue can’t move because the piece of skin ( lingual frenum) that connects the bottom side of the tongue to the floor of the mouth is shorter or tighter than usual. It can affect a baby's ability to feed, swallow & develop proper oral motor skills.² Early detection of tongue-ties is so important; If you live with a restricted frenulum, over time, you will begin to develop negative habits to compensate for the tongue's restricted range of motion.

Understanding tongue tie

Typically, the lingual frenum separates before birth. allowing a free range of motion, but in tongue-tie, it remains attached to the bottom of the tongue.to cause restricted tongue movements.

Types of tongue tie 

1. Kotlow’s assessment is based on the distance from the tip of the tongue to the frenum
   • Mild tongue tie: distance is about 16mm & tongue mobility is only slightly restricted . It may not cause significant tissue changes and sometimes goes unnoticed
   • A patient may feel that struggling to clean their teeth leads to dental issues
   • Severe tongue tie: distance is 3-7mm. Restricted tongue movement.  Tongue tie causes severe challenges in the development of speech, eating  & breastfeeding. Potential dental issues due to poor oral hygiene
   • Complete tongue tie: distance is less than 3mm. The tongue is completely immobilised since the frenum is thick.  movements restricted, major difficulty in feeding, speech, and poor oral hygiene. It is recommended in infants & kids to avoid complications⁶
     • Frenulum: The frenulum attaches 2-4 mm from the tip of the tongue to the floor of the mouth.  The tongue movements, leading to difficulty in feeding, speech, or eating
   • A noticeable difficulty in feeding, speech, seeing, and severe oral malocclusion, gum problems due to a lack of tongue movements
   • Type Ⅳ frenulum/posterior tongue tie: the frenulum is located farther back & visible only through examination. can be felt under the mucous membrane when touched.  Posterior tongue tie causes similar complications and requires more nuanced diagnostic approaches like manual examination & posterior imaging techniques
2. Based on the location  of the tie
   • Anterior tongue-tie
   • Posterior tongue tie

How tongue tie affects oral motor skills

• Feeding difficulties:⁸ Babies with tongue tie may struggle with feeding, often gaining weight slowly despite long and frequent feeding sessions. They may appear unsettled or unsatisfied after feeds. Common signs include excessive dribbling during feeding, pushing the nipple or bottle teat out of their mouth, and frequent choking on feeds
• Speech issues:⁹ Tongue tie can make it difficult to pronounce certain sounds clearly,  interfering with the ability to make '’'t,' d,' ’z,' 's,' ’th,' ’n,' and ’l”. This leads to speech delay & unclear articulation
• Oral motor coordination: Since the tongue plays tasks like speaking, drinking, and chewing, a limited range of motion can hinder coordination, leading to difficulties with daily oral activities
• Orofacial development: Tongue tie influences the development of orofacial structure,  including the jaw, palate, & teeth. The continuous pressure exerted by the tethered tongue leads to narrow dental arches,  misalignment of teeth,  and orthodontic problems

 Diagnosis & treatment options

• Treatment of tongue-tie is controversial;  some doctors & lactation consultants recommend treatment at the right time, even before being discharged from the hospital, while others take a wait-and-see approach
• The lingual frenum may get loose over time, resolving tongue tie
• If tongue tie persists, not causing much problem, consultation with a lactation consultant can assist breastfeeding. Speech therapy by a speech language pathologist  to improve speech sounds
• Surgical approach: If the tongue tie  causes problems
  • Frenotomy: It can be done with or without local anaesthesia, in the doctor's office or hospital nursery. Additional repair is needed; if it is done under general anaesthesia with surgical tools. Frenuloplasty, tongue exercises may be indicated to improve tongue movements                                                                                                              

Long-term effects of an untreated tongue tie

The longer a person lives  with a tongue tie, the more widespread the negative impact could be       

• It impedes speech development,  mouth breathing and severely aligns teeth (overbite, spacing of teeth)
• The most devastating health consequence is snoring, obstructive sleep apnea
• Acid reflux, heartburn,   and hernias are the long-term consequences of swallowing problems¹¹
• Long-term effects on overall health:  chronic oral & facial muscle tension,  poor digestion, and even postural issues associated with compensatory behaviour due to the restricted tongue movements

By undergoing myofunctional therapy¹³ post-release,  individuals can restore proper muscle function & mitigate long-term potential complications.

FAQs

Will it be painful for our babies?

We thought that the frenum does not have many nerve endings until babies are older. We believe that procedures are not painful for babies, but they can feel that something has been done & will often cry very briefly.  The procedure itself usually takes about 3-4 seconds, We will aim to feed babies immediately afterwards to minimise the discomfort & reduce any bleeding.

Some babies can be unsettled or fussy in the hours after the procedure.  may wish to feed more frequently or not feed as much for a while. Skin to skin, lots of cuddles,  calming measures, and relaxed feeding will all help if this is the case. Babies over 8 weeks can have paracetamol if needed, but this is often not required.

Will there be bleeding?

There will often be a few drops of blood collected under the tongue after release. This generally stops quickly with feeding; some need a few minutes of pressure applied under the tongue.

What will it look like afterwards?

After tongue-tie release, we will see a diamond shape under the tongue. After a day or two, it usually becomes a white or yellow ulcer or no ulcer.

What are the risks?

Complications are rare; we will always talk through the potential risks of the procedure. Before consent, we will discuss ways to minimise these risks          

• Bleeding: There are often a few drops of blood; this generally stops very quickly with feeding. Bleeding is a recognised risk, although this is extremely rare
• infection: Cases of infection are extremely rare, especially if giving breast milk, as this has many protective factors, but it is a good practice after the procedure to ensure that any bottles, dummies, etc., are sterilized before use, and that infant formula is prepared safely with hot water to ensure that there is no bacterial contamination
• Reattachment: Reattachment is uncommon but can occur, although not all babies with some reattachment will require a second division

What is the difference between ‘anterior’ and ‘posterior’ tongue tie?

Anterior tongue-tie describes a prominent restrictive frenulum, which can be seen more easily towards the front of the tongue. Posterior tongue-tie describes a restrictive frenum that is further back underneath the tongue. When assessing for any restriction, it is important to fully assess tongue movements and function, rather than judging on appearance alone.¹³

Summary

The tongue-tie is a congenital condition; the frenum that connects under the tongue to the floor of the mouth is short & tight. 

Babies with tongue tie may have problems with latching for both breast & bottle feeding. This can prevent them from getting enough nutrition.  Latching difficulties can also cause pain & discomfort for the breastfeeding parent,  who may feel they need to stop feeding. 

As infants grow, tongue tie can influence the development of sounds & language skills.

Tongue tie is diagnosed during clinical examination. In infants, doctors may need a screening tool to score various aspects of tongue appearance or the ability to move. The accurate diagnosis & treatment at the early stages of childhood can make a change in someone's overall well-being in life.