Tongue ties, oral ties, buccal ties, and baby sleep.
Tongue ties and infant sleep
When I had my first baby in 2007 no one was talking about tongue ties, my daughter struggled to latch, she was probably a prime candidate to be checked for a tongue tie. By the time my second was born in 2009 people were talking and my daughter was checked and had her tongue snipped. Did it help her with breastfeeding? Nope, she still failed to thrive and needed to formula fed….
She was my most unsettled newborn, correlation…probably.
In 2012 I had my third baby, and by this stage we had moved from chatting about just tongue ties, to posterior tongue ties and lip ties. He was not transferring milk properly, we saw an IBLC who booked us to see ENT at starship hospital, by the time I saw the ENT I had decided to pump and bottle feed and I was happy with my decision, so ENT said to come back in 6 months and they would check if he had naturally stretched out his tongue, and he had.
Fast forward to 2021 and we are not only talking about tongue ties, and lip ties, and….. posterior ties, were talking about buccal ties, encompassing these all as “oral ties”.
Thanks largely to social media, and the sharing of misinformation…. The list of ailments we blame on tongue ties has moved from poor latch and difficulty transferring milk while breastfeeding, to now include, reflux, colic, wind, poor sleep, migraines, mucous baby poo, excess crying, difficulties eating solids, posture, speech problems and more.
This fear mongering when it comes to oral ties has led to a staggering 420% increase in frenotomy surgeries in Australia between 2006 – 2016.
In NZ the Christchurch womens hospital recorded an increase to 12% of ALL babies receiving a frenotomy surgery by 2015......despite the evidence showing that between 1-11% of infants will be born with a tongue tie, and up to 40-75% of that 1-11% will go on to breastfeed successfully. Why were 12% of all babies born leading up to 2015 having tongue tie surgery?
Furthermore the increase in frenotomy surgeries was not showing an increase in breastfeeding rates. These rates remained static from 2013-2015, around 72% were exclusively breastfeeding at 6 weeks.
In 2015 in response to this incredible rise in frenotomy surgeries in young babies, a multifaceted program was initiated in Canterbury. This program offered mothers of babies with breastfeeding difficulties better care. The concern of those involved was that mothers were experiencing delay in access to the best breastfeeding support due to an extreme emphasis on tongue tie surgery.
The research found that there were inconsistencies in the anatomical description and assessment of tongue function, and it was apparent that frenotomy was viewed as quick fix.
This notion that surgery will solve your complex breastfeeding difficulties was found to be fueled by an online bias to surgery, creating unrealistic expectations for parents.
To correct these inconsistencies the study recommends all medical professionals diagnosing tongue ties used the universal BTAT system which evaluates tongue function.
Bristol tongue tie assessment tool
Appearance of tongue tip
Attachment of frenulum to lower gum edge
Attachment at top of gum ridge
Attachment to inner aspect of gum
Attached to floor of mouth
Lift of tongue wide to mouth view (crying)
Minimal tongue lift
Edges only to mid mouth
Full tongue lift to mid-mouth
Protrusion of tongue
Tip stays behind gum
Tip over gum
Tip can extend over lower lip
Total score of 0–3 indicates severe reduction of tongue function
Coryllos classification allows medical professionals to classify the type of tongue tie.
Type 1 Attachment of the frenulum to the tip of the tongue, usually in front of the alveolar ridge in the lower lip sulcus
Type 2 Attachment of the renulum 2–4 mm behind the tongue tip and on or just behind the alveolar ridge.
Type 3 Attachment to the mid-tongue or middle of the floor of the mouth.
Type 4 Attachment against the base of the tongue, thick, shiny, and very inelastic.
This change in assessment and increase to provide community breastfeeding support was evaluated in a 2017 audit.
The numbers showed the program had lowered the rate of tongue tie surgery from 10.2% in 2014 to 3.5% by 2017. This showed that they could lower the frenotomy intervention rate without negatively impacting on breastfeeding.
Since the launch of this program, and consistent assessment criteria, canterbury’s breastfeeding rates have risen to 75%. Less babies receiving unnecessary surgery, more babies receiving breastfeeding support, and an increase in the breastfeeding rate. Win win!
But what led to the situation of mass increase in tongue tie surgeries?
Some believe the rise of social media has allowed misunderstandings to spread like wild fire. A common misunderstanding is that a visible lingual frenulum (that bit of flesh holding your tongue to the floor of your mouth) means you have a tongue tie. But we now know without a function assessment this is just wild guessing!
But this misinformation spread and confusion creates anxiety in already anxious parents, and as newbies to breastfeeding we start to expect breastfeeding problems, then view the surgery as a quick fix, when in reality some infants just take a few weeks to settle into a confident breastfeeding pattern.
Is there a financial incentive behind the rise in tongue tie surgeries? Dr Pamela Douglas Dr MBBS FRACGP IBCLC PhD, points out that private tongue tie revisions are lucrative. $500 to $900. She states “I don’t think we can completely ignore the financial incentive that many of these practices have.”
What does the research say about tongue tie surgery?
There is a distinct lack of research that displays a consensus…. This is a problem in itself.
The second problem is the research is usually relying on self reports of improvements, and if you’ve ever breastfed a baby you’ll know that one thing that often helps… is time!
Dr Messner has pointed out that because we wait a couple of weeks before collecting data on breastfeeding improvements there is a real risk that the improvement would have come even without the surgery.
A recent Cochrane review of frenotomy in new-borns concluded that it “reduced breastfeeding mothers’ nipple pain in the short term,” but the investigators did not find a consistent positive effect on infant breastfeeding.
[ O’Shea, JE, Foster, JP, O’Donnell, CPF, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database of Syst Rev. 2017;(3):CD011065. ]
A systematic review evaluating frenotomy for reasons other than breastfeeding found that “data are currently insufficient for assessing the effects of frenotomy on non-breastfeeding outcomes that may be associated with ankyloglossia.
[ Chinnadurai, S, Francis, DO, Epstein, RA, Morad, A, Kohanim, S, McPheeters, M. Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review. Pediatrics. 2015;135(6):E1467-E1474.]
In 2020 the American academy of ear nose and throat surgeons set about forming some consensus statements due to the conflicting advice around tongue ties.
A few interesting statements came out of this study ….
There was a strong agreement and consensus among the members of this panel that breastfeeding mothers are a vulnerable population, and they needed proper support, education, and counselling when it came to making decisions about breastfeeding and tongue ties.
This panel easily reached consensus that pain and poor latch can be caused by a tongue tie, but also these problems can be caused by other factors. The panel explains that it is also very clear that not all infants with a tongue tie will experience breastfeeding problems. Many babies with a tongue tie feed perfectly without any surgery.
The group of experts agree that a full history should be taken when assessing a baby for a tongue tie and breastfeeding problems.
It is pointed out that experienced breastfeeding mothers will say their tongue tied babies latch feels different. Furthermore, we need to ensure that all infant factors are considered when there is a difficulties or pain with breastfeeding. Prematurity, abnormal palatal, mandibular or maxillary development, neurologic disorders, and upper air way obstructions.
You can see why when you consider this list, it is dam scary that mums with no medical backgrounds are running Facebook groups and diagnosing tongue ties, and recommending mothers seek private assistance with surgeries, bypassing a proper assessment.
This panel also concluded that mothers should be given options when it comes to treatment of tongue ties.
These options include observation, (this is one option I chose with my son, we waited 6 months and he resolved the issue himself) lactation consultation, and possibly speech and language therapy. Evidence supports the fact that a lot of the time breastfeeding can improve with these non-surgical interventions.
One interesting term we hear being thrown around in 2021 is “buccal tie”.
This is the perceived tightness of the maxillary and mandibular buccal frenula. These “ties” are what we commonly think of as a lip tie, and the second is a bottom lip tie. See the image below to make sense of this yourself. These connective tissues support the muscles in the face (buccinator) during important phases of swallowing.
The American academy of ear nose and throat surgeons state the importance of this function is shown by evidence that manual cheek support enhances suction during breastfeeding, therefore it is illogical to cut these “ties” to aid in breastfeeding problems. There is currently no criteria used to decide if this connective tissue is restrictive and therefore the panel reached a consensus that they do NOT recommend releasing the buccal frenula (Buccal ties).
What about sleep?
After all, you are on a sleep consultants blog….
I see hundreds of comments blaming frequent wakes, short sleeps, difficulties settling on tongue ties.
Lets get to the bottom of this….
If your baby has a tongue tie that is preventing them from being able to transfer milk properly, and they are not gaining adequate weight each week, or they’re dropping percentiles on their growth chart….then yes. Quite possibly they are waking frequently due to hunger, and we’ll need to get on top of the feeding before we can get on top of the sleep. This is why we always do a thorough intake when we work with you one on one.
If your baby is thriving and gaining weight, and can happily go 3-4 hours between feeds, there tongue tie is not waking them, and they aren’t hungry.
Some dentists will talk about obstructive sleep apnea when encouraging you to get a tongue tie surgery. They are presuming that a short frenulum (the connective tissue under the tongue) holds the tongue to the floor of the mouth, resulting in a narrow palate (roof of your mouth). The roof of the mouth is where your tongue is meant to sit while you sleep, and you are physiologically designed to nose breath while you sleep.
While it is true that a narrow palate can contribute to OSA, currently only one single study has shown an association between tongue ties and OSA.
The problem here is, it’s a retrospective study.
That means looking at people who have OSA and then looking for the tongue tie. There is no evidence the tongue tie caused the OSA or the narrow palate. Therefore, the ENT panal came to a consensus there is no evidence tongue ties cause OSA. They even warned that to some extent the connective tissue under your tongue serves to prevent the back on your tongue collapsing and blocking your airway, and releasing a frenulum “could” lead to worsening OSA.
I appreciate this has been a LOT of information to read. I also appreciate as a mother of 3 babies who ALL struggled to breastfeed, that breastfeeding is hard, and you are bombarded with suggestions and advice from all corners of your world.
As with every topic I cover, I believe knowledge is power.
The more knowledge and education on a topic we have, the more we are able to critical think when people give us well meaning advice. We can seek out the professionals who can follow best practice and evidence based guidelines to help us with any breastfeeding or sleep difficulties.
Emma is the owner and founder of Baby Sleep Consultant, she is a Certified Infant and Child Sleep Consultant, Happiest Baby on the Block Educator, Royal Children's Hospital in Melbourne Certificate in Infant Sleep, a Bachelor of Science, and Diploma in Education.
Emma is a mother to 3 children, and loves writing when she isn't working with tired clients and cheering on her team helping thousands of mums just like you.
Our Baby Sleep Program helps tired parents TO DEVELOP HEALTHY SLEEP HABITS BY FOCUSING ON NAPS, SETTLING AND NIGHT SLEEP.
- Empowered: Feel empowered as a Mum as you learn to understand your growing baby's needs and cues.
- Simple effective settling: Gentle, proven self settling, evidence based techniques.
- Content happy baby and parents: Better sleep creates content babies & happy parents.
- Freedom: Predictable routines and longer nights creates freedom. Solve your sleep problems for more freedom.
- Work with your babies circadian rhythm: Work with your babies biological clock for faster easier results.
- Awesome naps & nights: You'll create consistent naps and nights with our support.
Try our online sleep program, complete with FREE email support.
References for this blog
R.F. Power, J.F. Murphy
Tongue–tie and frenotomy in infants with breastfeeding difficulties: achieving a balance
Arch. Dis. Child., 100 (2015), pp. 489-494
Canadian Agency for Drugs and Technologies in Health
Rapid Response reports, Frenectomy for the correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines (2016)
J.E. O'Shea, J.P. Foster, C.P. O'Donnell, D. Breathnach, S.E. Jacobs, D.A. Todd, et al.
Frenotomy for tongue-tie in newborn infants
Cochrane Database Syst. Rev., 3 (2017), Article CD011065
L.M. Segal, R. Stephenson, M. Dawes, P. Feldman
Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review
Can. Fam. Physician, 53 (2007), pp. 1027-1033
Sethi, D. Smith, S. Kortequee, V.M.N. Ward, S.I. Clarke
Benefits of frenulotomy in infants with ankyloglossia
Int. J. Paediatr. Otorhinoloaryngol, 77 (2013), pp. 762-765
National Institute for Health and Care Excellence, Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional procedures guidance [IPG149]
Ankyloglossia and breastfeeding
Paediatr. Child Health, 20 (2015), pp. 209-218
Walsh, D. Tunkel
Diagnosis and treatment of ankyloglossia in newborns and infants. A review, JAMA Otolaryngol
Head Neck Surg., 143 (2017), pp. 1032-1039
A.N. Webb, W. Hao, P. Hong
The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review
Int. J. Pediatr. Otorhinolaryngol., 77 (2013), pp. 635-646
D.O. Francis, S. Krishnaswami, M. McPheeters
Treatment of ankyloglossia and breastfeeding outcomes: a systematic review
Pediatrics, 135 (2015), pp. e1458-e1466
Frenotomy may help resolve breastfeeding problems due to tongue-tie
Pediatr., 166 (2015), p. 1322
K.S. Joseph, B. Kinniburgh, A. Metcalfe, N. Razaz, Y. Sabr, S. Lisonkova
Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study
CMAJ Open, 4 (2016), pp. E33-E40 Walsh, A. Links, E. Boss, D. Tunkel
Ankyloglossia and lingual frenotomy: National trends in inpatient diagnosis and management in the United States, 1997-2012
Otolaryngol. Head Neck Surg., 156 (2017), pp. 735-740
Kapoor, P.S. Douglas, P.S. Hall, L.J. Walsh, M. Tennant
Frenotomy for tongue-tie in Australian children: an increasing problem
Med. J. Aust., 208 (2018), pp. 88-89
National Maternity Collection (MAT) Ministry of Health (2017)
Tongue ties-to snip or not to snip? http://www.stuff.co.nz/life-style/parenting/baby/74060883/tongue-ties–to-snip-or-not-to-snip
Haham, R. Marom, L. Mangel, E. Botzer, S. Dollberg
Prevalence of breastfeeding difficulties in newborns with a linguala: a prospective cohort series
Breastfeed. Med., 9 (2014), pp. 438-441
Tongue-tie Morphogenesis, Impact, Assessment and Treatment
Aidan & Eva Press, Columbus, Ohio (2010)
D.J. Madlon-Kay, L.A. Ricke, N.J. Baker, T.A. DeFor
Case series of 148 tongue-tied newborn babies evaluated with the assessment tool for lingual frenulum function
Midwifery, 24 (2008), pp. 353-357
Academy Breastfeeding Medicine
Protocol #11, Guidelines for the Evaluation and Management of Neonatal Ankyloglossia and Its complications in the Breastfeeding Dyad
Ingram, D. Johnson, M. Copeland, C. Churchill, H. Taylor, A. Emond
The development of a tongue assessment tool to assist with tongue-tie identification
Arch. Dis. Child. Fetal Neonatal, 100 (2015), pp. F344-F348
Community HealthPathways. http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/Pages/Health-Pathways.aspx
Tongue-tie in the newborn: what, when, who and how? Exploring tongue-tie division
Breastfeed. Rev., 22 (2014), pp. 7-10
D.A. Todd, M.J. Hogan
Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes
Breastfeed. Rev., 23 (2015), pp. 11-16
Donati-Bourne, Z. Batool, C. Hendrickse, D. Bowley
Tongue-tie assessment and division: a time-critical intervention to optimise breastfeeding
Neonatal Surg., 4 (2015), p. 3
Kupietzky, E. Botzer
Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management
Pediatr. Dent., 27 (2005), pp. 40-46
The Academy of Breastfeeding Medicine
Protocol #11 – Guidelines for the Evaluation and Management of Neonatal Ankyloglossia and Its complications in the Breastfeeding Dyad
McGeoch, I. Anderson, J. Gibson, C. Gullery, D. Kerr, B. Shand
Consensus pathways: evidence into practice
Z. Med. J., 128 (2015), pp. 86-96 1408
McGeoch, P. McGeoch, B. Shand
Is HealthPathways effective? An online survey of hospital clinicians, general practitioners and practice nurses
Z. Med. J., 128 (2015), pp. 36-46
J.K. McIntosh, C. Jacques, J. Mitrani-Reiser, T.D. Kirsch, S. Giovinazzi, T.M. Wilson
The Impact of the 22nd February 2011 Earthquake on Christchurch Hospital
University of Canterbury Research Repository (2012)
N.C. Rollins, N. Bhandari, N. Hajeebhoy, S. Horton, C.K. Lutter, J.C. Martines, et al.
Lancet Breastfeeding Series Group, 2016, Why invest, and what it will take to improve breastfeeding practices?
Lancet, 387 (2016), pp. 491-504
The Council of Medical Colleges, Choosing Wisely. choosingwisely.org.nz/
Buryk, D. Bloom, T. Shope
Efficacy of neonatal release of ankyloglossia: a randomized trial
Pediatrics, 128 (2011), pp. 280-288
Berry, M. Griffiths, C. Westcott
A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding
Breastfeed. Med., 7 (2012), pp. 189-193
Emond, J. Ingram, D. Johnson, P. Blair, A. Whitelaw, M. Copeland, et al.
Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie
Arch. Dis. Child. Fetal Neonatal Ed., 99 (2014), pp. F189-F195
Hogan, C. Westcott, M. Griffiths
Randomized, controlled trial of division of tongue-tie in infants with feeding problems
Paediatr. Child Health, 41 (2005), pp. 246-250
Dollberg, E. Botzer, E. Grunis, F.B. Mimouni
Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study
Pediatr. Surg., 41 (2006), pp. 1598-1600
Walsh, D.E. Tunkel
Tongue-tie and frenotomy: what evidence do we have and what do we need?
Med. J. Aust., 208 (2018), pp. 67-68
Colloca, F.G. Miller
Role of expectations in health
Curr. Opin. Psychiatr., 24 (2011), pp. 149-155
Wattis, R. Kam, P. Douglas
Three experienced lactation consultants reflect upon the oral tie phenomenon
Breastfeed. Rev., 25 (2017), pp. 9-15