Oral Motor – South Lakes Speech & Language Therapy

As a speech and feeding therapist, I regularly am asked whether a tongue-tie may be a factor in a child’s speech or feeding difficulties. Over the course of my career, I have completed additional training in tongue-tie and have worked alongside colleagues who sit on both sides of the tongue-tie debate. Increasingly, I find myself squarely in the middle which got me thinking; why are tongue-ties controversial and why do we not have a definitive, universally agreed upon way to diagnose and manage tongue-ties in children?¹

A Brief History of the Tethered Tongue

If you are wondering whether tongue-tie is a fad or a condition with historical roots, wonder no longer! Almost 2000 years ago, Cornelius Celsus, a Roman encyclopaedist, described ankyloglossia or what we more commonly refer to as ‘tongue-tie’. A reference to tongue-tie can also be found in the bible, where it is noted that speech was improved when “the string of his tongue was loosened”.² As early as the 1600s tongue-ties were regularly treated in newborns with midwives keeping one fingernail longer and sharper to cut a tethered tongue.² ³ However in the 1900s, as formula milk grew in popularity, this practice fell out of favour.²

The diagnosis and medical management of tongue-tie has ebbed and flowed with many linking it to the rise and fall of breastfeeding rates; in other words, when breastfeeding is more common, so is the diagnosis and treatment of tongue-tie.⁴ So, where does that leave ankyloglossia today, at a time where The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life?⁵ You guessed it, diagnosis and treatment of tongue-tie has sky rocketed in the developed world. It is estimated that between 4% and 11% of babies are born with tongue-tie.⁶ With one study finding an almost 10-fold increase in the diagnosis of ankyloglossia between 1997 and 2012 and a further doubling between 2012 and 2016.⁷ As the diagnosis of tongue-tie increases, so do the number of tongue-tie surgeries with rates of tongue-tie surgeries more than quadrupling in high-income countries over the past ten years.⁶ This increase in tongue-tie diagnoses and surgical procedures however, is not without controversy.⁸

An Agreed Upon Definition and Response?

Surprisingly (or perhaps not so surprisingly) the controversy over tongue-tie starts with the definition. Most professionals agree that a tongue-tie involves an abnormally tight lingual frenulum, the band of tissue that connects the tongue to the floor of the mouth; but that is where the agreement ends. Some tongue-ties are attached close to the front of a person’s mouth with a visible short and tight lingual frenulum (resulting in a heart shaped tip of the tongue); while others are attached toward the back of the mouth where the lingual frenulum may not be visible but there is restricted tongue movement (a ‘posterior tongue-tie’).⁹ So, the question becomes, ‘Should we diagnose a tongue-tie when we see the ‘tie’, or should we diagnose a tongue-tie when we ‘see’ decreased tongue function?’ (Professionals have yet to agree on an answer to this.) And, ‘What do we do when we diagnose a tongue-tie?’

The most common and immediate fix for a tongue-tie is a lingual frenectomy which involves cutting or lasering the lingual frenulum. For babies under 6 months, this generally can be done as a part of an office visit with a skilled practitioner, but older babies and children will need an anaesthetic.¹⁰ Following a lingual frenectomy, most practitioners recommend specific aftercare to prevent re-attachment.¹¹

But, does every tongue-tie warrant a lingual frenectomy or are there some tongue-ties that can be managed with specialist input and a ‘wait and see’ approach? And how do we know which is which? (Professionals have yet to agree on an answer to this as well.)

Commonly Agreed Upon Symptoms

Despite not agreeing on a definition or response, there are a generally agreed upon set of symptoms of a tongue-tie (although not every person has every symptom). These include:¹² ¹³

Difficulty with breastfeeding for both baby and mother.
Difficulty managing solid foods, especially as a part of early weaning.
Poor oral hygiene for older children and adults (due to an inability to use the tongue to clear food from between the teeth and cheek).
Difficulty producing speech sounds that involve the tongue tip making contact with the roof of the mouth such as ‘t, d, l, and n’.
Difficulty with other activities involving specific tongue movements such as licking an ice cream cone, licking one’s lips, and playing a wind instrument.
A change in oral structures such as the palate, jaw, and teeth (due to an altered resting position of the tongue).

Given this list of clear symptoms, you may wonder why diagnoses and treatment is controversial; can’t we simply agree that a person with the above symptoms has a tongue-tie (and ‘fix’ it)? Unfortunately no, we can’t. Many of the above symptoms can have causes other than tongue-tie, and delaying investigation of other causes in favour of immediately defaulting to tongue-tie as the cause can delay the individual receiving the appropriate treatment (and may put the person through an unnecessary medical procedure).

What Does this Mean for My Child?

The answer to this question is not simple and depends on what medical professional your child sees (much like the answer to the questions of how we identify and treat a tongue-tie). I have met parents whose child had a lingual frenectomy and they found that following the procedure their child’s symptoms improved or resolved; other parents I have met whose child had the procedure reported little or no difference in symptoms. Some families I have worked with who have been offered the procedure and declined, have found that their child’s symptoms improved with therapy and time.

As I finish writing this, I find that I am no closer to shifting my ‘middle of the road’ position when it comes to tongue-ties. Children who have difficulty with feeding or speech need a thorough assessment, including an oral motor examination. If a tongue-tie is identified or suspected, parents should be given the opportunity to discuss their child’s symptoms with a practitioner who specializes in tongue-ties and performs lingual frenectomies to determine whether this is an appropriate consideration for their child. Equally, their child needs quality feeding or speech therapy to directly address their symptoms and improve outcomes whether or not a lingual frenectomy is performed.

If you have concerns for a tongue-tie in your child and would like information about feeding or speech therapy with South Lakes Speech & Language Therapy, please get in touch. Follow us on Facebook for speech, language and feeding tips and sign up for South Lakes Speech & Language Therapy’s newsletter if you would like new posts sent directly to your inbox.