Making Sense of Conflicting Advice About Tongue Tie

Dr Helen Fung

If you have been reading about tongue tie, you have probably found strong opinions pointing in both directions. Some articles warn against releasing tongue ties in newborns at all. Others treat a release as the answer to almost any feeding problem. Neither is much help when you are the one trying to feed your baby at three in the morning.

A tongue tie is only one of the possible reasons feeding is hard, and it is worth saying plainly that it is sometimes diagnosed when it is not the problem. What matters is that somebody looks carefully at the feeding itself, early, before anyone reaches for a pair of scissors.

Breastfeeding is not simply a matter of checking that the baby’s weight is going up. Weighing a baby is quick, cheap and genuinely useful, and it answers one question well: is this baby getting enough. It does not answer why the baby cannot attach, why a mother’s nipples are blistering or bleeding at each feed, why she keeps getting mastitis, or why a baby is still crying after an hour at the breast. Those questions take time and a particular kind of training, and most general practice is not set up to provide either.

Lactation Consultants, on the other hand, have spent years learning the anatomy and physiology of breastfeeding, as well as thousands of practical hours under supervision as part of their training on breastfeeding and bottle feeding. It is their profession to monitor mothers breastfeeding, offer suggestions on how to better position themselves and their baby, explain the causes of each symptom, and offer solutions to each problem. It is this knowledge and dedication that makes a Lactation Consultant a wonderful ally for any mother struggling with breastfeeding.

The modern scientific history of tongue ties may be brief, but tongue tie and frenotomies have been mentioned in numerous written documents that precede the modern medical literature. For centuries, breastfeeding was the only way to feed a baby, and the presence of a tongue tie restricting the ability of a baby to extract milk from the breast, was a matter of survival. Releasing tongue ties was a routine procedure to enable the baby to feed and hence stay alive. It was only with the invention of rubber teats, and the development of commercially available formula, that the babies with tongue ties were able to have an alternative. This caused a dramatic reduction in frenotomies, along with the declining rate of breastfeeding. Where 90% of infants were breastfed in the 1900’s, it had decreased to 42% in the 21st century. At the same time, the formula business has developed into an enormous industry, worth US$44.8 billion in 2014.

In recent years, the atmosphere has started to change again. In modern research, human milk has been recognised as the best source of infant nutrition, and the current medical research indicates that formula fed babies have an increased risk of developing atopy or hypersensitivity, diabetes mellitus, and childhood obesity. Similarly it has been discovered that breastfeeding protects nursing women against breast cancer, and may also protect against ovarian cancer and type 2 diabetes. It has been this new knowledge and the recovering rates of breastfeeding, that has caused the need for tongue tie releases to increase again.

The body of evidence on tongue tie and its treatment is still developing, but it is no longer as thin as it once was. A Cochrane review of frenotomy has since been published, finding a short-term reduction in nipple pain for mothers but no consistent improvement in infant feeding on standardised measures. In 2020 the Australian Dental Association, together with paediatric dentists, lactation consultants, midwives, speech pathologists and surgeons, produced a national consensus statement on diagnosis and management. The direction of that work is towards more careful diagnosis and non-surgical support first, rather than towards more procedures — and that is a good thing for families, not a threat to them. Collecting evidence is time consuming and challenging however, as there are a number of issues to the researching bodies. For example, it is almost impossible to randomly assign a breastfeeding dyad for the purposes of a study. Which struggling parent would accept the diagnosis of a condition, and then allow someone else to decide whether to accept the symptoms and persevere, or proceed with treatment, for the sake of collecting data?

Helping mothers feed their babies is a collaborative effort between a number of health professionals: learning about the issues surrounding breastfeeding, documenting formally what was once accepted as common sense, and passing on knowledge that was once simply picked up as part of growing up in a community. The common goal is to give mothers the means to feed their children comfortably — and, where it turns out that no procedure is needed, to say so clearly.

Making Sense of Conflicting Advice About Tongue Tie

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