Tongue-Tie—The Disease du Jour

Ankyloglossia or tongue-tie is the presence of sublingual frenulum, which causes a change in appearance or function of the tongue. The frenulum is shortened, inelastic, thickened, or positioned toward the tie of the tongue or close to the gingival ridge. The average dictionary does not include the word, but the word ankylosis is described as the consolidation of bones or tissue to form a single unit. The incidence of tongue-tie is estimated as 3–5% of infants.

Historically the attention paid to this anchoring of the tongue to the floor of the mouth has varied over the decades. In the 1940s and 1950s, there was concern that a tight tongue would cause speech problems as the child grew up. As a result many obstetricians would inspect the mouth of the newborn, take the scissors off the Mayo stand, and snip the frenulum before handing the infant over to be dried and measured. Most babies were bottle-fed in this era. The speech pathologists protested, and gradually the process was abandoned.

As breastfeeding has returned to its proper place in the nourishment of the infant, attention has been drawn to the tongue. The proper undulating or peristalic motion of the tongue is used to eject milk and propel it posteriorly, down the esophagus, and into the stomach promoted by the peristalic motion of the gastrointestinal track. Concern for proper latch, correct positioning, and smooth suck and swallow became important to lactation management. ¹ At first, infection with Candida albicans (thrush) was blamed for the pain some mothers experienced while nursing. Antifungal treatment was initiated without benefit of a positive culture. The diagnosis in vogue was thrush for several years. Now the paradigm has shifted.

It has been said when all you have is a hammer, everything looks like a nail.

There is considerable controversy regarding tongue-tie as a diagnosis, the indications for treatment, and the method of treatment. Treatment options include frenulotomy by clipping or laser. The conversation has broadened to include the clinical description, definition, and diagnosis of posterior tongue-tie and suffers from little research and no blinded controlled studies. The Academy of Breastfeeding Medicine has a tongue-tie protocol for dealing with the dilemma of anterior tongue-tie that thoroughly reviews the empirical evidence around ankyologlossia (Protocol #11). ²

In this issue, Douglas from Australia speaks out on “Rethinking 'posterior' tongue-tie.” ³ It is a very modest, thought-provoking review of the issues from diagnosis to treatment and possible lasting complications. Does the evidence support the treatment of posterior tongue-tie, and if so, how should it be performed? Who is best able to make this decision? The primary care physician, the ear-nose-throat expert, or a dentist? It is clear that only the infant's physician can assess all aspects of the clinical presentation and needs to be the captain of this ship if we are to avoid the perfect storm.