The topic of posterior tongue tie (and lip tie) is a controversial one. Research is limited and opinions are divided. As an IBCLC/CST, my intention is to help mothers meet their breastfeeding goals and to minimise unnecessary harm to babies. I have worked with mums who have decided to release their baby’s posterior tongue tie (with laser frenectomy) and it has made all the difference in their breastfeeding journey! Any temporary pain or stress caused by the procedure is offset by the benefits of breastfeeding for longer. However I do have concerns around some current practices and feel there are important things to be considered before undertaking tongue tie release, especially posterior tongue tie release.
1. Have breastfeeding issues been assessed by an IBCLC?
Babies with feeding problems who are to undergo a laser frenectomy need a full feeding assessment by an IBCLC. It is not enough to only assess the mouth. A full feed needs to be observed by someone who is comprehensively trained. There needs to be clarity that it is the impact of the tight frenum under the tongue that is causing feeding issues, such as nipple pain and poor milk transfer. An IBCLC can help to rule out nipple infections, positioning and attachment issues or anything else that could potentially avoid surgery.
Non-surgical management strategies can be effective first-line therapies for management of functional limitations associated with ankyloglossia. Surgical management should be considered only after non-surgical management has failed to address the functional issue that led to the diagnosis.
ADA Statement
2. How do you feel about doing any oral exercises that may be prescribed after the procedure?
The prescription of routine stretches/exercises after a laser frenectomy varies between providers. Some do not advise to do them at all; others will recommend three times a day for a week and others are advised to do them six times a day for weeks. These are well intentioned, with the idea that they will prevent the lingual frenum from reattaching or scarring, and thereby avoid a repeat procedure. The recurrence rate of needing a repeat frenotomy is 2.6% to 13% of cases. But there is no scientific evidence to prove that they prevent reattachment. In fact, this recent study shows no difference between babies who had post frenotomy massage and those who did not. However, it is interesting to note that only 43.5% of those advised massage adhered to the massage regimen. Many parents, instinctively, are not comfortable with performing the aftercare.
And what of the risks? In my experience, they can cause oral aversion and exacerbate feeding issues. Babies are very orally sensitive. We need to respect when they are telling us “no”. Overriding this can potentially disrupt the parental bond. As a craniosacral therapist, working with the nervous system, I have a unique perspective as I can assess the nervous system and have noticed the impact of persistent stretches on (some, not all!) of the babies that I have worked with. Like adults, babies do respond differently to challenges and some babies do not seem disturbed by the aftercare. Those that find it stressful respond with a fight or flight response. And others , because they are physically unable to run away or fight, can easily shift into freeze – a dissociative state. Both fight or flight and freeze are protective survival mechansims and are meant to be temporary. With care and sensitivity the body can integrate any trauma with minimal lasting impact. Undergoing a laser frenectomy can be a difficult experience for both mother and baby. I believe that regular stretches for weeks afterwards has the potential to interfere with the integration of the trauma, instead driving it deeper into the body.
3. Have you thought about organising bodywork for your baby before and after the procedure?
Bodywork, such as craniosacral therapy, beforehand may address issues such as myofascial tightness (eg. jaw or neck tightness), cranial nerve dysfunction, birth trauma or other stresses that can impact breastfeeding. Then, if no improvement in feeding, laser frenectomy can be trialled, as a last resort. If babies do need to undergo laser treatment for tongue tie , just one session of cranio afterwards can help them to integrate the experience, bringing them out of fight or flight or a dissociative state. This has lasting positive impacts on feeding and the nervous system.
4. Are you considering laser frenectomy for feeding problems or to prevent future issues?
Parents may feel they need to to treat posterior tongue tie to prevent future speech or dental issues. These aren’t yet substantiated by evidence. Social media perpetuates this fear. In my opinion, the only reason to treat posterior tongue tie in babies is for feeding issues.
“Further research is needed regarding other reported adverse health outcomes, such as problems with speech, malocclusion, lingual gingival recession and obstructive sleep apnoea as evidence of a consistent causative relationship is lacking. No evidence exists to support buccal or labial frena1 causing problems with feeding or speech.”
ADA statement
Laser frenectomy (compared to scissors frenotomy) needs much more consideration as it is a more invasive procedure. A holistic approach is preferred, taking into account the physical and emotional needs of the parents and the baby. Parents will need to make a decision taking into account the risks of the procedure, versus the benefits of breastfeeding. Every family is different and will choose differently. It is my intention to provide information so that parents can make an informed choice and have no regrets about their decision.
My preferred referral option is to a provider that:
- Requires a thorough assessment by an IBCLC before the procedure.
- Does not recommend invasive oral aftercare and;
- Recommends bodywork (eg cranio) before and after a procedure.
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Footnotes:
- Despite no evidence, I have seen lip ties interfere with attachment/seal at the breast and contribute to decay at the top of the central incisors.
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