Do tongue-tie and oral connective tissue or fascial restriction commonly cause of breastfeeding problems?

True tongue-tie (or ankyloglossia) sometimes causes breastfeeding problems but is not that common

What information can you trust as parents if your baby has been diagnosed with tongue-tie or oral connective tissue or fascial restrictions? What does the science actually tell us? What are there limitations to this science (because all science is limited)?

Does your baby really have tongue-tie, lip-tie, buccal ties, or fascial restrictions which are causing breastfeeding problems, and how can you sort this out?

We definitely don't want to miss diagnosing and treating a classic tongue-tie in your baby. You can find out about tongue-tie starting here, infant fascial restrictions starting here, and other oral connective tissue restrictions here and here.

The research gives us wildly variable estimates of how many babies have tongue-tie because there is no clear definition

The true rate of tongue-tie is difficult to know, because there is no agreement in the research about how to define tongue-tie. Estimates range from 1.7% to 10.7% or even more.

In my view, the search for objective numeric measures and cut-offs to help us diagnose tongue-tie misunderstands the nature of 'continous variable traits' or spectrum presentations in human bodies. The search for screening and diagnostic tools also misunderstands the complexity and art of clinical decision-making in highly dynamic and complex functional contexts, including in breastfeeding.

You can find out why you and your baby form a complex biological system here.

There may be a role for screening tools (after which the baby is referred for definitive assessment and diagnosis by a cinician). But at the moment, there are no clinically valid screening tools for ankyloglossia - and worse, screening tools are often being wrongly used as diagnostic tools. None of the screening tools in use currently are based on accurate understandings of the biomechanics of infant suck and swallow in breastfeeding.

You can find out about the gestalt biomechanical model of infant suck here and here.

Tongue-tie is overdiagnosed and overtreated in babies

Tongue-tie and fascial restrictions are currently and seriously overdiagnosed and overtreated in our breastfeeding babies in advanced economies in the West. The research clearly demonstrates the rapid increase in rate of infant frenotomies and how this is consistent with overtreatment.

Sometimes you might read that the rates of tongue-tie have only increased because breastfeeding rates have increased, or because we are better at diagnosing it. You'll specially hear this said by health professionals who have a special interest in (and perhaps business or reputational commitment to) treating ankylofrenula. This claim is not accurate.

In bringing you Possums Breastfeeding and Lactation, I hope to help you avoid inaccurate diagnoses of tongue-tie and oral connective tissue or fascial restrictions, and to avoid unnecessary expense and worry. I also hope to help protect your baby from unnecessary side-effects of treatments - which can sometimes be severe, or even on rare occasions life-threatening.

• You can find out about possible side-effects of frenotomy, and why laser risks more side-effects than scissors, here.

• You can find out what drives overdiagnosis and overtreatment of tongue-tie and oral connective tissue restrictions here.

• You can find the help of an NDC Accredited Practitioner here.

It's not possible to tell if the baby in the photograph ata the top of this page would benefit from a frenotomy, again because a single image can be very misleading. There is certainly a prominent opaque anterior membrane, which would be easy to snip. The baby's tight lips don't tell us anything - other than at the moment of the photograph, the little one is somewhat dialled up or defensive, and pulling his lips, in particular his upper lip, in tight. A full assessment is required, including of breastfeeding (or, if relevant, bottle feeding).

Selected references

Borowitz SM. What is tongue-tie and does it interfere with breast-feeding? - a brief review. Frontiers in Pediatrics. 2023;11:1086942.

Dixon B, Gray J, Elliot N, Shand B, Lynn A. A multifaceted programme to reduce the rate of tongue-tie release surgery in newborn infants: observational study. international Journal of Pediatric Otorhinolaryngology. 2018;113:156-163.

Ellehauge E, Schmidt Jensen J, Gronhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.

Fraser L, Benzie S, Montgomery J. Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain. BMJ. 2020;371:m3928.

Hill R, R, Lee CS, Pados BF. The prevalence of ankyloglossia in children aged < 1 year: a systematic review and meta-analysis. Pediatric Research. 2021;90(2):259-266.

Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40

Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018;208(2):88-89.

Larrain M, Stevenson EGJ. Controversy over tongue-tie: divisions in the community of healthcare professionals. Medical Anthropology. 2022:DOI:10.1080/01459740.01452022.02056843.

Lisonek M, Shiliang L, Dzakpasu S, Moore AM, Joseph KS. Changes in the incidence and surgical treatment of ankyloglossia in Canada. Paedaitrics and Child Health. 2017;22(7):382-386.

Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997-2012. Otolaryngology Head and Neck Surgery. 2017;156(4):735-740.

Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020:https://doi.org/10.1177%1172F0194599820925415.