Tethered Oral Tissue

My dad and I

I had a conversation with my mother recently about tongue and lip ties. We have recognized that my father had a severe tongue tie, and very few could understand him. It wasn't until many years after his death that it all clicked for me. Before he died, I remember having a conversation with him. He asked if I could roll my tongue and if I could stick my tongue past my lips. We sat at the table, sticking our tongues out at one another. Fast forward, and a niece and nephew plus 2 grand nephews have had tongue and/or lip tie releases done to be able to successfully breastfeed. Other questions that surfaced were around all of my siblings, nieces, and nephews who went undiagnosed. After much research, I have discovered that tethered oral tissue can be connected to difficulty breathing, sleep apnea, crowded teeth, high palates and sinus issues, reflux, and ADHD.

I wanted to know more and started asking questions. What is the history of tongue and lip tie? When was it first documented, and how early were releases documented? Why is it "more prevalent" today than 15-30 years ago? How does the introduction of formula play into the diagnosis of ties? My family story is a perfect example of how long-standing anatomy can go unnoticed for decades.

1) When was tongue tie first documented?

Tongue-tie has been noticed and treated for centuries. Tongue tie is mentioned in the Bible, in Mark 7:35. It describes a healing miracle in which a person's tongue was loosed, allowing him to speak plainly. This reference indicates an understanding of the condition in ancient times. During much of the 20th century - when breastfeeding rates fell and bottle-feeding became common - many functional problems related to tongue-tie were less obvious and therefore less frequently diagnosed or treated. As breastfeeding returned to prominence starting in the 1980s-2000s, clinicians and parents began noticing feeding problems attributable to restricted tongue/lip movement, and diagnoses and frenotomies started to rise. But not all were successful. Some babies continued to have trouble breastfeeding, bottle feeding, still had reflux, gas, and upset tummies. PubMed+1

2) When were releases (frenotomy/frenectomy) first documented?

Frenotomy is centuries old, with frequent documentation from the Middle Ages onward. Cutting/dividing the frenulum is an ancient practice. Medieval midwives reportedly used fingernails to divide tight frenula; by the 18th-19th centuries, the procedure was widely described in medical texts and performed by midwives or physicians. PMC+1

3) Why are tongue/lip ties “more prevalent” today?

• Breastfeeding creates more opportunities to notice functional problems. Tongue-tie often becomes apparent because it interferes with effective latch, milk transfer, nipple pain, or infant weight gain. When more infants are bottle-fed, those functional breastfeeding problems are less obvious, though still prevalent. When breastfeeding doesn't work, is painful, or babies have trouble gaining weight even when getting bottles, clinicians and parents begin to look for anatomical reasons for latch pain or poor milk transfer, and this awareness has created an increase in diagnoses. AAP Publications+1

• Increased awareness, screening tools, and specialty care. In the 1990s-2010s, lactation consultants, pediatric dentists, ENT physicians, and pediatricians developed assessment tools and protocols. More infants were assessed and referred for release. Recently, social media/Internet awareness has grown, and parents are looking for answers. On top of that, bottle feeding has become more difficult with the change in all the bottle nipples. In the early 2000s, latex nipples were no longer available, and nipples have become firmer. With the push to use the slow flow nipples, many babies are struggling to get enough to eat, especially when their suck isn't effective. PMC+1

4) Did the introduction/widespread use of formula (mid-20th century) make tongue/lip ties less recognized (1940-2000)?

Yes. Bottle-feeding became much more common from the 1930s through the mid-20th century; many infants were not breastfed for long or at all. Because tongue-tie often causes breastfeeding-specific problems (i.e., painful latch, poor milk removal), many infants were switched to bottles. With the ease of bottle feeding, especially with a latex fast flow nipple, fewer parents and clinicians connected feeding difficulty to a tethered frenulum. In short, the formula era reduced the visibility of breastfeeding-related functional problems, and that likely contributed to fewer diagnoses and fewer frenotomies during much of the 20th century. PubMed+1

5) Important nuance — not everything that looks like a tie needs cutting

Recent clinical reports (and the American Academy of Pediatrics guidance) emphasize careful assessment: some infants with tight frenula do fine without surgery, and some breastfeeding difficulties respond to lactation support, positioning, or time. But is breastfeeding pain or difficulty the only reason to release a tie? We need to look past a breastfeeding baby's ability to gain weight and whether the mom is having nipple pain. There are other symptoms that may be associated with tethered oral tissue, like reflux, gas, upset tummies, mouth breathing, and congestion. When a baby appears to have tethered oral tissue but is feeding well and not having any complaints, it is best to leave the frenulum alone. Watch that baby for any complications as the baby gets older and treat if problems arise later. Randomized trials and observational studies show that selected infants with clear functional limitation (and breastfeeding failure or maternal nipple pain) often improve after frenotomy. And some show no improvement at all. This can be confusing to parents and clinicians. NCBI+2BioMed Central+2

It is important to do your research and ask questions. If your baby is:

• having trouble nursing,

• is not gaining weight as expected,

• if your latch is painful,

• if your milk supply is low, or

• if your baby has reflux and is unusually fussy,

then seek help. An IBCLC can help assess the latch, position, and feeding behavior. Speech therapists and occupational therapists can also evaluate for oral restrictions. There are many times that a painful latch is fixed just by adjusting the baby's position. If mom has a low milk supply, it may be due to other factors, and reflux may be diet-related. Gulf Coast Lactation is available to help provide guidance and education. Please visit our website to learn more about our available services.