Tongue Tie Interview!

by Bobby Ghaheri

I recently had the opportunity to speak with Veronica Jacobson, CLC, regarding tongue tie and the impact on breastfeeding. We discussed the following:

  • Why is there more awareness of the issue now versus 5 or 10 years ago?
  • What is the biggest hurdle to getting HCPs to understand tongue and lip ties and the health effects?
  • Why do posterior tongue ties need to be taken more seriously as something that needs fixed?
  • What kind of research is currently being done on the subject?
  • What's your advice to parents who are having a tough time getting a pediatrician or other HCP to take their concerns about a possible tongue or lip tie?

Here's a link to the video

The Evidence Supports Treating Tongue Tie for Breastfeeding Problems

by Bobby Ghaheri

This post aims to address the common argument that there is no published evidence supporting the treatment of tongue tie when breastfeeding is problematic. It's directed at the doctors, lactation consultants, speech pathologists, and family members of mother/baby dyads who, for whatever reason, think that the release of a tongue tie is completely unwarranted. Often, the adamant negative response mothers get is so strong that they are scared to pursue treatment. This is especially true when the negativity comes from a doctor or lactation consultant, who mom may feel are "experts" in the field and whose opinion carries weight.

Unlike other medical conditions with a perceived significant societal impact, studies looking at TT and breastfeeding don't include large numbers of babies. You will not find a multi-center, double blind, randomized controlled trial (RCT) that looks at the efficacy of the procedure. But that does not discount the available body of literature, and we will examine the best studies to demonstrate the safety, efficacy and importance of tongue tie release when breastfeeding isn't going well. Keeping in mind that the majority of the studies were likely only treating anterior tongue tie (ignoring the posterior tie that is always behind the anterior ties), it's impressive to see how much these moms and babies benefit. Additionally, there are currently no studies that show that frenotomy does NOT help breastfeeding symptoms - they universally show improvement, regardless of study design.

Steehler and colleagues (2012) retrospectively collected data on 367 babies seen in a 5 year period of time who had breastfeeding problems related to tongue tie. 302 of them underwent a procedure but only 91 agreed to participate in the study. 80% of those participating felt that the procedure helped their baby breastfeed. 83% of the babies were able to initiate or resume breastfeeding. This study is limited by its retrospective nature and the very young mean age of the babies (18 days old), which makes extrapolation of the results to older children difficult. That being said, the study demonstrates a high level of satisfaction and safety. This study does look at posterior tongue tie, making it one of the only ones to demonstrate that even those babies can be safely treated in the office.

Berry, Griffiths, and Westcott analyzed 57 babies who were referred for tongue tie who were having problems breastfeeding. The groups were divided into a treatment and non-treatment group to create a double blind, randomized study. The babies were taken away, treated (or not treated) and then returned to mom. Pre and post-treatment evaluations were performed and those in the non-treatment group were treated after the data were collected. 78% of the treatment group noted improvement; interestingly, 47% of the non-treatment group also reported improvement, showing the bias involved. 1 day after the procedure, the cumulative improvement was 90%. At 3 months, 92% reported continued improvement. The double-blind RCT design of this study is admirable, but it truly only blinds the results for the improvement noted on the day of the procedure. In reality, the vast majority of babies treated don't improve immediately, especially in the setting of posterior TT.  This study does not look at posterior TT, nor does it truly control for bias beyond the day of the procedure.

In 2011, Buryk and colleagues published in Pediatrics a randomized trial studying the same topic. They looked at 58 babies who were randomized to a treatment arm vs a sham treatment arm. The babies in the sham treatment arm were offered treatment at or before 2 weeks following the initial visit. Whereas the Berry study's sham group was offered treatment that day, this study allowed for babies to wait well beyond what I feel is reasonable. Despite that ethical problem, however, the study shows improvement in the frenotomy group when compared to control, using objective measures to grade the latch and the presence of nipple pain. 

Hogan and colleagues (2005) looked at the association between TT and breastfeeding problems in a different way. They identified 201 babies with TT and determined that only 88 of them were having breastfeeding problems. This study emphasizes my contention that not all babies who have tongue tie need treatment. Those that are asymptomatic should be followed rather than empirically treated. Of the 88 in the study having problems, 57 were included in the study. 28 babies were included in the treatment group, and 96% had improvement in breastfeeding. The 29 controls were subsequently offered treatment after intensive non-surgical treatment was offered, and 28 of the 29 requested frenotomy. 96% of those babies also showed improvement in breastfeeding. 

Arguably the most important study that furthered our understanding of breastfeeding mechanics came from Dr Geddes and colleagues in 2008. Recently, Dr. Elad's paper emerged to further characterize how babies actually nurse. Geddes' paper looked at 24 babies and analyzed their breastfeeding using ultrasound, identifying appropriate nipple position, what happens to the nipple pre- and post-frenotomy, and most importantly, what the babies' tongues do when they nurse. It redefined our understanding of this motion, changing it from a previous theory where we thought babies stripped the breast to nurse to the current understanding of the generation of a vacuum in the mouth that draws the milk out via negative pressure. If doctors and lactation consultants fail to understand the implications of this paper, they will categorically fail to understand why frenotomy is helpful in the setting of tongue tie. This paper showed how objective latch scoring, maternal pain scores, milk intake and milk-transfer rate almost universally improved in babies who underwent frenotomy.

Earlier this year (2014), Dr Ochi, a pediatric ENT in San Diego, conducted a small study showing improvement in 20 babies who underwent frenotomy for breastfeeding problems. He also showed the importance of using a breastfeeding quality of life survey to measure maternal satisfaction following the procedure.

Finally, the best examination of the improvement babies can experience following frenotomy comes from Dr. O'Callahan in his 2013 study. He looked at 300 babies who underwent frenotomy (along with lip tie revision in 37% of those babies) for breastfeeding issues. More than 1/2 of them responded to survey follow-up, making it a large patient sample studying this topic. For moms reporting nipple pain, 64% reported improvement within 1 week. Unfortunately, long term follow-up wasn't done, so the remaining moms and babies couldn't be studied further. Importantly, no moms experienced worsening pain. About 1/2 of the moms reporting latching difficulties reported improvement at the 1 week follow-up. The likely explanation for why more babies didn't improve in both arenas is that follow-up beyond 1 week wasn't performed, and it is well-understood that a subset of babies (especially older children) need a longer period of time to relearn appropriate sucking patterns. I feel that the most important part of this paper is the fact that only 16% of babies who presented with breastfeeding problems had an anterior TT (class 1 or 2). 84% had a posterior TT (class 3 or 4), which we already know is the type of TT that is most often missed or misunderstood by doctors and lactation consultants. If only babies with an obvious anterior TT are the ones that doctors are willing to treat, they would be missing 5 out of 6 potential babies who would benefit from treatment.

As time goes on, more data will emerge. But in my opinion, there is already a sufficient body of evidence to demonstrate that frenotomy is a very safe and effective treatment for babies with ankyloglossia who are having difficulty with breastfeeding. If we demand large RCT's for every disease process, we would never make any progress. In this sense, we must walk before we can run, and in this instance, I feel that we're jogging in the right direction.


References

Steehler, MW, et al. A retrospective review of frenotomy in neonates and infants with feeding difficulties. International Journal of Pediatric Otorhinolaryngology 76 (2012) 1236–1240

Berry, J, et al. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. BREASTFEEDING MEDICINE Volume 7, Number 3, 2012

Buryk, M, et al. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics 2011;128;280

Hogan, M et al. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J. Paediatr. Child Health (2005) 41, 246–250

Geddes, DT, et al. Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. Pediatrics 2008;122;e188

Elad, D, et al. Biomechanics of milk extraction during breast-feeding. PNAS. 2014 Apr 8;111(14):5230-5

Ochi JW. Treating Tongue-Tie - Assessing the Relationship Between Frenotomy and Breastfeeding Symptoms. 2014 United States Lactation Consultant Association Clinical Lactation 2014, 5(1), http://dx.doi.org/10.1891/2158-0782.5.1.20

O'Callahan, C, et al. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology 77 (2013) 827–832

How To Choose Your Provider: Does Laser vs Scissors Matter?

by Bobby Ghaheri

Families frequently ask me whether they should go to a particular tongue tie provider because they use a laser for their procedures. I always respond that the tool that the provider is using for the procedure is far less important than their skill and understanding of how tongue tie affects breastfeeding. Anyone can buy a laser, so that cannot be the deciding factor for how a doctor or dentist should be chosen.

This post will serve to answer two major questions. I will show you the questions you should ask before a potential procedure in addition to the advantages and disadvantages of using laser vs scissors.

How can a family know whether or not a provider will do a complete job when treating tongue tie? This isn't an easy question to answer, but there are certain questions you should ask if you're unsure of their expertise:

  • How many tongue tie procedures do you perform per month? There isn't a magic number that is necessary. This is more for you as parents to gauge whether a provider embraces the concept that tongue tie affects breastfeeding or not. If the answer is "1 or 2" vs "10 or 20", that tells you something.
  • Do you treat posterior tongue tie as well? If the provider gives you a blank stare, then I can almost guarantee you that their tongue tie procedure will be incomplete. Going back to the concept that all tongue ties have a posterior, submucosal component, if a provider isn't aware of the anatomy, the result will be suboptimal. You will also know this is a problem if your baby has a posterior tongue tie (confirmed by your IBCLC or your own homework) and the provider tells you that no tongue tie exists.
  • Do you require general anesthesia? This doesn't necessarily prevent you from seeking treatment from a provider because it may be your only option for treatment. If you have to choose between the principle of avoiding GA or improving your breastfeeding relationship, you will hopefully choose the latter, because the only other feasible alternative is to travel to another provider. Unfortunately, most providers don't realize that the procedure can be done safely in the office.
  • What is your post-procedure stretching routine? Again, if you get a blank stare here, it's a tipoff that they aren't familiar with the concept of reattachment of the wounds. Alternatively, if the provider says something to the effect of "the baby's tongue moves so much that scar tissue can't develop", I would recommend you look elsewhere because this sort of advice frequently accompanies an incompletely done procedure.

Additionally, if you go to a provider and hear some of the myths many of us have been told about tongue tie and breastfeeding, I would recommend looking elsewhere. While it may seem excessive, if you live somewhere where no one makes you feel comfortable with proceeding, you need to consider traveling to someone who knows more.

Does it matter whether a provider uses laser or scissors for the procedure? This is one of the most frequently asked questions I get. My opinion is that for the purposes of breastfeeding, I don't think there is any difference in outcomes between laser and scissors. There has never been a head to head study comparing the two techniques. While I currently use a laser for my procedures, I performed over 200 procedures using scissors when I began treating babies, and my revision rate and rate of improvement was no different then. There are some inherent differences between the two techniques:

  • The scissor procedure is faster than the laser procedure. 
  • I allow parents in the room when I use scissors, but when using laser, they cannot accompany the baby to the treatment room (these are laser safety guidelines that should be followed).
  • The scissor procedure often needs injected local anesthetic to control pain and bleeding whereas the laser procedure has a delayed onset of pain but doesn't have issues during the procedure.

That being said, practitioners who embrace laser technology do so because they have a specific interest in breastfeeding medicine. It also implies that they are doing more procedures than most others. Because lasers are indeed expensive, the practitioner who does 1 or 2 procedures per month isn't going to make that investment. The flip side, however, is that some already have lasers in their offices for other procedures. We see this most commonly in the dental field, where lasers are used for a multitude of other problems. In those situations, going to a dentist who has never done a laser frenotomy on a newborn just because they have a laser may not be the best option. You need to be an advocate for your child and you need to be willing to walk away if you don't feel comfortable proceeding.

Lasers do offer a precision that can't be matched by a scissor revision. They are more effective in removing the entire upper lip tie in the setting of abnormal dental spacing and dental decay. In those instances, mere release of tension (that could be achieved by scissors) isn't going to completely deal with the dental problems, so I feel that laser is superior. The lack of bleeding during most laser procedures also improves visualization and can help complete removal of the restrictive tissue.

There are no peer-reviewed studies of frenotomy using lasers to date. The best studies available to us (specifically Dr. O'Callahan's study) were conducted using scissors, and in those studies, breastfeeding outcomes improved dramatically. While it might be difficult to do a head to head study comparing the two techniques, the coming years will bring us data using laser, and it will be curious to see if those outcomes are as good. I suspect they will be.

Rethinking Tongue Tie Anatomy: Anterior vs Posterior Is Irrelevant

by Bobby Ghaheri

There is no doubt that tongue-tied children have a higher propensity for breastfeeding difficulty. In trying to understand how best to treat children with tongue tie, practitioners have developed a classification system to describe tongue tie.

Most practitioners use a classification where the tongue tie is given a grade of 1, 2, 3, or 4. Classically, class 1 and 2 are thought of as anterior, whereas class 3 and 4 are posterior. Unlike cancer grading, where stage 1 is minimal disease and stage 4 is severe disease, that distinction does not apply for grading the severity of tongue ties. Instead, the tongue tie classification system is merely a description of where the tie attaches to the tongue. I have seen class 4 babies with severe breastfeeding problems and class 1 babies who feed normally, and vice versa. The problem with the word "posterior" is that those unfamiliar with this classification may erroneously think that the tongue tie is in the back of the throat, back by the tonsils. Better descriptive terms would be submucosal or hidden tongue ties, but we are unfortunately stuck with the term posterior.

Class 1 Tongue Tie. This is the classic heart-shaped tongue that most doctors feel is the only real tongue tie. The tie inserts into the tip of the tongue.

Class 2 Tongue Tie. Considered to be an anterior tie, this tie inserts just behind the tip of the tongue. We don't see a heart-shaped tongue, but the tie is still clearly seen.

Class 3 Tongue Tie. Classified as a posterior TT, the distinction between this and a class 4 TT is that the class 3 still has a thin membrane present.

Class 4 Tongue Tie. No thin membrane is present, so this type of tie is the most commonly missed. The front and sides elevate, but the mid-tongue cannot.

Unfortunately, what I have encountered when most practitioners treat tongue tie is that the procedure is done incompletely. This post will describe how to completely treat a tongue tie to completely release any tension on the tongue. 

After treating over a thousand babies with breastfeeding problems, it has become clear to me that our previous understanding of the anatomy of tongue tie is inaccurate. In my training, we only were taught to release the thin membrane of a tongue tie if restriction was noted (this was in the setting of speech problems, not breastfeeding). Most practitioners who haven't done a significant number of tongue tie procedures also tend to just snip this front membrane. Parents are impressed because of the lack of bleeding, and the practitioners willingly do it because it carries no risk. They don't usually acknowledge the possibility that a class 3 or 4 tongue tie exists because the thin membrane that is present in class 1 or 2 tongue ties is minimal in size or absent altogether. I contend that the presence or absence of a thin membrane is irrelevant if the baby is having problems with breastfeeding. Why? It goes back to the mechanics of breastfeeding. A previous post demonstrated that the critical motion in breastfeeding is elevation of the tongue. 

In my experience, every anterior tongue tie has a posterior tongue tie behind it. Reworded, every tongue tie that affects breastfeeding is a posterior tongue tie. Some of those also have an anterior thin membrane, but there is always a posterior component. I like to use a sailboat analogy to help describe tongue tie.

Imagine the sail as a class 1 or 2 tongue tie. That sail is visible. But behind that sail, there is a mast that also needs to be addressed.

In this example. the sail is down. The only thing visible is the mast. The absence of that sail doesn't affect the presence of the mast.

This concept must be understood if we are to understand how to effectively treat tongue tie in the setting of breastfeeding. Whereas treating just the sail (the anterior tie) may be sufficient in treating older children with speech problems, treating just the anterior tie is insufficient in helping the baby with breastfeeding problems. The ultrasound data show that the front of the tongue must advance slightly and then elevate to cup the breast against the palate. This motion may be helped by snipping an anterior tie. But the ultrasound data also show that the mid-tongue must be fully mobile to elevate towards the palate. If the tongue is only released up front (the sail is cut) and the posterior component is left behind (the mast), then the mid-tongue won't elevate and the latch will still be problematic. This analogy also applies to the baby with a posterior tie (where only the mast is the problem). In these babies, the front of the tongue may elevate just fine, but the posterior restriction won't allow the mid-tongue to elevate, again affecting the latch.

A classic diamond-shaped wound seen in an appropriate release.

It is absolutely essential that the practitioner gets through the posterior component of the tongue tie for the procedure to be effective. How can the practitioner know if they've gone far enough? The tongue tie that is fully released has a diamond-shaped wound. If there is no diamond, then the release is incomplete. The alternative way to know for sure that no further tie exists is to release the tie until muscle is seen. This is why I contend that the tool used to do the frenotomy is irrelevant: whether it's scissors or a laser, as long as the diamond is visible, then I know that the tongue has been fully released. This technique should be everyone's goal.