Ankyloglossia and the SLP: A Look at Both Sides of the Frenectomy Debate

Whether you’re working in the NICU with newborns struggling to feed or helping older kids with swallowing or speech, the issue of tongue ties will come up sooner or later. This is the one area in SLP practice where you’re likely to encounter some strong opinions from parents and other practitioners so it’s important to be well-versed in the debate and  prepared with a response.

We aren’t taking a neutral position simply because it’s the safest. We feel it’s important to present both scientific and anecdotal evidence on both sides of the debate so that parents and practitioners can arrive at their own conclusions.

When mother and nurse practitioner Katy S. saw her first child, Hudson, drop from the 89^th percentile to the 1^st percentile and labeled failure to thrive, no one mentioned examining his tongue. Now, though, she wonders if this simple step could have saved her family from an agonizing start to parenthood.

“Spending a few weeks with your child in the NICU is not an experience you forget,” Katy says.

When Katy’s second child, Harper, also lost a dramatic amount of weight within the first week of life it felt like her worst nightmare on repeat.

This time, though, Katy took the advice of a family member and friend and brought Harper in for a tongue tie evaluation by a pediatric dentist.

“Once her tongue tie was lasered she gained a pound a week for the next two weeks,” Katy says.

Katy shared this success with her pediatrician and the SLP working with her oldest, Hudson, on his speech. “They both were pretty astounded by the fact that she (Harper) had gained so much so quickly.”

This experience sparked a number of questions for Katy, both as a mother and medical practitioner: Did her son have a tongue tie? (Yes, she discovered after a recent dental appointment.) Could they have been spared the trauma of his dramatic weight loss and time in the NICU? (Possibly.) Could this tongue tie be a factor in his current slow progress with speech therapy? (Depends on which professional you ask.)

Caught in the Controversy

It’s these questions that have Katy, and many parents like her, lost in the ongoing tongue tie debate: from the prevalence of ties to the extent of their impact on swallowing and speech each practitioner offers their own opinion on the subject, often giving little evidence to support their assertion either way.

Parents, then, are left to make decisions based on conflicting information:

• Should I subject my tiny newborn to an uncomfortable albeit minor laser surgery, or focus on therapeutic modalities such as non-nutritive sucking and oral motor interventions?
• If I don’t opt for a tongue tie revision, will my child face increased swallowing issues when we start solids? What about speech development?
• What about my older child who struggles to make certain sounds? Would a tongue tie revision help, or should my therapist focus on compensatory methods of forming these sounds?

You, the practitioner, can equip parents to make decisions they are less likely to regret by providing a clear explanation of the pros and cons, as well as some of the controversy around tongue tie revisions.

A Tongue What?

In some individuals the frenulum, or thick band of tissue stretching between the tongue and floor of the mouth, appears to restrict the tongue’s ability to function properly. This “tongue tie” is also known by its more formal name: ankyloglossia.

Anterior Tongue Ties are visible flaps of tissue attaching the tip, middle, or base of the tongue to the floor of the mouth.

Posterior Tongue Ties (PTT) are “hidden” ties, generally beneath the mucous membrane, and need to be felt in order to be diagnosed. Sometimes a child is observed as having a “short tongue”, when in actuality there is a posterior tongue tie.

Some babies also present with a lip tie, where the flap of tissue from the upper lip to the gums appears to restrict proper flanging for breast and spoon-feeding.

Visibly seeing a tie doesn’t indicate a child will automatically face difficulties, as not all ties significantly restrict movement. This is why practitioners are encouraged to focus on function as opposed to form.

Ties in the NICU and Breastfeeding

As a pediatric SLP you may be called on to support mothers like Katy, whose infants present with extreme, inexplicable weight loss in the first weeks of life.

A 2014 study of 264 mother/baby pairs by Dollberg, Marom, and Botzer found “favorable effects of frenotomy on breastfeeding”.

Additional AAP endorsed studies showed immediate, significant improvement that could not be attributed to placebo. In fact, 78% of babies in one small study showed immediate improvement, as opposed to 47% in the placebo group. By three months out, 92% reported improved feeding.

SLP and IBCLC Nina Isaac notes that tongue ties can lead to numerous issues, including the following:

• Nipple pain
• Damaged nipples
• Poor milk transfer
• Low milk supply
• Early cessation of breastfeeding
• Failure to thrive
• Dyspaghia
• Difficulty transitioning to solids
• Dental issues

Some professionals continue to express doubt regarding the effectiveness of frenectomies (also called tongue tie revisions or releases) for infants, usually citing “not enough” studies or studies that are too small in scale.

A larger percentage, however, agree that in certain circumstances a revision can prove to be an important factor in infant feeding issues.

The general controversy with infants tends to circle around whether tongue ties today are under- or over-diagnosed, which we will look at further along in this article.

Ties and Feeding: Toddlers and Older Children

In her ASHA Leader Blog post Melanie Potock, MA, CCC-SLP notes that she has observed a number of indicators for tongue tie among children referred to her practice for feeding difficulties. Some of these indications include the following:

• Inadequate caloric intake due to inefficiency and fatigue.
• Tactile oral sensitivity secondary to limited stimulation/mobility of tongue.
• Difficulty progressing from “munching” to a more lateral, mature chewing pattern.
• Affected swallowing patterns and compensatory motor movements.
• Picky eating because certain foods are challenging.
• Gagging and vomiting when food gets “stuck” on tongue.

In an anecdote published in the ASHA Leader Blog, Robyn Merkel-Walsh (MA, CCC-SLP), writes that a 34-month-old child, Bobby, developed food aversions and couldn’t properly use his tongue to move food around his mouth in order to swallow. After a series of treatments including surgery, Bobby continued to struggle. Ultimately, an aggressive tongue tie revision resulted in successful eating.

While these anecdotes appear compelling, you’ll be hard pressed to find any comprehensive research on the connection between tongue ties and feeding difficulties related to eating solids.

In an interview for an article about the overtreatment of ties, Australian SLP Holly Tickner says, “Many children have trouble learning to eat and they have no oral ties at all.” She is also concerned that older babies are sometimes referred for frenectomies before practitioners explore other possible physiological issues.

Tickner isn’t alone in her assessment…any time spent researching tongue ties and swallowing stirs up a confusing mix of professionals strongly supporting and firmly denying the connection between tongue ties and difficulties with solids. Most of these opinions, on either side, are based on personal belief or experience as so little research is available.

Ties and Speech

Interestingly Katy learned that her own brother and mother had ties released at ages 5 and 7, respectively, in order to improve speech problems. She shares that both family members showed significant improvement after the procedure.

SLP Dawn Moore has also observed impressive improvement among some of her patients following a tongue tie release.

“So many SLPs have struggled with children not making progress and wondered why they could not correct their errors,” she writes. It is these children she suspects may be impacted by a tongue tie.

For those with doubts, she offers audio clips demonstrating speech before and after revision for one such child.

Again, however, evidence tends towards the more anecdotal and there is a lack of solid research based on large studies.

One small study of 30 children aged 1-12 concluded that “tongue mobility and speech improve significantly after frenuloplasty in children with ankyloglossia who have articulation problems.”

Those who harbor doubts, however, point out that in most related studies pre-and post-operative assessments could be months apart, sometimes with additional therapy in the interim.

So again, you as the SLP find yourself in a place with no clear answers, only a mix of minimal data and anecdotal evidence to present to parents making a difficult decision.

Over- or Under- Diagnosing Tongue Ties: The Great Debate

Much noise in the tongue tie conversation focuses on the question of over- or under-diagnosis.

While it is true that tongue tie seems to have “suddenly” surfaced in the past 10-20 years, mentions of tongue tie can be found as far back as biblical times. In medieval times midwives kept one fingernail long specifically to slit the frenulum directly after birth. In the 1900’s, however, with the advent of formula and bottle-feeding, tongue ties were much less likely to affect infant growth and so fell out of the modern birth conversation.

With the recent emphasis on breastfeeding in the West the question of tongues ties has resurfaced, as a surprising number of mothers discover breastfeeding difficulties.

It is possible that the increase in diagnoses is simply the result of changing times. It is also possible, however, that as practitioners have become more aware of tongue ties they have also inadvertently become over-focused on them, to the point of over-diagnosing.

In an interview with IBCLC Renee Kam, pediatric ENT (ear, nose and throat) surgeon Dr. David Mcintosh says that regarding tongue tie releases “too many inappropriate ones and not enough appropriate ones” are being done.

In her ASHA Leader Blog post, SLP Melanie Potock explains that the SLP’s role is to screen, not diagnose, and then refer concerns to an ENT or pediatric surgeon or pediatric dentist trained in recognizing tongue ties. This team approach helps to avoid missing or over-diagnosing ties.

Need for More Research

One thing that all professionals appear to agree on is the need for more research.

“Much is being talked about in this area and there is a lot of controversy, yet no one is systematically studying this,” says David Francis (M.D., MS), author of a report examining the existing literature on tongue tie release.

And, as ENT Dr. Christopher Chang points out, “Just because quality data is lacking does not mean tongue tie release should not be performed.”

This is exactly where Katy feels her family fell through the cracks. To have been seen by so many professionals during a critical situation without a single one recommending a tongue tie check seems off balance…especially since Hudson, the son who dropped from the 89^th percentile to the 1^st, was later diagnosed by his dentist as having a severe tie.

Now Katy faces the decision of whether or not to release the tie in hopes of improving his speech. The healing process with a two year old for this procedure is a bit more drawn out and tricky than it would have been had Hudson been treated in the NICU.

“I’m not sure if I want to put…[him] through that,” she says.

At the end of the day, each practitioner must decide what actions will best serve the patient. Sometimes mistakes will be made. By working as a team with other disciplines you yourself will gain a more well-rounded understanding of the issue and be able to better provide parents with the opportunity to make fully-informed decisions.