Tongue-Tie: The Power and Challenge of Trends in Diagnosis

Tongue-Tie: 

The Power and Challenge of Trends in Diagnosis

In the last few years, a great surge of interest in the condition commonly referred to as tongue-tie has emerged.

Tongue-tie is rapidly becoming the new, most compelling explanation for trouble with nursing one's newborn.

A close look at the evidence shows that this new interest fits into the well-known occurrence of trends in diagnosis.

What is a Trend in Diagnosis?

A great number of problems we experience are more complex than simple, meaning that there can be a variety of causes, and outcomes, for each such problem.  Examples include problems like struggling in school, oppositional behavior, back pain, having frequent colds.   In each of these problems, it is not always so clear exactly why the problem is present, or what the course will be over time, and so it is very hard to know what will "work" to get rid of the problem.

Such problems lead us to be very frustrated.  Someone must be able to do something, and so when an idea appears that promises to "fix" the problem, it is very hard to resist the promise.

Here is where the power of the diagnosis comes in.   A diagnosis, after all, is an explanation.  It answers the question why.   Why do I have my problem?  The diagnosis is why.

Our minds seek explanations so avidly, that we all will welcome an explanation, even before it is proven to be a true explanation.

And so, in our profession, we regularly see diagnoses,  suddenly appear, without much proof, but gain tremendous popularity as explanations for difficult challenges.   In these trends of diagnoses, it is typical that the diagnosis and its treatment will be perceived initially as a very convincing solution, until over time it emerges that it really wasn't as much of an explanation as we once thought.  Usually this cycle takes many years to fully appear, arise, and fade away.

What is tongue-tie?

Tongue-tie refers to the motion of the tongue in relation to a bit of tissue that connects the bottom of the tongue to the floor of the mouth.  This thin ridge of tissue is called the lingual, or tongue, frenulum.

Now, in every newborn, the face is structured dramatically different than ours.   All newborns have a much smaller mouth than an adult, their jaw is very small and recessed compared to an adult, and the frenulum tends to be attached much more forward towards the tip of the tongue than in an adult.  Overall, every aspect of a newborn face is far smaller than in an adult, and so everything is in a different relative position.

The tongue-tie theory states that some newborn's tongue frenulum interferes with nursing, and if that frenulum is cut the problem with nursing will go away.

Does tongue-tie explain trouble nursing?

Yes and no.

It does appear to be the case that some newborns' tongues and mouths are shaped such that clipping the frenulum is necessary for nursing to occur successfully and without pain.

The problem is that science has not yet actually developed a system that will allow us to really know who those babies are.

It has only been a few years since an attempt a classifying how tight the tongue is and how far forward or backward the frenulum sits has been created.

Curiously, studies using these classifications of severity have found little connection with more severe tightness and trouble nursing.   

Most of the studies looked at the impact of cutting the frenulum, but only in settings where the parents were told their newborn had a diagnosis, namely tongue-tie.

Knowing what-causes-what is tricky

Since our minds are so eager, really hungry, for explanations, when one comes along, it is very hard to resist being convinced.

A good example is the difficulty knowing what causes back pain.   It sure seemed as though bulging or herniated spinal disks caused most serious back aches until we found that about 60-75% of healthy people with no back pain have bulging and herniated spinal disks.   What a surprise, here were all these people with back pain whose CT scans showed bad disks, the disks must have been the cause- until a bigger look was taken and we found that having a bad disk on a CT or MRI is seen more with people with no back pain than with back pain.

So, to be really convinced that something causes a problem, one must take a look at those with the problem, and those without the problem.   To be convinced a treatment really works, one must take a look at those who got the treatment and compare them fairly to those who have not, or have had other treatments.

So, How Do You Know if you Have a Tongue Tie Problem, and if You Need the Frenulum Clipped during Infancy?

It turns out the science on this question is not well worked out or studied yet.

Here is what we do know:

1.  All babies born have jaws much smaller than we do, and their tongues sit in their mouth very differently than ours.  So seeing some difference should be something seen in every newborn.

2.  That strip of tissue, the frenulum, that connects the tongue to the floor of the mouth is very often positioned differently than in us.

3.  This point is very important, so simply noticing that the frenulum attaches to the tongue more forward or more back on the tongue than in us does not mean anything is wrong, and does not mean anything needs to be done.

4.  There are some newborns whose frenulum position AND tongue use, combine to cause painful nursing and poor latch and milk flow into the baby.  It looks like this is not a frequent event.

So, the way to know if the tongue and the frenulum are a problem, is if after thoughtful and effective lactation counseling, painful nursing continues, weight gain is not as expected, and the explanation seems to be that the baby's use of their tongue is playing a role.

Pitfalls to Avoid

The most common pitfall parents now experience, is in the newborn nursery, where someone will look at your baby's tongue and raise a concern that the frenulum is badly positioned or too short and recommend that it be clipped.

It turns out to be quite unusual for a tongue and frenulum problem to be clearly the problem and identifiable as such in the first few days of  life.   Breast feeding typically involves lots of transitions in the first three days after birth:  the baby learns to latch, starts to suck, milk often takes the full 3 days to come in, babies are born with an extra 10% of their birth weight to live on while waiting for milk to come in.  So if someone is not nursing well the first day or two, or even three, that can be due to a good number of reasons.

Keep in mind, it makes sense to consider other options before hurrying into clipping someone's tongue, no matter how safe that might be.

BOTTOM LINES
1.  Tongue-tie happens, but not that often, probably 98% or more of newborns have a normal tongue that can nurse just fine.
2.  The unusual circumstance of the frenulum and tongue being so dysfunctional that they need a procedure to work does happen, but one shouldn't come to that conclusion in the first few days of life unless a very atypically severe anomaly of the tongue is evident.
3.  The only reason to clip a newborn's tongue is if it has truly been demonstrated that the tongue-frenulum is causing the baby to fail to latch to the breast or cause painful nursing, a conclusion that should not be accepted until a skilled lactation counselor and your pediatrician ensure there is not another reason for trouble latching and painful nursing.
4.  We are currently right in the middle of a true diagnostic trend.  The popularity of diagnosing newborns with tongue-tie is rising rapidly, a true move towards making this diagnosis in many newborn nurseries is in full swing.  So beware.   Keep in mind there is no rush on this diagnosis, it should take in most circumstances at least several days to be sure this is the cause before your baby is asked to have their frenulum clipped.
5.  In the unusual circumstance that the frenulum does need to be clipped, then of course it should.

Here is easy and comfortable nursing to all who seek it!

To your health,
Dr. Arthur Lavin

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