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Posterior Tongue Tie - What do we know?

Posterior tongue tie

Increasingly, health professionals are diagnosing posterior tongue ties and surgically cutting the tie with a procedure called a frenotomy citing the tongue tie as a reason for breastfeeding issues. There is a lot of debate about posterior tongue ties and the current data about posterior tongue ties seems to be unreliable. The data does not always take into account the many connected factors that can cause problems with breastfeeding.  The medicalisation we see in birth is now creeping into breastfeeding. Given that having a tongue tie cut is a medical procedure (with associated possible side effects), it's important to consider carefully what the reasons are for such a procedure and thus the strength of the evidence for treating a posterior tongue tie.

The way that a baby's tongue moves, and how flexible the tongue is, is really important when it comes to breastfeeding. In a newborn baby there is an instinctive suck reflex that enables the baby to start breastfeeding. The movement of the baby’s tongue is a key part of this sucking action.

Tongue Tie

Two types of tongue ties exist – anterior tongue tie and posterior tongue tie. The tongue is joined onto the base of the mouth by connective tissue called the frenulum. The frenulum plays an important role in stabilising the tongue. In some babies, the frenulum is too short or anchors the tip of the tongue too tightly. An 'anterior tongue tie' is the most common sort of tongue tie and can be easily seen (see left diagram). A posterior tongue tie, also known as a submucosal tongue tie, is where the tongue tie is hidden under the mucus lining of the tongue.

When a baby has a tongue tie they cannot move their tongue properly because the frenulum is too short or too tight. This can have an extremely negative impact on breastfeeding as it can stop a baby latching on or sucking properly and so affect the amount of breastmilk which is taken from the breast. Poor latch or sucking can also cause damage to mum's nipples.

In babies with an anterior tongue tie a frenotomy is usually recommended, where the frenulum is cut to release the tongue. It is a simple procedure and a clinician can perform it using scissors or a laser. The procedure can even be carried out in the parents' own home.

As anterior tongue ties have become better understood (as well as their negative impact on breastfeeding) another type of tongue tie was suggested – the posterior tongue tie. This was thought to be the possible cause of breastfeeding problems in babies with no anterior tongue tie but where mum and baby were still struggling with breastfeeding problems typical of a baby with a tongue tie.  A posterior tongue tie is suggested to be a type of tongue tie which cannot be seen but can be felt. Similarly to frenotomy performed on anterior tongue ties, frenotomy for posterior tongue ties can be performed with scissors or a laser. However research shows that in cases where a posterior tongue tie is diagnosed the frenotomy often needs to cut deeper into the hidden frenulum.

Clinicians seem to be aware of more and more cases of problems with frenulum. This increase could well be linked to social behaviours surrounding breastfeeding, and the mother and baby. As birth has become medicalised and technologised so has breastfeeding. Breastfeeding is no longer seen as a natural extension of mothering, and women are less likely to see good models of breastfeeding as they are growing up or when having their own babies. As a result women often lack knowledge and experience as to what normal breastfeeding is like.  Breastfeeding knowledge is sadly even lacked by the very health professionals who should be supporting women to breastfeed. Many nurses, doctors and midwives do not have up-to-date breastfeeding training. What a tragedy it is when new mothers are given incorrect or incomplete breastfeeding information and support, and experiences problems as a result.

The factors which can affect the success of breastfeeding are complex and interrelated. It seems that a simple 'cause-effect' model can't be applied to breastfeeding success.  In other words, it is inaccurate to say that if there is a problem with breastfeeding and no anterior tongue tie is evident, the reason must be an posterior tongue tie and simply treat that.

Worrying repercussions can occur when treating a misdiagnosed posterior tongue tie with a frenotomy, not the least of which is that the mum's commitment and motivation for breastfeeding could be affected when a frenotomy does not solve the problem. Other negative consequences include the possibility of scar tissue and possible discomfort for the baby.  Perhaps incorrect diagnoses of a posterior tongue tie could even affect the manner that anterior tongue ties are treated and viewed. Again this could lead to more negative repercussions for breastfeeding mums – an irony given that posterior tongue ties were first suggested to try and help breastfeeding mum-baby pairs who were having difficulties.

It's possible that there is a link between tongue muscle tension and the tension in the frenulum. Both birth becoming more medicalised and breastfeeding support professionals attempting to quantify the functioning of the tongue, could affect the tension in the tongue and the tension in the frenulum. This could lead to possible incorrect posterior tongue tie diagnoses. Breastfeeding is so important and valuable that we owe it to new mums and babies not to medicalise breastfeeding. Misdiagnosing and treating posterior tongue ties without good research evidence contributes significantly to this.

Written 15th August 2015

Reference

Douglas, P., (2013). Rethinking "Posterior" Tongue-Tie. Breastfeeding Medicine 8 (6).

Milk Matters (2011). The hidden cause of feeding problems?  [online]. Available from: milkmatters.org.uk/2011/04/15/hidden-cause-of-feeding-problems-however-you-feed-your-baby/ [Accessed 27 June 2015]

Palmer, B. (2003). Breastfeeding and Frenulums.  [online].  Available from: www.brianpalmerdds.com/pdf/Bfing_Frenum03.pdf [Accessed: 28 June 2015].

Laura-Jane Marsden is a writer with a special interest in pregnancy, birth and parenting.  She works for the company Pregnancy, Birth and Beyond. Her passion is to see breastfeeding accepted as normal feeding worldwide.

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