Unravelling Tongue Tie 

For any Chiropractor wanting to encourage breastfeeding, knowledge of tongue tie is absolutely essential.  The ability to distinguish functional tongue restrictions from ankyloglossia is the key to helping these babes and their mothers.
Ankyloglossia affects 4-10% of the population and is more predominant in males. It is sometimes associated with other midline defects including lip tie, has a hereditary link, but not all cases are explained by genetics (CADTH 2016).     
In Australia, there are approximately 300,000 births each year (Australian Bureau of Statistics 2015). This equates to 12000-30000 tongue ties each year.  It is a very real and relatively common problem that needs to be understood and screened for because its potential sequelae can be quite limiting.
Current research indicates that ankyloglossia is at best poorly understood among health professionals, which can lead to prolonged difficulties with both mother and child. Distressingly, most of these difficulties get blamed on the mother (Edmunds JE1, Fulbrook PMiles S 2013).

Development
Breastfeeding should be considered a measure of normal; it makes no evolutionary sense to have a baby that cannot breastfeed. The action of breastfeeding is a complex balance, made up of a sequence of movements that allow for the suck- swallow-breathe rhythm. When feeding, the baby’s lips flange, tongue extrudes out and anterior tongue curls under the nipple to form a tight seal. The posterior tongue then lifts up and down in a peristaltic motion creating an intra-oral vacuum. These pressure changes allow the milk to be extracted and moved as a bolus to the back of the mouth. This same peristaltic motion is important in co-ordinating the movement of the bolus with the inhalation and exhalation so as not to aspirate the milk nor ingest air (Geddes DT, et al 2008). When this action is performed successfully, the baby is easily able to feed and bond with its mother. 

As the tongue is formed embryologically, it uses the midline frenulum to guide its growth.  At approximately five weeks gestation, this tissue undergoes apoptosis. Ankyloglossia is the result of incomplete apoptosis of this tissue. It restricts the moveability of the tongue. It can occur in differing degrees giving us different classes of Tongue Tie.  This process has genetic links though growing evidence points to environmental factors as well (Hazelbaker, AK 2010).

Signs and Symptoms of Tongue Tie
Ankloglossia has been associated with a number of clinical symptoms, (Elvira Ferrés-Amat, et al  2015).

  1. Abnormal breastfeeding including poor attachment; clicking, coming on/off breast, blistering along lips, leakage from mouth or nose, falls asleep at breast “lazy feeders”, short frequent feeds, chomping action, extra sucking of buccinators whilst feeding, arching of back, clenching of hands while feeding, cortisol sign, thumping on boob while feeding, decreased weight gain, severe nipple pain with latch (ongoing), damaged nipples; creased or blanched, flattened cracked, bruised, blistered, bleeding and lipstick shaped. Blocked ducts, mastitis, infected nipples and thrush, compromised milk supply, maternal feelings of stress, anxiety, guilt, fatigue, depression, incompetence.
  2. Structural clues; heart shaped tongue, high arched and ridged palate, milk on dorsum of tongue (can be misdiagnosed as thrush), stork bite, cupping of tongue whilst crying, laryngomalacia, abnormal bites, retrognathia, anterior head carriage.
  3. Systemic clues; reflux, gagging,  supplemental (formula) feeding, chronic burping, flatulence, distended belly, green poos, mouth breathing excessive dribbling, enlarged tonsils, enlarged adenoids sinus and ear infections,
  4. Dental clues; difficulty teething, increased dental caries, gap between upper teeth, mouth breathing, excessive dribbling, abnormal bites, teeth grinding,

Anatomy and Physiology
The innervation of the tongue is complex and is linked to its embryological development. The tongue has no neuromuscular spindles so its spatial regulation is conditioned by external conditions to it (Dezio, M et al 2015). The sensitivity (touch) of the tongue is innervated by the Facial nerve, Trigeminal (via lingual and mandibular branches) and Glossopharyngeal nerves. The motor innervation is largely Hypoglossal with the innervation of the palatoglossus muscle (whose function is to lift the posterior tongue) largely attributed to the Vagal nerve (Grays Anatomy 2008).

The tongues’ sympathetic and parasympathetic innervation is also part of salivation, head position relative to neck, body position and posture, jaw position and the affects these all have on heart rate and respiration rate (Edwards IJ, et el 2009).

There are many functional synergies among the different systems of the oral cavity and the balance of these systems is fundamental for balanced facial and body development and posture. Dysfunctional tongue movement affects palate development and therefore the airways. This may lead to increased mouth breathing which affects head posture which in turn affects tongue movement. It is in this way that Tongue Tie can be related to sleep apnoea and obstructive sleep disorders and their potential sequelae (decreased cognition, tonsillectomy, adenoidectomy, etc.) (Dezio M, et al 2015).

Chiropractic examination
It is clear that cranial strains such as the ones described by Waddington et al (2015) attributed to trauma resulting from birth or womb positioning can affect the way a baby feeds (Genna CW 2015). Clinical experience indicates addressing these cranial problems could be linked to improvements in breastfeeding.  

This all points towards the necessity of a thorough neurological examination of the whole baby before an adequate diagnosis can be made. It also explains the importance of ruling out cranial strains as a possible cause for tongue dysfunction prior to frenectomy. Chiropractic examination needs to consider the whole baby with particular attention to the upper cervical and cranial bones (especially but not limited to, occiput, sphenoid, maxillary, palatine and zygomatic bones).

When we consider the dysfunctional tongue, it is important to question whether the tongue is unable to perform the necessary movements due to sensory inhibition, motor inhibition or structural inhibition. When you can confidently assess tongues in this manner, you can make informed clinical decisions about management.

Management Approaches
The number of possible variations reflects the reports of variations in success of frenotomies. Success in resolving these issues relies on the ability to diagnose accurately the problems present and to work affectively as a team to resolve any complications that occur with the baby’s presentation.

Once a tongue tie diagnosis has been confidently made, the best solution is a frenectomy (Elvira Ferrés-Amat 2015). This requires a referral to a qualified paediatric dentist or GP. It is best to research the persons in your area, choosing one with experience rather than focussing of the method of revision. There is not enough evidence to support the use of laser revision over snipping or vice versa.

Following a frenectomy, the baby may require follow up care with a lactation consultant, chiropractor, speech therapist and/or orofacial myologist to gain adequate function of the tongue.  As a chiropractor referring it is imperative that you refer to a practitioner with knowledge of tongue tie including the often controversial “posterior” tongue tie.

The world doesn’t need any more babies with hypermobile, dysfunctional tongues due to a revision that wasn’t necessary. Nor does it need any more mother- baby dyads struggling through excruciating breastfeeding or giving up entirely because they have been told ankyloglossia doesn’t exist/ isn’t a problem/ shouldn’t be revised. 

Chiropractors, particularly those with cranial expertise, are well placed to guide parents through this struggle.  The key is a good, functional assessment that leads to a proper diagnosis and kind and gentle care of both the babes and their family units.
 
Written By Jo Sexton, Chiropractor


References:

  1. Australian Bureau of Statistic 2015
  2. Canadian Agency for Drugs and Technologies in Health (CADTH) (2016) “Frenectomy for the Correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines” Ottowa, Canada
  3. Coryllos, E, Watson Genna, C, Salloum, AC, (2004) “Breastfeeding: Best for mother and Baby” newsletter American Paediatric Association
  4. Dezio M, Piras A, Gallottini L, Denotti G. (2015) “Tongue-tie, from embriology to treatment: a literature review.” J Pediatr Neonat Individual Med.
  5. Edmunds JE1, Fulbrook PMiles S (2013) “Understanding the experiences of mothers who are breastfeeding an infant with tongue-tie: a phenomenological study.” J Hum Lact. 
  6. Edwards IJ1, Deuchars SADeuchars J2009 “The intermedius nucleus of the medulla: a potential site for the integration of cervical information and the generation of autonomic responses.” J Chem Neuroanat. 
  7. Elad D1, Kozlovsky PBlum OLaine AFPo MJBotzer EDollberg SZelicovich MBen Sira L. 2014 “Biomechanics of milk extraction during breast-feeding” Proc Natl Acad Sci USA
  8. Elvira Ferrés-Amat,1 Tomasa Pastor-Vera,2 Eduard Ferrés-Amat,3 Javier Mareque-Bueno,4 Jordi Prats-Armengol,5 andEduard Ferrés-Padró  2015 “Multidiscilinary management of ankyloglossia in childhood. Treament of 101 cases. A protocol” Med Oral Patol Oral Cir Bucal
  9. Geddes DT1, Kent JCMitoulas LRHartmann PE. (2008) “Tongue movement and intra-oral vacuum in breastfeeding infants” Early Hum Dev
  10. Genna CW (2015) “Breastfeeding infants with congenital torticollis” J Hum Lact. 
  11. Grays Anatomy (2008) Section 3, Chapter 35 - Neck and Upper Aerodigestive Tract - Pharynx. In: Standring, S, editors. Gray's Anatomy: The Anatomical Basis of Clinical Practice, 39th Edition. London: Elsevier; 2008. p628
  12. Hazelbaker, AK (2010) Tongue Tie Morphogenesis, Impact, Assessment and Treatment Columbus Ohio
  13. Ito Y, Shimizu T, Nakamura T, Takatama C.(2015) “ Effectiveness of tongue-tie division for speech disorder in children.” Pediatr Int. 
  14. Kotlow, LA (1999) “Ankyloglossia (tongue-tie): a diagnostic and treatment quandary” Paediatric Dentistry
  15.  Kotlow, LA et al (2011) “Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers” European Archives of Paediatric Dentistry 12 (Issue 2).
  16. Li RFein SBChen JGrummer-Strawn LM. (2008) “Why mothers stop breastfeeding: mothers' self-reported reasons for stopping during the first year.” Pediatrics.
  17. National Health and Medical Research Council (2012), Infant Feeding Guidelines,Canberra
  18. Saccomanno S, Antonini G, D'Alatri L, D'Angelantonio M, Fiorita A, Deli R.(2012) “Causal relationship between malocclusion and oral muscles dysfunction: a model of approach.” Eur J Paediatr Dent.
  19. Waddington ELSnider KTLockwood MDPazdernik VK. 2015 “Incidence of Somatic Dysfunction in Healthy Newborns” J Am Osteopath Assoc
  20. World Health Organization statement (2011), Exclusive breastfeeding for six months best for babies everywhere, Geneva: World Health Organization