Tongue ties, or ankyloglossia, have become a significant topic in infant feeding and oral health. Yet, many healthcare providers, especially pediatricians, often miss diagnosing tongue ties. This oversight can leave parents confused and frustrated, particularly when feeding challenges persist despite other interventions. Here, we explore why tongue ties often go undiagnosed, the critical components of a thorough assessment, and how they impact feeding and overall health.
Why Tongue Ties Go Undiagnosed by Pediatricians
Lack of Training in Oral Function
Pediatricians are invaluable in monitoring a baby’s growth and development, but their training rarely includes in-depth education on oral function or how to identify oral restrictions like tongue ties. Most pediatric training focuses on general health and anatomy without delving into the nuanced mechanics of feeding and oral motor function. As a result, subtle signs of a tongue tie, especially posterior ties, are often overlooked.
Pediatricians receive minimal formal training in infant feeding and oral mechanics during their medical education and residency programs. Here's a breakdown:
Medical School:
Focus is primarily on general anatomy, physiology, and pathology. Specific training on breastfeeding, oral mechanics, or feeding challenges is nonexistent or rare.
Residency in Pediatrics:
The American Academy of Pediatrics (AAP) recommends some training on breastfeeding and infant nutrition, but the time devoted to these topics is typically limited to a few hours of lectures or workshops, if that.
Clinical experience might include observing or assisting with feeding-related cases, but this is not always standardized or comprehensive.
Continuing Education:
Pediatricians can pursue additional training in breastfeeding and oral mechanics through certifications, such as becoming an International Board Certified Lactation Consultant (IBCLC), but this is optional and uncommon.
Further reading here
Challenges:
Lack of Emphasis on Oral Mechanics: While pediatricians are trained to identify visible abnormalities, such as cleft palate, more subtle issues like posterior tongue ties or oral tension are often missed due to insufficient training in oral function.
Reliance on Specialists: When feeding issues arise, pediatricians frequently refer families to specialists. However, these specialists, such as:
Occupational Therapists (OTs)
Speech-Language Pathologists (SLPs)
Ear, Nose, and Throat Specialists (ENTs)
...may not always have expertise in oral function or feeding dynamics. As a result, families can face delays in receiving appropriate care or accurate diagnoses.
Missed Opportunities to Refer to IBCLCs
International Board Certified Lactation Consultants (IBCLCs) who have received additional training in oral ties are experts in infant feeding and oral function, yet many pediatricians do not refer families to them when feeding challenges arise. Instead, they may attempt to address feeding issues themselves, often focusing on:
Adjustments to feeding positions
Temporary solutions like nipple shields or changes in feeding frequency
Suggesting formula or bottle feeding if breastfeeding becomes challenging for the dyad
These approaches may help manage symptoms but fail to address the root cause, leaving families without a long-term solution.
For parents seeking comprehensive evaluations of feeding issues, consulting a skilled IBCLC and pediatric dentist with expertise in oral mechanics is often the best approach.
Visual-Only Assessments Many tongue ties, particularly posterior ones, are not immediately visible during a routine oral exam. A quick glance under the tongue may fail to reveal a restriction that significantly impacts function. Comprehensive functional assessments, which go beyond a simple visual check, are rarely part of a pediatrician’s evaluation.
Dismissal of Feeding Challenges Feeding challenges such as poor latching, nipple pain, or slow bottle feeding may be attributed to other factors like positioning, milk supply, or normal baby behavior. Without specific training in identifying compensations for oral restrictions, these challenges are often misdiagnosed or minimized.
The Importance of a Comprehensive Oral Functional Assessment
A proper assessment for tongue tie goes far beyond a visual examination. It involves:
Detailed Oral Function Examination
A skilled provider evaluates the baby’s tongue range of motion, elevation, lateralization, and suction. They also assess how the tongue interacts with other oral structures, including the lips, cheeks, and palate.
Feeding Observation
Observing a baby during breastfeeding or bottle feeding is crucial. This allows the provider to identify compensatory behaviors in real-time, such as excessive jaw movement, lip tension, poor tongue activation, or poor milk transfer. Feeding observations can reveal how a tongue restriction impacts not only feeding efficiency but also maternal comfort during breastfeeding.
Signs of Compensation
Babies with oral ties often develop compensations to manage feeding despite limited tongue mobility or oral function. These compensations can occur during breastfeeding or bottle feeding and may lead to inefficient feeding, discomfort, or other challenges. Here's a list of common signs:
Signs of Compensation at the Breast:
Shallow Latch:
Baby latches to the nipple instead of drawing it deeply into the mouth.
Clicking Sounds:
Indicative of losing suction repeatedly while feeding.
Frequent Unlatching or Fussiness:
Baby may pull off the breast due to frustration or fatigue.
Lip Gripping:
Baby uses the lips instead of the tongue to maintain suction.
Excessive Air Intake:
Causes gassiness, reflux, or colic-like symptoms.
Increased Feeding Frequency:
Baby compensates for poor milk transfer by feeding more often.
Breast or Nipple Pain:
Shallow latch or biting behaviors can cause maternal discomfort or damage (e.g., cracking, blistering).
Noisy Breathing While Feeding:
Difficulty maintaining suction can result in sounds like snorting or gulping.
Fatigue During Feeding:
Baby tires quickly and falls asleep at the breast before completing a feeding.
Signs of Compensation with a Bottle:
Poor Seal Around the Nipple:
Milk may leak out the sides of the mouth.
Tongue Thrusting:
Pushing the nipple out instead of drawing it in.
Choking, Gagging, or Coughing:
Difficulty managing milk flow due to ineffective suck-swallow coordination.
Suck-Swallow-Breathe Discoordination:
Difficulty pacing feeding, leading to pauses for catching breath, choking, coughing, or sputtering
Extended Feeding Times:
Baby may take longer to finish a bottle due to weak suck.
Excessive Jaw Movement:
Baby may chomp or chew because of poor tongue activation.
Preference for Bottle Over Breast:
Bottles allow milk flow with less effort, leading to a preference.
Inconsistent Feeding Patterns:
Alternating between gulps and pauses, or sucking inconsistently.
General Signs of Oral Compensations:
Limited Weight Gain:
Despite frequent feeds, milk transfer may be insufficient.
Excessive Drooling:
Difficulty managing saliva due to poor oral function.
Cheek or Jaw Dimples During Feeding:
Indicates overuse of facial muscles to create suction.
Tension in the Body:
Babies may arch their back, clench fists, or exhibit hypertonicity due to feeding stress.
Without observing these behaviors during feeding, many tongue ties, particularly posterior ones, go unnoticed.
Anterior vs. Posterior Tongue Ties
Anterior Tongue Tie
This is the classic tongue tie, where the frenulum—the tissue connecting the tongue to the floor of the mouth—is visibly short or tight. An anterior tie often restricts the tongue’s forward movement, making it more apparent during a quick oral exam.
Posterior Tongue Tie
Posterior ties are less visible but can significantly restrict tongue mobility. They are often located further back under the tongue and can affect elevation, lateralization, and the ability to create an effective latch. Despite being harder to see, posterior ties can cause just as many feeding challenges and often go undiagnosed without a functional assessment.
Broader Impacts of Tongue Tie
Tongue ties don’t just affect feeding. They can influence:
Speech development: Restricted tongue movement can lead to articulation issues.
Oral health: Poor tongue mobility can impact swallowing, leading to tooth decay or gum issues.
Airway function: Tongue ties are sometimes linked to sleep-disordered breathing and other airway concerns.
Posture and body tension: Oral restrictions can create compensations that affect the entire body’s alignment and muscle tension.
Much more! See here https://tonguetie.net/consequences/
The Role of Skilled Providers in Tongue Tie Assessment
The best person to assess for oral ties is a *skilled International Board Certified Lactation Consultant (IBCLC) or a *skilled dentist who specializes in oral restrictions. These professionals are uniquely qualified to:
Perform comprehensive oral and feeding assessments.
Identify both anterior and posterior tongue ties, any other oral ties (lip ties, cheek ties).
Provide appropriate referrals for further treatment, such as bodywork or a frenotomy.
*Note that not all IBCLC's and not all dentists have training in oral ties and oral function. Skilled IBCLC's and skilled dentists have taken additional training and education in this area.
Resources for Parents
If you suspect a tongue tie, here are some helpful resources:
Connect with an IBCLC near you who is trained in oral function.
ICAP: International Consortium of Ankylofrenula Professionals directory for tongue-tie-savvy providers.
Books: “Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More” by Dr. Richard Baxter.
The Tongue Tie Experts Podcast with Lisa Paladino
Dr. Bobby Ghaheri's website and social media platforms offer a comprehensive resource for understanding oral ties.
Websites:
- https://tonguetieindia.com/myths-about-tongue-ties-and-lip-ties/
A parent’s firsthand account of their baby’s oral ties being dismissed by a pediatrician. The baby experienced choking episodes and struggled with eating solids. Read their story here.
Final Thoughts
Identifying and addressing tongue ties requires a multi-faceted approach involving trained professionals and careful observation. While pediatricians play a crucial role in your baby’s health, they may not always have the specialized training necessary to diagnose tongue ties accurately. If you’re facing feeding challenges, consider seeking an evaluation with an IBCLC or a dentist experienced in oral restrictions. Early identification and intervention can make a significant difference in feeding success and overall health.
Your journey through parenthood is unique, and finding the right support is essential. Don’t hesitate to advocate for your baby and seek the help you need.
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