Tongue function assessment for tongue-tied babies.

A BRIEF DEFINITION OF A TONGUE-TIE

“A tongue-tie (also known as Ankyloglossia) is determined by the presence of a tight lingual frenulum (connective and fascial tissue), that restricts normal movement of the tongue”.

Tongue-tie is determined by more than what you can visibly see (the tip of the iceberg, so-to-speak). It is identified by many factors of tongue movement and it is accurately assessed with a working clinical knowledge of normal baby tongue function. This requires a deep understanding and experience of how babies remove milk.

THE PARENTS EXPERIENCE OF FEEDING

When parents report prolonged feeding difficulties (breast or bottle), despite professional feeding support, efforts should be made to investigate early in the process. Assessment by a suitably qualified healthcare professional, with an internationally recognised feeding qualification helps to achieve an accurate diagnosis and appropriate treatment.

TREATMENT DELAYS & MISSED DIAGNOSIS

Current delays in diagnosis of tongue function assessment for tongue-tied babies or missed diagnosis leads to prolonged poor feeding. This often includes ONE OR MORE of the following:

weight-loss or slow weight gain
insufficient breastmilk supply
nipple pain and damage
engorgement, mastitis
restricted jaw and tongue mobility
reflux, colic, hiccoughs
reduced breastmilk supply
frequent and insufficient feeding
exhaustion, restlessness
difficulty controlling flow of milk
difficulty managing solids
difficulty achieving and sustaining latch
poor confidence levels in breastfeeding, mental health demise
inevitable uptake of bottle feeding
clicking, dribbling, choking
aspiration of milk
severe gastro-intestinal symptoms brought on by poor feeding technique
un-necessary and ill advised medications to mask these symptoms

UN-NECESSARY MEDICATION

There are an alarming number of babies prescribed drugs such as omeprazole or gaviscon for reflux symptoms. These medications create a change in the stomach pH (making it more alkali). The reduced acidity in the stomach makes babies more susceptible to gastro-intestinal upset and infection. Whilst a small number of babies may have an accurate diagnosis of GORD, (blood in their sick and evidence of inflamed mucosa in the oesophagus), expected levels would certainly not reach the numbers we are seeing in clinical practice.

ANTERIOR OR POSTERIOR TONGUE-TIE

There seems to be a growing obsession about whether a tongue-tie is anterior (at the tongue tip) or posterior (not involving the tongue tip), as if it should make a difference to diagnosis. These descriptions are vague and inaccurate, not to mention misleading to parents. It merely describes how much of the tongue is involved, which has limited use and it does not determine function.

Unfortunately, health professionals seem to be in conflict about the significance. This confusion is usually caused by a misunderstanding of the basic principles of tongue peristalsis.

Peristaltic contraction involves the whole length of the tongue, not just the tongue tip. During tongue function assessment for tongue-tied babies, there is a focus on the assessment of anatomy parameters and frenulum attachment to the tongue is considered for appearance scoring. However, this is only in conjunction with a thorough function assessment.

There is no physical measurement of how or when a perceived anterior tie becomes a posterior tie, so its very subjective. It is also worth recognising that the anterior aspect of the frenulum also has a posterior aspect as it is one structure. If the full structure of restriction does not get fully released, normal tongue function is unable to be resumed.

TONGUE FUNCTION ASSESSMENT IS CRUCIAL

This is how we audit whether a tongue-tie procedure is a necessary risk or un-necessary. As clinicians, it is important to compare feeding symptoms before and after a procedure. This helps us understand whether tongue function has improved or not.

Therefore, the dismissal of a tight and restrictive lingual frenulum that does not involve the tongue-tip, causes women to give up breastfeeding. It also condemns babies to poor bottle feeding techniques and a lifetime of suffering the consequences of poor tongue function. This can later affect all sorts of issues with poor oral health and development, dental concerns and poor body posture in adulthood.

WHAT ABOUT BODYWORK?

We know that birth can be a traumatic process, regardless of mode of delivery. In addition to skilled feeding support and tongue function assessment, we also need to consider whether other factors are at play. Many babies take shock and trauma into their tissues, membranes and fascia during the birth process.

SIGNIFICANCE OF FASCIA

In the last 20 years we have learned so much about the significance of fascia and how it holds tissue memory. Much like the fascial tissue of the lingual frenulum, we have fascia throughout the body. It is present from within the cranium to the tips of our toes. This fascia can become stiff, restricted and in-elastic, causing the body to compensate and create unhealthy patterns with our body system.

The human body can struggle to regulate and facilitate natural healing potential. Treatment such as Craniosacral Therapy, helps to resource underlying health. This moves the body from an overstimulated (sympathetic nervous system) “fight and flight” state, to a relaxed (parasympathetic nervous system) “rest and digest” state.

This allows the body to unwind fascial tension, in parts of the body under stress. The body can be affected within the cranial membranes, the jaw, neck, shoulders, diaphragm, digestive system, to name but a few. Sometimes the Craniosacral therapy is required instead of tongue-tie surgery. We always recommend it afterwards to help with rehabilitation following tongue-tie surgery.

CHOOSING THE RIGHT PROVIDER

When choosing the right tongue-tie provider, it is crucial to understand that function has to remain the focus of any assessment. This predominantly informs the decision of whether frenulotomy (the surgery to release the tongue-tie) is going to improve the function and ability to remove milk.

Most Frenulotomy providers in the UK, use a Function Scoring Assessment Tool (HATLFF – Hazelbaker Assessment Tool for Lingual Frenulum Function). This provides a robust and evidence-based framework to assess tongue funtion and allows accurate diagnosis to inform whether treatment is necessary.

The gold standard to achieving accurate and accountable diagnosis relies on the provider to be skilled in knowing what is normal tongue function for a baby. This requires the provider to be qualified in two equally important skills. Firstly, as a Lactation Consultant (IBCLC is the only internationally recognised qualification in Breastfeeding and lactation) as well as being a Qualified and professionally regulated healthcare professional, who is also regulated by the Care Quality Commission. You can find a list of trusted providers on the Association of Tongue-tie Practitioners (ATP) website www.tongue-tie.org.uk. This is a specialist tongue-tie charity who provide advice, guidance and support to parents, NHS services and private providers.

TONGUE FUNCTION ASSESSMENT FOR TONGUE-TIED BABIES

The examination of tongue function assessment for tongue-tied babies involves a physical digital assessment of tongue function.

FUNCTION – Involves 7 aspects of movement (Lateralisation, Lift, Extension, Spread, Cupping, Peristalsis, Snapback).

APPEARANCE – Also assessed (When lifted, Elasticity, Length of frenulum, Attachment to tongue, Attachment to alveolar ridge).

Assessment CANNOT be determined on a video / photograph or based on what the tongue looks like when a baby cries.

Physical feeding symptoms tell us feeding is not going well and therefore indicates a need for further investigation.

PARENTS SEEKING ADVICE

Parents should always ensure that the clinician they choose has the necessary credentials to assess function competently, with skilled knowledge of normal tongue movement. Competent assessment of feeding difficulties and on-going feeding support should form the basis of care. Bodywork should also be considered, to ensure adequate rehabilitation of normal tongue function post procedure.

Frenulotomy should never be an isolated surgical procedure based on a frenulum that just looks like it “needs a snip”. Equally a frenulum attached further away from the tongue tip should never be overlooked. Breast or bottle feeding support and discussion about bodywork, ensures holistic care is at the heart of professional and accountable tongue-tie care.

FOR FURTHER INFORMATION

For more information in all things tongue-tie related, or for treatment in the Warwickshire and West-Midlands areas, Please go to: www.feeding-untied.co.uk

To find a practitioner in your geographical area or to check out further information and recent tongue-tie national research and audits, go to www.tongue-tie.org.uk

Why is tongue function assessment a key aspect to an accurate diagnosis of tongue-tie for babies?