Mouth breathing and tongue-tie

The link between tongue-tie and mouth breathing and the consequences of mouth breathing are issues that are increasingly being raised on social media and in my clinics.

Some babies, and indeed some children and adults, sleep with their mouths open and this can lead to noisy breathing, snoring and a dry mouth.

So why do some babies do this? Well, the answer lies with the resting posture of the tongue. When we are asleep the body of our tongue should rest upwards forming a seal against the roof of the mouth with the tip of the tongue sitting just behind the upper teeth. This creates what is known as complete lingual palatal suction and this has an influence on the formation of the palate (roof of the mouth) and the airway. For this reason the tongue is often described as the ‘architect of the mouth’.

Correct resting tongue posture creates pressure against the roof of the mouth, in the womb and during infancy, causing the palate bones to spread to create a broad dental arch and open airway. When a tongue-tie is present the resting position of the tongue will be low in the mouth resulting in a high arched or bubble palate and associated deviation of the nasal septum with narrowing of the nasal airway. Tongue-tie may also influence lower jaw development and a small and/or recessed jaw can impact the airway too.  (For more information see here.) Furthermore, when a tongue-tie is present the posterior part of the tongue may, when relaxed, drop blocking the pharynx (upper part of the throat) causing further airway obstruction.

Babies, as well as older children and adults, naturally breathe through their noses but will breathe through their mouth in a situation where the nasal airways are compromised.

Why does it matter whether we breathe through our noses or our mouths?

In children mouth breathing can lead to microtrauma of the tonsils and adenoids causing them to enlarge and restrict the airway and this is associated with sleep disordered breathing (SDB) and obstructive sleep apnoea (OSA).

What is SDB/OSA?

Sleep Disordered Breathing is characterised by open mouth breathing, snoring and noisy breathing and may develop into OSA later in childhood or adulthood.

Obstructive Sleep Apnoea affects all age groups but is rare in full term babies and babies under 6 months old. Preterm babies are more likely to be affected due to their small airway and low muscle tone.

OSA is the abnormal collapse of the upper airway during sleep and symptoms include:

• Prolonged pauses in breathing of more than 20 seconds
• Repeated pauses of less than 20 seconds
• Low oxygen levels and slow heart rate (blue episodes)
• Blue/floppy episodes requiring emergency care

Factors associated with OSA, other than the compromised airway already discussed, include:

• Reflux
• Obesity
• Allergies
• Neurological/muscular problems including fits, cerebral palsy, muscular dystrophy
• Low muscle tone – Downs Syndrome, floppy larynx.

Great Ormond Street Hospital for Children in London describes the impact of OSA in children:

Younger children who suffer from sleep deprivation may be hyperactive or aggressive, whereas older children may feel tired. A child with sleep apnoea may have difficulty concentrating or behave differently. They may awake from sleep feeling tired and unhappy, with a headache, or may refuse breakfast. Poor growth and weight gain, poor school performance, a lack of concentration and aggressive behaviour may also be seen. 

It is possible that children may be mis-diagnosed with conditions such as ADHD as a result and Richard Baxter, a US Dentist, suggests that screening for sleep disorder and preferably sleep studies should be carried out before children are placed on medication for ADHD (Baxter, 2018).

Should we divide tongue-ties in babies to prevent SDB/OSA?

Whilst there is growing acknowledgement of the influence tongue resting posture, and therefore tongue-tie, has on oro-facial development including the development of the airway, there is a paucity of research on the effectiveness of tongue-tie division in preventing and treating these issues. Richard Baxter (2018) talks about using palate expansion alongside the removal of tonsils and adenoids as being effective in reducing SDB and OSA. He explains that tongue-tie division and expanding the palate will increase nasal volume and thereby enable a child to breathe through the nose, reducing the microtrauma to the tonsils and adenoids. But says research on this approach in reducing SDB/OSA is lacking.

Dr Soroush Zaghi, a US ENT and Sleep Surgeon, has spoken about a multi-interventional approach to these issues in older children at the 2019 conference of the Australasian Society for Tongue and Lip Ties. He uses a combination of the traditional approaches of adenoidectomy and tonsillectomy alongside tongue-tie division (in some cases) and may combine this with myotomy (division of the genioglossus muscle at the base of the tongue) and uses myofunctional therapy to retrain the tongue in correct positioning. More information about his work can be found  here. He has also published a paper on a series of case studies.

A paper by Dr Zaghi’s now retired colleague Dr Guilleminault et al (2016) reports an association between tongue-tie and sleep problems. But is also states clearly that there is no evidence that tongue-tie causes SDB/OSA. It is also important to point out that there is currently no evidence that sleep apnoea is a risk factor for sudden infant death syndrome. However, more research on all of this very much needed.

So where does this leave you with your concerns about your baby or child?

Most practitioners who treat babies for tongue-tie in the UK are following the NICE (2005) Division of Ankyloglossia (Tongue-tie) for Breastfeeding. There is no guidance relating to division in relation to sleep or indeed other issues such as speech. Consensus statements on tongue-tie from other countries have also generally focused on breastfeeding since this is the issue where there is the most research in relation to the efficacy of tongue-tie division.

This leaves professionals like me, who have a background in infant feeding, in a position where we have  knowledge and expertise when it comes to infant feeding and tongue-tie. But, we do not have the skill set needed to assess and decide the best approach for babies with mouth breathing and sleep related difficulties. As such it would be very wrong for us to simply divide a tongue-tie on a promise that this will prevent or cure SDB or OSA because the research to support this is lacking and expert opinion suggests a multi-interventional approach is warranted in most cases, which may or may not include addressing the tongue-tie.

So, just as I am very vocal in my view that all babies having a division should have had a robust feeding assessment by an International Board-Certified Lactation Consultant (IBCLC), or someone with similar expertise, before division to ensure it is likely to be of benefit. I would urge parents to seek out an ENT Surgeon with an interest in sleep disorders so the entire picture can be evaluated, and an appropriate treatment plan put in place. Of course, if there are concerns about the baby’s feeding then having a division in that situation will certainly help with improving tongue resting posture and if breastfeeding can continue this can help with the spread of the palate. So, this certainly will not be detrimental in terms of any evolving sleep issues.

I am happy to see parents of babies up to one year of age who have any concerns relating to tongue-tie and evaluate this from a feeding perspective and provide information in relation to other issues such as speech, mouth breathing, sleep and so on.

Sarah Oakley 30 December 2021.