Myths and controversies

Vitamin K and implications for division of tongue-tie

All babies in the UK are offered prophylactic vitamin K at birth to prevent a rare but serious bleeding condition called Haemorrhagic Disease of the Newborn. The vitamin K can be given as a one-off intramuscular injection or as a course of oral doses. Exclusively breastfed babies are thought to be most at risk as breast milk is low in vitamin K. However, vitamin K is synthesised in the gut by bacteria and given that breast milk supports the development of healthy gut flora you might expect exclusively breastfed babies to develop sufficient vitamin K very quickly. But of course there are lots of factors at play and interventions such as medications given to mum during labour and post birth, or given to baby in the early days after birth, and how baby is born (whether vaginally or by section)  can have significant effects on the establishment of a healthy microbiome (more information here). So, it is impossible to know how much vitamin K a baby is benefiting from, and which babies may be at risk of bleeding. What we do know is that the older the baby gets the lower the risk but there have been reported cases of Haemorrhagic Disease of the Newborn in babies up to 5 months old.

Given that bleeding is a risk post tongue-tie division then practitioners have a duty if care to do all they can do reduce this risk so asking about family history of bleeding disorders in one way of identifying those babies that may be at risk of excessive bleeding and ensuring babies have had vitamin K prior to division is another. For this reason, NHS hospitals in the UK and practitioners elsewhere in the world have developed policies on this. These policies vary because the numbers of significant bleeds post division are small, we have very little experience and no studies to base these on. Typically, babies will be required to have had the vitamin K injection or two doses of oral vitamin K prior to division or in some cases a blood test to check clotting may be offered.

Below are links to examples of policies on vitamin K from a UK hospital and New Zealand:

Https://www.health.govt.nz/system/files/documents/pages/hp7416-parent-information-on-tongue-tie-v3-jan21.pdf

https://www.evelinalondon.nhs.uk/resources/patient-information/division-of-your-babys-tongue-tie.pdf

Some private practitioners will provide division in the absence of vitamin K with full parental consent acknowledging the potential increased risk of bleeding. However, certainly in the UK the Nursing and Midwifery Council can be very quick to put sanctions in place restricting a practitioners practice when there is a complaint made that involves bleeding post division, so some practitioners are cautious when it comes to this issue and follow NHS guidelines. This response by Sara Wickham MW, who has written extensively on this issue and newborn vitamin K deficiency, is also useful.

I have devised a risk assessment I use for babies who have not had vitamin K which I go through with parents prior to division to enable us to make an informed choice about how best to proceed.

Tongue-tie and open mouth breathing

Tongue-tie and its link to airway development and obstructive sleep apnoea is a hot topic on social media currently. It is a source of huge anxiety for parents as the claims being made by some practitioners in relation to this can sound extremely scary. But these practitioners are jumping ahead of the current research. My blog post explains where we are at with the research currently and provides advice on what to suggest to parents concerned about this issue.

Orofacial Myofunctional Therapy is increasingly being recommended as a therapy that can improve resting tongue posture in conjunction with tongue-tie division or as a standalone therapy.But again research evidence to support the efficacy of this is still lacking particularly in infancy. With OMT the client has to be an active participant in the exercises they are asked to so and understand how to do them and why. So it really isn’t suitable for use in babies and young children. There are OMT practitioners developing strategies for infants but then aren’t these simply going to be a system of exercises similar to those already used routinely be speech therapists and IBCLCs working with infants?

Robyn Merkel-Walsh, a speech pathologist, has written about the use of OMT in babies, young children and children with special needs here.

A systematic review of the literature on OMT published in 2022 by María del Puerto González Garrido highlights papers looking at efficacy in older children and adults but very little on young children.

I have written a blog post on myofunctional therapy which has further information.

Tongue-tie and speech issues

This extract from my book ‘Why Tongue-tie Matters’ addressed the issue of tongue-tie and its relationship to speech problems and provides information on appropriate treatment.

One of the most common concerns parents have with regards to tongue-tie is will it cause difficulties with speech later if left untreated. Most of the available research on tongue-tie focuses on breastfeeding. Little can be found on tongue-tie in relation to speech. So how might a tongue-tie impact speech? Mags Kirk, Independent Speech, and Language Therapist, explains:

We know that the NICE guidelines specify that a tongue tie should only be divided if it is affecting an infant’s feeding. But what if it doesn’t get cut at an early age and then poses a problem with speech development later on?  In my experience children with undivided tongue ties may go on to have speech articulation problems in the future. It’s not a guarantee though, and of course, your child might end up with speech problems regardless of whether they have a tongue tie or not.

So, what are the main issues I see?  Well, I have found that speech and feeding development are intrinsically linked. Think about the way that the tongue develops for feeding from birth. A healthy full-term baby is born with the ability to suckle, and so they learn to suck from the breast or a bottle. The suck gradually gets stronger, and so the baby becomes more efficient at feeding.

At the age of six months, weaning foods are commonly introduced, and now the tongue learns lateral, side to side movements, because it needs to move the food around the mouth so that it can be chewed. This lateral movement is absolutely essential as it is needs to develop before tongue tip elevation can occur. Tongue tip elevation is a crucial part of how most consonant speech sounds are made.

The stability of the tongue in the mouth is crucial for clear development. Try this:

Close your eyes, then count out loud from number one through to twenty while focusing on what your tongue is doing in your mouth. What did you notice? Think about how many times the sides of your tongue touch your top molar teeth. It happens on practically every word and is particularly apparent when you get into the teen words for the ‘ee’ sound. The place where your tongue goes for the ‘ee’ sound is how your tongue gets stability. Without tongue stability it is impossible for the tongue tip to move to where it needs to go to articulate clearly.

Children with untreated tongue tie are frequently unable to achieve this tongue stability. They start to move their tongue in all sorts of ways to get stability. Some children will develop an open mouth posture with their tongue slightly out of their mouth.  Some will be able to keep their mouth closed, but the tongue will remain in a downwards posture in their mouth, rather than where the tongue should live, resting on the palate, on the roof of the mouth.

So why is tongue resting posture important? Well, if an incorrect tongue resting posture is formed, this has an impact on how the tongue can move for specific speech sounds. Think of all the sounds in English that need the tongue tip to elevate…. T, d, s, z, sh, ch, j, l, n, and r. If the tongue is in a low resting posture because of a tongue tie, it makes it hard for the tongue to be able to elevate to the spot just behind the top teeth to make these sounds. The sounds might come out sounding slushy or distorted. The child might end up having a lisp – either a frontal lisp where the ‘s’ and ‘z’ sounds become like a ‘th,’ or a lateral lisp, where the air comes out of the sides of the mouth rather than the front, resulting in a sound a little like the Welsh ‘ll.’ 

Tongue tie can also play havoc with the ‘r’ sound. For the correct production of the ‘r,’ the tongue needs the back of tongue stability we discussed above when thinking about the ‘ee’ sound, but also it needs tension within the tongue muscles. Try this: make a long ‘rrrrr’ sound, keeping your tongue tight and the tongue tip up to the roof of the mouth. Now relax the sides of your tongue but keep your tongue tip up to the palate. You might notice that the sound becomes more like a ‘w’ sound. Children with tongue tie might have difficulty with the tongue tip elevation, but they can also struggle with getting the side tongue muscles nice and tight to get the correct ‘r’ sound.

The ‘l’ sound can also be problematic. If a child has a tongue tie, they might be able to get the ‘ee’ back of tongue stability, but they might not be able to elevate their tongue tip. The result – often the child will say a ‘w’ or a ‘y’ sound instead.

I find it interesting that even adults can continue to experience articulation problems. Some adults have even cashed in on their speech problem – think of Jonathan Ross’ ‘r’ sound, or Drew Barrymore’s lisp… 

Most childhood articulation difficulties clear up eventually as the child matures, but some adults continue to have problems with their ‘s’ ‘r’ and ‘l’ sounds. I would be interested to look in these adults’ mouths to spot whether they have an untreated tongue tie. In most cases where I have been able to have a look, I have found the answer to be a definite yes.

A Japanese paper from 2015 (Ito, et al) looked at the effectiveness of division in five children aged 3-8 years with articulation difficulties. The results were mixed with some early improvement seen in omission and substitutions of sounds in the first 3-4 months post division but ongoing issues with distortion noted at 1-2 years. A study in the USA by Richard Baxter and colleagues (2020) reported in a sample of 37 children aged 13 months to 12 years, that 89% showed improvements in speech at one month but there was no long term follow up. However, both studies are severely limited by their small sample size, the lack of a control group, and the lack of comparison with other interventions such as speech therapy which could be as effective or more effective than surgery.

Interestingly, another small study looking at 59 children aged 2 years one month to 4 years 11 months found no significant differences between those children that had had division, had a tongue tie but had not had division, and those that had never had a tongue-tie (Salt et al, 2020). They measured frenulum structure and function, tongue mobility and speech production and intelligibility. The authors concluded:

This study provides preliminary evidence of no difference between tongue mobility and speech outcomes in young children with or without intervention for tongue-tie during infancy. This study assists with clinical decision making and makes recommendations for families not to proceed with surgical intervention for tongue-tie during infancy, for the sole outcome of improving speech production later in life.

This conclusion supports the stance adopted in the UK when it comes to tongue-tie division which is to only divide the frenulum if it seems to be causing a significant feeding difficulty. This can be a source of anxiety for parents worried about speech. But as this study shows, having a division may not result in significant differences in tongue function and speech long term. The Z plasty division procedure combined with myotomy (release of the genioglossus muscle) when the child is older may provide better results in terms of resolving speech issues (Choi et al, 2011).

There is also the possibility that the tongue-tie will reoccur over time. Research on wound healing suggests that the wound may remodel over a period of two years so recurrence many months or even a year or two down the line is possible. Plus, we also need to keep on mind that, as Mags has explained above, impaired tongue tip elevation is a significant factor in speech difficulties. But babies with significant restriction in tongue elevation are likely to have significant feeding issues, particularly in terms of weight gain and efficiency, so are highly likely to fall into the criteria for division for feeding anyway. Finally, of course, division is not without potential complications and can disrupt breastfeeding, even if only briefly, and this is not something we would want to risk based on preventing an issue that may never arise.

Dental issues and tongue-tie

Tongue posture and function influences the growth and development of bony structures of the oral cavity including the palate and jaw. ‘The shortness of the lingual frenum can affect the physiological posture of the tongue and its neuromuscular behaviour’ (Dezio et al, 2015). The low tongue posture and tongue thrust associated with a tongue-tie can cause malocclusion, such as an open bite and spreading of the lower front teeth (Vaz & Bai, 2015, Jang et al, 2011, and Dezio et al 2015).

A study in Spain by Calvo-Henriquez, et al (2021) of 100 patients found an association between a short lingual frenulum and class 3 malocclusion where the lower jaw is larger than the upper jaw. This class of malocclusion impacts around 8% of people with malocclusion. In the study 48% of the short lingual frenlum group presented with this, compared to 24% of the group with normal lingual frenula.

A lack of tongue mobility, particularly lateral (side to side) movement may make it difficult to clear food debris away from teeth and spread saliva predisposing to dental decay.

So, should tongue-tie division be offered to babies and young children to prevent dental problems later? Paediatric surgeon Paul Johnson (2006) writes:

Problems with dentition have been reported with tongue-tie including lower incisor deformity, gingival recession, and malocclusions. However, the evidence is not strong enough to recommend prophylactic division of tongue-tie in order to prevent malocclusion. Often these conditions are associated with additional abnormalities such as deviation of the epiglottis or larynx. It is widely accepted that the tongue can influence face development and cases of impaired maxillary and mandibular development being resolved by tongue-tie division have been reported.

Clearly, as with feeding and speech, the impact of tongue-tie on dentition needs further research. But dental concerns may be a reason for division of tongue-tie to be considered in older children and adults.