Tongue-tie and Speech

Whilst I totally understand parental concerns about the potential for a tongue-tie to cause future speech issues it remains the case that the only justification for doing a tongue-tie division (frenulotomy) procedure is babies under one year of age is a ‘significant feeding difficulty’. This difficulty may be with breastfeeding, bottle feeding or solids.

A lingual frenulum is a normal anatomy found in 99% of babies (Haham, 2014). It becomes a restricted lingual frenulum or ‘tongue-tie’ when it is too short, tight or anchored too close to the tongue tip to allow the tongue to function as it should. But it is even more complicated than this because the lingual frenulum is formed from a fold in the fascia that extends across the floor of the mouth (Mills, et al, 2019). In cases where this fascia is more flexible even a short, tight frenulum won’t necessarily have any significant impact on function.

As Mills et al (2019) state:

‘Ankyloglossia can perhaps be considered an imbalance of the fascial roles, where its provision of tongue stability impacts on tongue mobility.’

No functional deficit means no justification for putting a baby through a surgical procedure which is not without risks. These can include infection, significant bleeding requiring medical intervention, damage to surrounding structures (which may lead to the need for surgical repair in the case of salivary duct damage or numbness and deterioration in tongue function in the case of lingual nerve damage), pain and recurrence (which may require further surgical intervention). So, if your baby is feeding well no ethical practitioner is going to offer a division.

So what is the likelihood that a tongue-tie will impact speech later on?

In babies who have sufficient function to feed well then the likelihood is that they won’t have issues with speech as more movement is required for feeding than is required for speech. A speech therapist colleague of mine has observed that the older children she sees who are struggling with speech due to tongue-tie as usually those that have had significant issues with feeding and should have had division as a baby, but did not get diagnosed or missed out on treatment, and those who have other developmental problems which means they struggle to compensate for any restriction in their tongue movement.

Obviously, speech difficulties can arise from a number of different issues including autism, apraxia, cerebral palsy, learning disability, general developmental delay and so on. It is not all about tongue-tie. In fact, research evidence linking tongue-tie to speech issues is very lacking.

Two studies have compared speech outcomes in children who had division for breastfeeding difficulty, children who had untreated tongue-tie and children without tongue-tie.

Dollberg et al (2011) looked at 25 children in total split into the 3 groups and concluded:

‘We conclude that intelligibility was not different between children with no tongue-tie and children with either treated tongue-tie or children with tongue-tie. The articulation of ( ⁄ t⁄ , ⁄d⁄, ⁄l⁄, ⁄r⁄) consonants is not significantly different between children with untreated and treated tongue-tie. However, children with treated tongue-tie do have more articulation errors than children with no tongue-tie. The small sample size of our study, together with the disagreement on what comprises tongue-tie, precludes our ability to recommend frenotomy in early infancy for the indication of the prevention future articulation problems. The excellent results seen in treating lingual frenulum-related articulation problems by frenotomy after these problems are diagnosed further support this recommendation.’

Salt et al, (2020) looked at 59 children aged 2 years one month to 4 years 11 months and 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. They measured frenulum structure and function, tongue mobility and speech production and intelligibility and 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.’

Research linking tongue-tie to speech difficulties is limited. A recent study (MeLong et al, 2021) of 25 children (average age 3.7 years) whose parents and healthcare providers had expressed specific concerns in relation to tongue-tie impacting speech development concluded:

‘Overall, no significant improvements were noted in speech articulation or intelligibility after tongue-tie release.’

They point out that there are several other studies that concluded tongue-tie division did improve speech outcomes in some patients. But these were primarily subjective outcomes reported by parents and caregivers. In a study where children were evaluated post division by speech language pathologists with 9 out of 15 children reportedly improving the SLP assessments were limited by the fact that they did not involve standardised speech samples and did not report on specific articulation errors.

‘In our study, all children were assessed by a licensed speech language pathologist with a standardized speech sample before and after tongue-tie release to objectively assess speech articulation. To our knowledge, this is the first study to report specific speech sound errors in children presenting with ankyloglossia using a validated speech sound articulation test to assess the effects of tongue-tie release. The results showed that many children had speech sound errors that were considered age-appropriate on presentation. Furthermore, many speech sound and articulation errors were sounds not typically caused by tongue tip immobility.’

‘The results from this study demonstrated that the majority of children being referred for tongue-tie release had age-appropriate speech. In fact, most speech sound errors (87.9%) were found to be age-appropriate phonological substitutions that parents and referring providers thought were being caused by ankyloglossia. Given these findings, it is not surprising that there was no significant change demonstrated in speech articulation or intelligibility following tongue-tie release. Therefore, it is important for healthcare providers to understand that many different types of speech errors (eg, articulation disorders, dysfluency, phonological disorders, voice disorders) can exist, and some sounds that necessitate maximal tongue tip extension (eg,/l/sounds) are not expected to develop until later in childhood.’

‘Almost half of parents reported that they noticed an improvement in their child’s speech following tongue-tie release, despite no objective improvement being demonstrated.’

So, many speech issues attributed to tongue-tie are age appropriate and resolve as a child gets older. Plus there is a placebo effect here with division. The authors do concede that there may be a sub group of children with alveolar-dental or lingual speech issues (Iisps and difficulty with consonant sounds) that persist past the developmentally appropriate age who may benefit from division.
 
Timing and procedure matter.

Furthermore, the timing of division and the type of procedure used effect outcomes when division is performed in relation to speech difficulties.

We use the frenulotomy procedure which simply involves making an incision into the frenulum to ‘divide it’ to enable more tongue movement. Frenulotomy is minimally invasive so can be done without the need for anaesthetic (general anaesthetics come with increased risks when given the babies) and with minimal disruption to feeding post division. But is this procedure effective when it comes to speech?

Evidence is conflicting with some studies finding good outcomes in some patients undergoing frenulotomy. However, other studies suggest the more invasive procedures may be more effective. A study by Klockers et al (2011) found that frenuloplasty under general aneasthetic (which involves the removal of the frenulum and the placing of stitches) gave better results than frenulotomy with less risk of recurrence. Other studies comparing frenuloplasty (also known as Z Plasty) with frenulotomy have reported better outcomes in terms of speech issues (Yousefi et al, 2015, Ariestiana et al, 2024).

Waiting to do a procedure until your child is older and will need an anaesthetic may seem counter intuitive. But the evidence suggests only small numbers of babies with untreated tongue-tie will go on to have speech issues, and for those that do waiting may give better outcomes as surgical procedures that seem to be more effective are then options. Furthermore, an older child will be able to engage of rehabilitation exercises post division under the guidance of a speech therapist which will help to optimise tongue function and outcomes.
 

Any concerns you have about your toddler or child’s speech should be raised with a speech therapist who can do a thorough assessment to identify what is causing the difficulty. No reputable, ethical practitioner will intervene and carry out division without a speech therapy assessment.

It is important to understand that Nurse/Midwife practitioners, such as myself, who specialise in infant feeding should not be offering division for any other reason other than feeding difficulty as that would fall outside of out scope of practice. We should also not be treating babies over one year old for reasons explained in the Association of Tongue-tie Practitioners Position Statement on Frenulotomy in Different Age Groups.