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Do tongue-ties really cause breastfeeding problems?

Updated: Jun 8


Is a tongue-tie just a trend?

Do tongue-tied babies really need a surgery?

Which method is better? Laser or scisors?

If I agree to a division, do I have to do pre and post exercises or stretching at or near the incised area?

And what about lip and cheek ties, do they also cause a problem?


There has been lots of confusion around tongue-ties in recent years, not only between parents, but also health care practitioners. Paediatricians on one side, who do not believe that tongue-tie can cause any problems, lactation consultants on the other, who believe that it can cause many breastfeeding problems, chiropractors and osteopaths who claim that tongue-tie can cause many problems and it is not just a breastfeeding issue and midwives who stand somewhere in between.


I have decided to present an article which has been published at the beginning of year 2021 by an Academy of Breastfeeding Medicine. As many of us do not have the time and means to read all the research which has been done on this topic, 9 experts got together, looked at all the available research and wrote a Position Statement. I believe that everyone who works in healthcare with babies, paediatricians, midwives, lactation consultants and parents of tongue-tied babies should read this article. It is long, but it will save you time reading all the personal opinions, myths and thoughts of other people on this topic. I decided not to summarise this article and leave it exactly as it is in order not to add accidentally more confusion to an already very controversial topic.


BREASTFEEDING MEDICINE

Volume 16, Number 4, 2021 Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2021.29179.ylf

ABM Position Statement

Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads

Yvonne LeFort,1 Amy Evans,2,3 Verity Livingstone,4 Pamela Douglas,5,6 Nanette Dahlquist,7 Brian Donnelly,8 Kathy Leeper,9 Earl Harley,10 Susan Lappin11; and the Academy of Breastfeeding Medicine

Introduction

In recent years there has been growing interest in ankyloglossia or tongue-tie as evidenced by a substantial increase in the number of publications(1). This parallels a dramatic increase in the diagnosis and treatment of tongue-tie globally.(2/4) Despite this reality, there exists a lack of agreement regarding the diagnosis and treatment of tongue-tie around the world and among various heath professions. (5)


The lack of high-quality evidence-based studies including randomized-controlled trials and longitudinal data to guide clinicians to develop the optimal management of this condition is problematic. In response to this situation, the Academy of Breastfeeding Medicine gathered a task force of experts—clinicians who have worked extensively in this area—to provide a position statement to summarize the available evidence regarding tongue-tie. It is our hope that all who assist breastfeeding mothers and their infants become familiar with this document as to achieve collaborative consistency and care.


Background


Clinical experience has identified neonatal ankyloglossia, or ‘‘tongue-tie,’’ in a breastfeeding infant, as a potential source of maternal nipple discomfort and trauma, and of impeded breast milk transfer by the infant, thereby being considered a risk factor for premature breastfeeding cessation.(6)

A tongue-tie exists when the tongue is limited in its range of movement, and subsequent function, due to the presence of a restrictive sublingual frenulum. Recent anatomic studies on the microanatomy of the sublingual frenulum show that it is not a histologically discrete structure or band. The sublingual frenulum is a fold of tissue that arises as the tongue lifts and places tension on the floor of the mouth. This fold is always composed of oral mucosa. Sometimes the fold also contains floor of mouth fascia, or fascia and genioglossus muscle, which remain normal anatomic variations. (7,8)


Ultrasound imagery has identified that specific movements of the tongue and the positional proximity of the maternal nipple relative to the infant’s hard/soft palate junction are associated with effective and comfortable breastfeeding. When the tongue moves up and down within the oral cavity, tracking the excursion of the mandible, the magnitude of negative pressure changes, facilitating the transfer of milk during breastfeeding. An increase in vacuum or negative pressure occurs when the tongue is lowered and conversely a decreased negative pressure occurs as the tongue elevates.(9,10)

It is further understood that the presence and tactile sensation of breast tissue in the oral cavity cause a reflexive lower jaw excursion, which the tongue follows, generating a vacuum in the context of a seal (11)


Clinical Considerations


A restrictive sublingual frenulum, resulting in less movement of the tongue, may cause a significant functional impediment to effective infant latch, suckling, and breast milk transfer, along with maternal nipple/areolar discomfort and trauma while breastfeeding, resulting in an increased risk of discontinuing breastfeeding.(6,12)


Subjective complaints reported by mothers who are breastfeeding an infant with a tongue-tie may include latch- ing difficulties, nipple pain, poor breast drainage, prolonged duration of individual breastfeeding sessions, and inadequate infant satiation when directly feeding at the breast. Objective findings may include nipple compression and/or damaged nipples, milk stasis within the breast, and suboptimal infant weight gain due to inefficient milk transfer/intake at the breast.(13-16) As these are not uncommon issues among many breastfeeding dyads, it is important to note that they may be inappropriately attributed to an anatomically normal sublin- gual frenulum, which has been labeled as ‘‘restricted.’’ The primary importance of performing a thorough skilful clinical breastfeeding assessment, including the consideration of the differential diagnoses, and addressing these potential confounders, cannot be overstated.(17)


Assessment and Diagnosis


Several tools pertaining to tongue movement in the presence of a potentially restrictive sublingual frenulum have been published with the purpose of assisting the clinician in determining whether a particular infant requires surgical intervention.(18-23)

These tools vary greatly in their specific assessment components and their complexity as well as the inter-rater reliability of the tool. No specific tool is meant to be used in the clinical setting as the sole means of deciding whether a frenotomy is indicated or not. Such a decision can only be made in conjunction with a skilled clinical breast-feeding assessment.(24)


A detailed clinical breastfeeding assessment, before the decision to treat a tongue-tie, should include the maternal history taking and physical examination, looking for evidence of nipple trauma and poor breast drainage, and the infant history and physical examination with emphasis on the detailed oral anatomic findings. Direct observation of breastfeeding is essential. The potential impact of any an-atomic variation, such as tongue-tie, on the infant’s ability to transfer milk at the breast requires an assessment at the breast that includes maternal comfort and milk transfer as evidenced by audible and/or visible swallowing.(25) Test weighing of the infant before and after breastfeeding, on digital infant scales, can provide an indication of the amount of milk transferred in a single specific feeding session but cannot be interpreted as applicable to all feeding sessions of given mother and infant dyad.


Conservative/Expectant Management


Many breastfeeding problems can be effectively managed by skilled lactation support. By modifying the latch and position and with the temporary use of nipple shields and ex-pressed breast milk for supplementation when necessary, many breastfeeding and lactation challenges can be improved upon if not resolved. With time, the baby’s ability to latch effectively may improve with overall growth.(26,27) However, as is the case with the lack of high-quality evidence concerning the efficacy of a frenotomy for tongue-tie, there are limited similar studies regarding the efficacy of nonsurgical strategies for the range of breastfeeding problems mothers encounter and their long-term follow-up.


Surgical Management


Among the numerous publications on tongue-tie over the past20 years, at least five randomized-controlled trials have been performed, comparing the outcomes of surgically treated versus nonsurgically managed infants with a diagnosis of tongue-tie. These selected studies were analysed in a 2017 Cochrane Database of Systematic Reviews.(28) All five studies were found to be limited by several key factors including the lack of a standardised tongue-tie definition and treatment method, the consistently small sample sizes, and a lack of long-term follow-up data. However, in pooled analysis, frenotomy was associated with reduced nipple pain experienced by breastfeeding mothers. The authors point out that many unanswered questions remain including the optimal timing of a frenotomy and the long-term outcomes for treated versus nontreated infants.


Indications for Frenotomy


Classic tongue-tie is a fold of mucosa and sometimes fascia that is visible on elevation of the tongue and that restricts its function. If it is assessed to be significantly restricting the infant’s tongue function, regarding breastfeeding, a frenotomy can be offered at this time. As with any intervention, this should be a shared decision between the clinician and the family, incorporating the family’s values and preferences, with attention to the risks and the benefits of each alternative. If conservative management is chosen, follow-up in a setting where breastfeeding can be assessed and a frenotomy performed if indicated at a future time needs to be made accessible to the family. As tongue-tie is a functional diagnosis, the presence of a sublingual frenulum alone, a common and normal anatomic structure, is not an indication for surgical intervention.(29–31)The surgical release of a restrictive sublingual frenulum, a ‘‘classic’’ tongue-tie, can be an effective intervention if maternal nipple pain and/or poor milk transfer cannot be corrected in a timely way through conservative measures.(24,32–38)


Methods of Frenotomy


There are several methods of frenotomy that can be done depending on the expertise of the clinician. The overall goal is to perform the surgery in a minimally invasive way, effectively dividing the sublingual frenulum to release the re-striction of the tongue and restore an adequate range of movement, allowing for effective and comfortable breast-feeding. All clinicians who perform frenotomies need to be aware of the risks of the procedure they undertake, which are then clearly communicated to the parents and acknowledged by their written informed consent. Such Clinicians must be prepared to provide appropriate immediate postsurgical management and support as required.(30)


The use of scissors for treating a ‘‘classic tongue-tie’’ in breastfeeding infants has a long clinical history and remains the gold standard. In addition, scalpels, electrocautery, and lasers are currently used to perform frenotomies. To date there are no published studies comparing these surgical instruments or the methods used when performing frenotomies. There are, however, some animal studies regarding oral surgery where cold steel incisions were shown to heal faster than diode laser-treated tissue possibly due to a thermal injury to the frenulum and surrounding tissues when laser is used. (39,40) These principles may apply to human oral mucosal incisions.(41)


Deep oral tissue incisions, beyond the classic tongue-tie incision, in breastfeeding infants, have unique hazards and require a high level of skill and attention to avoid the potential risks of bleeding, hematoma formation, collateral tissue damage or nerve injury with resultant paresthesia, or numbness of the tongue.(42) It is not possible to visualise all branches of the lingual nerve and infants are unable to report any loss of tongue sensation.(8) Post-procedural pain from extensive mucosal incisions can result in oral aversion in an infant. (43,44) There is one published case study of oral aversion associated with staphylococcus infection in the wound after a frenotomy, and other published case reports of life-threatening haemorrhage (45,46) which attest to the possible serious complications of a frenotomy.


Postfrenotomy Care



The members of this task force believe that clinical follow-up after a frenotomy has been performed is imperative. In doing so, the clinician should assess the effectiveness of the surgery and document the occurrence of any adverse event or complication experienced by the infant—including protracted bleeding, persistent pain, infection at the incision site, and/or oral aversion experienced by the infant, noting any worsening or cessation of breastfeeding that occurred after the procedure. Further breastfeeding assistance should be made available if required by the mother and infant at this time. Evidence is lacking to support the prescribing of post-procedural manual manipulation or stretching at or near the incised area after a frenotomy procedure. Similarly, there is no evidence or safety guidelines supporting the use of topical substances being applied to the incision site after a frenotomy. The practice of surgically treating other intraoral or peri-oral tissue beyond the sublingual frenulum has no published evidence of improving milk transfer or of reducing maternal nipple trauma in breastfeeding dyads.41The upper labial frenulum specifically is a normal structure with poor evidence for intervention improving breastfeeding and therefore cannot be recommended. Additionally, surgery to release a ‘‘buccal tie’’ should not be performed.(47–50)


Conclusion


In the presence of a restrictive sublingual frenulum, frenotomy can be an effective way to increase maternal comfort and breast milk transfer by the infant. Providing this service may prevent the premature cessation of breastfeeding. However, the decision to treat is one that requires a high level of clinical skill, judgment, and discernment. There is an ongoing need for high-quality research in these specific areas related to the treatment of tongue-tie:1. A clear definition of ‘‘tongue-tie’’ in distinction from the normal sublingual frenulum.2. The extent of incision of the sublingual frenulum required for an optimal breastfeeding outcome.3. Consistent documentation of immediate and long-term adverse outcomes after surgical intervention by anymethod,4. Identification of the optimal surgical instrument and technique for frenotomy.5. The subsequent long-term outcomes after frenotomy in the presence of a restrictive sublingual frenulum on effectiveness and duration of breastfeeding.


Disclosure Statement


The authors are clinicians who practice Breastfeeding Medicine and have all contributed to this document. There are no competing financial interests to disclose among authors.


1 Milford Breastfeeding Clinic, Auckland, New Zealand.

2 Center for Breastfeeding Medicine, Community Regional Medical Center, Fresno, California, USA.

3 UCSF-Fresno, Fresno, California, USA.

4 Vancouver Breastfeeding Clinic, Department of Family Medicine, UBC, Vancouver, Canada.

5 Maternity Newborn and Families Research Collaborative MHIQ, Griffith University, Queensland, Australia.

6 Discipline of General Practice, University of Queensland, Queensland, Australia.

7 Westside Breastfeeding Center, Hillsboro Pediatric Clinic, Hillsboro, Oregon, USA.

8 General Pediatrician, Allegheny Health Network, Pediatrics Adjunct Professor Pediatrics, Carlow University, Clinical Instructor ofPediatrics, Duquesne University, Pittsburgh, Pennsylvania, USA.

9 Milkworks Non-profit Breastfeeding Center, Lincoln and Omaha, Nebraska, USA.

10 School of Medicine, Georgetown University, Washington, District of Columbia, USA.

11 Family Medicine, Dalhousie University, Director of Newborn Services, IWK Hospital and Medical Direct Collaborative Breastfeeding,Halifax, Canada.


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