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.
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
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.
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)
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.
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.
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.
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)
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.
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.
BREASTFEEDING MEDICINEVolume 16, Number 4, 2021ªMary Ann Liebert, Inc.DOI: 10.1089/bfm.2021.29179.ylf278
Downloaded by Society - Active - Academy of Breastfeeding Medicine (ABM) from www.liebertpub.com
1. Bin-Nun A, Kasirer YM, Mimouni FB. A dramatic increase in tongue-tie related articles: A 67-year systematic review. Breastfeed Med 2014;12:410–414. 2. Joseph KS, Kinniburgh B, Metcalfe A, et al. Temporal trends in Ankyloglossia and frenotomy in British Columbia Canada 2004–2014: A population-based study. CMAJ Open 2016;4:E33–E40. 3. Kapoor V, Douglas P, Hill P, et al. Frenotomy for tongue- tie in Australian Children, 2006–2016, an increasing problem. Med J Australia 2018;208:88–89. 4. Walsh J, Links A, Boss E, et al. Ankyloglossia and lingual frenotomy: National trends in inpatient diagnosis and management in the United States, 1997–2012. Oto Head Neck Surg 2017;156:735–740. 5. Jin RR, Sutcliffe A, Vento M, et al. What does the world think of tongue tie? Acta Paediatr 2018;107:1733–1738. 6. Todd DA, Hogan MJ. Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding out- comes. Breastfeed Rev 2015;23:11–16. 7. Mills N, Pransky S, Geddes D, et al. What is a tongue-tie? Defining the Anatomy of the in-situ Frenulum. Clin Anat- omy 2019;32:749–761. 8. Mills N, Keough N, Geddes D, et al. Defining the anatomy of the neonatal frenulum. Clin Anatomy 2019;32:824–835. 9. Geddes DT, Langton D, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 2008;122:e188–e194. 10. Geddes DT, Kent JC, McClellan HL, et al. Sucking char- acteristics of successfully breastfeeding infants with anky- loglossia: A case series. Acta Paediatr (Oslo, Norway: 1992) 2010;99:301–303. 11. Douglas P, Geddes D. Practice-based interpretation of ul- trasound studies leads way to more effective clinical sup- port and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery 2018;58:145–155. 12. Scott JA, Binns C, Oddy W, et al. Predictors of breast- feeding duration: Evidence from a Cohort Study. Pediatrics 2006;117:e646–e655. 13. Wright JE. Tongue-tie. J Paediatr Child Health 1995;31: 276–278. 14. Messener AH, Lalakea L, Aby J, et al. Ankyloglossia: In- cidence and associated feeding difficulties. Arch Otolar- yngol Head Neck Surg 2000;126:36–39. 15. Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lactat 2004;4:409–414. 16. Ricke LA, Baker N, Madlon-Kay DJ, et al. Newborn tongue-tie: Prevalence and effect on Breastfeeding. J Am Board Fam Pract 2005;18:326. 17. Caloway C, Hersh C, Baars R, et al. Association of Feeding Evaluation with frenotomy rates in Infants with Breastfeeding Difficulties. JAMA Oto Head Neck Surg 2019;145:817–822. 18. Hazelbaker A. Assessment Tool for Lingual Frenulum Function. Columbus, OH: Aiden and Eva Press, 2010. 19. Hazelbaker A. Assessment Tool for Lingual Frenulum Function. Columbus, OH: Aiden and Eva Press, 2012. 20. Srinivasan A, Al Khoury A, Puzhko S, et al. Frenotomy in infants with breastfeeding problems. J Hum Lactat 2019; 35:706–712.
21. Marchesan IQ. Lingual frenulum protocol. Int J Orofac Myol 2012;38:89–103.
22. Ingram J, Johnson D, Copeland M, et al. The development of a tongue assessment tool to assist with tongue-tie iden- tification. Arch Dis Child Fetal Neonatal Ed 2015;100: F344–F349.
23. Ingram J, Copeland M, Johnson D, et al. The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY). Int Breastfeed J 2019;14:31.
24. Schlatter S-M, Schupp W, Otten J-E, et al. The Role of tongue-tie in breastfeeding problems—a prospective ob- servational study. Acta Peadiatrica 2019;108:2214–2221.
25. Riordan J, Gill-Hopple K, Angeron J. Indicators of effec- tive breastfeeding and estimates of breast milk Intake. J Hum Lactat 2005;21:406–412.
26. Lalakea ML, Messener AH. Ankyloglossia does it Matter? Pediatr Clin North Am 2003;50:381–397.
27. Douglas PS. Making sense of studies that claim benefit of Frenotomy in the absence of classic Tongue-tie. J Hum Lactat 2017;33:519–523.
28. O’Shea JE, Foster JP, O’Donnell CPF, et al. Frenotomy for tongue-tie in newborn Infants. Cochrane Database Syst Rev 2017;3:CD011065.
29. Haham A, Marom R, Mangel L, et al. Prevalence of Breastfeeding difficulties in newborns with a lingual fren- ulum: Prospective cohort study. Breastfeed Med 2014;9: 438–441.
30. Power RF and Murphy JF. Tongue-tie and frenectomy in infants with breastfeeding difficulties: Achieving a balance. Arch Dis Child 2015;100:489–494.
31. Walker R, Messing S, Rosen-Carole C, et al. Defining tip to frenulum length for Ankyloglossia and its impact on Breastfeeding: A Prospective Cohort Study. Breastfeed Med 2018;13:204–210.
32. Hogan M, Wescott C, Griffiths M. A Randomized con- trolled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005;41:246–250.
33. Srinivasan A, Dobrich C, Mitnick H, Feldman P. Ankyloglossia in breastfeeding infants: The effect of frenotomy on maternal nipple pain and latch. Breastfeed Med 2006;1:216–224.
34. Dollberg S, Botzer E, Grunis E, Mimouni F. Immediate nipple pain relief after frenotomy in breastfed infants with Ankyloglossia: A randomized prospective study. J Plastic Surg 2006;41:1598–1600.
35. Buryk M. Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics 2011;128:280.
36. Kumar M and Kalke E. Tongue-tie, breastfeeding diffi- culties and the role of Frenotomy. Acta Paediatr 2012;101: 687–689.
37. O’Callahan C, Mccary S, Clemente, S. The effects of office- based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Ped Otol 2013;77:827–832. 38. Ramoser G, Guoth-Gumberger M, Baumgartner-Sigl S, et al. Frenotomy for tongue-tie (frenulum linguae breve) showed improved symptoms in the short and long-term follow up. Acta Paediatr 2019;108:1861–1866. 39. Morosolli ARC, Veeck EB, Niccoli-Filho W, et al. Healing process after surgical treatment with scalpel electrocautery and laser radiation. Lasers Med Sci 2010;25:93–100. 40. D’Arcangelo C, Di Maio FDN, Prosperi GD, et al. A pre- liminary study of healing of diode laser versus scalpel in- cisions in rat oral tissue: A comparison of clinical, histological and immunochemical results. Oral Surg Oral Path Oral Radiol Endodont 2007;103:764–773. 41. Romeo U, Russo C, Palaia G, et al. Biopsy of different oral tissue lesions by KTP and diode laser: Histological evalu- ation. Sci World J 2014:6. 42. Varadan M, Chopra A, Sanghavi AD, et al. Etiology and clinical recommendations to manage complications fol- lowing lingual frenectomy: A critical review. J Stomatol Maxillofac Surg 2019;120:549–553. 43. Walsh J, McKenna Benoit M. Ankyloglossia and other oral ties. Otolaryngol Clin North Am 2019;52:795–811. 44. Hale M, Mills N, Edmunds L, et al. Complications fol- lowing frenotomy for ankyloglossia: A 24-month pro- spective New Zealand Paediatric Surveillance Unit study. J Paediatr Child Health 2019;56:557–562. 45. Reid N, Rajput N. Acute feed refusal followed by Sta- phylococcus aureus wound infection after tongue-tie re- lease. J Paediatr Child Health 2014;50:1030–1031. 46. Kim DH, Dickie A, Shih ACH, Graham ME. Delayed hemorrhage following laser frenotomy leading to hypovo- lemic shock. Breastfeed Med 2021;346–348. 47. Messener AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolar- yngol Head Neck Surg 2020;162:597–611. 48. Rizeq N, Wasserteil N, Mimouni F, et al. Upper lip tie and breastfeeding: A systematic review. Breastfeed Med 2019; 14:83–87. 49. Douglas P, Cameron A, Cichero J, et al. Australian Col- laboration for Infant Oral Research ACIOR Position Statement: Upper lip tie, buccal ties and the role of fre- notomy in infants. Austr Dental Pract 2018. 50. Santa Maria C, Aby J, Truong MT, et al. The Superior Labial Frenulum in Newborns: What is normal? Global Pediatr Health 2017;4:1–6.