To snip or not to snip: the dilemmas of tongue-tie

Ankyloglossia in Central Australia: Prevalence, identification and management in infants

PURPOSE

To investigate the prevalence and management of ankyloglossia for infants in Central Australia.

METHOD

Retrospective chart review consisting of a medical file audit of infants (n = 493) <2 years old diagnosed with ankyloglossia from January 2013 to December 2018 in the primary hospital in Central Australia. Patient characteristics, reason for diagnosis, reason for procedure and outcomes of procedures routinely recorded in the patient clinical files were recorded.

RESULTS

The overall prevalence of ankyloglossia in this population was 10.2%. Frenotomy was performed in 97.9% of infants diagnosed with ankyloglossia. Infants with ankyloglossia were more likely to be male (58% vs 42%), diagnosed and managed with a frenotomy on the third day of life. Most ankyloglossia diagnoses were identified by a midwife (>92%). Most frenotomy procedures were completed by lactation consultants who were also midwives (99%) using blunt-ended scissors. More infants were classified with posterior ankyloglossia than anterior ankyloglossia (23% vs 15%). A frenotomy procedure resolved feeding issues in 54% of infants with ankyloglossia.

CONCLUSIONS

The prevalence of ankyloglossia and rate of frenotomy procedures were high when compared to previous reports in the general population. Frenotomy for ankyloglossia in infants with breastfeeding difficulties was found to be effective in more than half of the reported sample, improving breastfeeding and decreasing maternal nipple pain. A standardised approach and validated screening or comprehensive assessment tool for the identification of ankyloglossia is indicated. Guidelines and training for relevant health professionals on non-surgical management of the functional limitations of ankyloglossia are also recommended.

The development of a tongue assessment tool to assist with tongue-tie identification

AIM

To produce a simple tool with good transferability to provide a consistent assessment of tongue appearance and function in infants with tongue-tie.

METHODS

The Bristol Tongue Assessment Tool (BTAT) was developed based on clinical practice and with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF). This paper documents 224 tongue assessments using the BTAT. There were 126 tongue assessments recorded using the BTAT and ATLFF tools to facilitate comparisons between them. Paired BTAT assessments were obtained from eight midwives who were using the new assessment tool.

RESULTS

There was acceptable internal reliability for the four-item BTAT (Cronbach's α=0.708) and the eight midwives who used it showed good correlation in the consistency of its use (ICC=0.760). The BTAT showed a strong and significant correlation (0.89) with the ATLFF, indicating that the simpler BTAT could be used in place of the more detailed assessment tool to score the extent of a tongue-tie. Midwives found it quick and easy to use and felt that it would be easy to teach to others.

CONCLUSIONS

The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure.

Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance

AIMS

Currently there is debate on how best to manage young infants with tongue-tie who have breastfeeding problems. One of the challenges is the subjectivity of the outcome variables used to assess efficacy of tongue-tie division. This structured review documents how the argument has evolved. It proposes how best to assess, inform and manage mothers and their babies who present with tongue-tie related breastfeeding problems.

METHODS

Databases were searched for relevant papers including Pubmed, Medline, and the Cochrane Library. Professionals in the field were personally contacted regarding the provision of additional data. Inclusion criteria were: infants less than 3 months old with tongue-tie and/or feeding problems. The exclusion criteria were infants with oral anomalies and neuromuscular disorders.

RESULTS

There is wide variation in prevalence rates reported in different series, from 0.02 to 10.7%. The most comprehensive clinical assessment is the Hazelbaker Assessment Tool for lingual frenulum function. The most recently published systematic review of the effect of tongue-tie release on breastfeeding concludes that there were a limited number of studies with quality evidence. There have been 316 infants enrolled in frenotomy RCTs across five studies. No major complications from surgical division were reported. The complications of frenotomy may be minimised with a check list before embarking on the procedure.

CONCLUSIONS

Good assessment and selection are important because 50% of breastfeeding babies with ankyloglossia will not encounter any problems. We recommend 2 to 3 weeks as reasonable timing for intervention. Frenotomy appears to improve breastfeeding in infants with tongue-tie, but the placebo effect is difficult to quantify. Complications are rare, but it is important that it is carried out by a trained professional.