Tongue Tie
Ankyloglossia, or tongue-tie, is a congenital oral cavity anomaly, affecting between 4 per cent and 10 per cent of infants, and is characterised by an abnormally short, thick or tight, sublingual frenulum, often causing restricted latching to the maternal breast, with adverse feeding outcomes for both infant and feeding mother. Breastfeeding difficulties may arise as a result of poor, or ineffectual, latching, giving rise to an unsettled or dissatisfied infant, who may dribble, reflux, or exhibit signs of early fatigue, frustration, disinterest, or poor weight gain.
Not infrequently these difficulties may be compounded by heightened maternal anxiety, which may be transferred to the struggling infant, aggravating further attempts to breastfeed successfully. Other features of a poor latch may be a clicking of the tongue, or chewing of the nipple, resulting in painful breasts, often leading to nipple cracks, poor breast emptying, and not infrequently to mastitis, thereby impeding further attempts to breast-feed.
The Frenulum
The frenulum, or frenum, is a narrow fold of mucous membrane that connects a moveable part of the body to a fixed part, and the lingual frenulum helps to stabilise the base of the tongue without restricting tongue movement. It forms the attachment between the underside of the tongue and the floor of the mouth, and is a remnant of the initial attachment of the tongue to the floor of the mouth before birth (1). Normal tongue movements include tip elevation, retraction, grooving and protrusion, and provide for suckling, chewing, eating, drinking, clearing the mouth and speech function. Tongue-tie may inhibit these natural movements.
Breastfeeding Problems
Tongue-tie is unlikely to be detected in bottle-fed babies, since the complex movements of the tongue required for latching, extraction and swallowing, are not required when artificial feeding from a bottle is presented to the infant mouth. It is likely that tongue-tie has not been widely recognised over the past three or four decades because of the low incidence of breastfeeding in Ireland, largely due to national cultural habits, and the over-enthusiastic promotion of formulae feeding in hospitals by nursing staff.
While breastfeeding rates in Ireland continue to be lower than in neighbouring European countries, there appears to be a discernible reversal of this historical trend, linked to the increasing emergence of lactation supporting groups and the promotion of breastfeeding by lactation consultants. Lactation consultants (LC) are registered nurses who have gained additional training and experience in infant feeding difficulties, and are more likely to recognise and correctly diagnose tongue-tie than other clinicians. Referrals to our Tongue-Tie Clinic are invariably made by LC nurses on behalf of breastfeeding mothers.
With more Irish mothers opting to breastfeed an increased incidence of tongue-tie diagnosis is inevitable, placing a greater burden of responsibility on nursing and medical staff, and supportive structures. Reports from the Growing Up in Ireland study revealed breastfeeding rates in Ireland to be as low as 56 percent (ever breastfed) compared to 90 per cent in other European countries.
While some mothers express frustration with lack of support for breastfeeding while in hospital, others will report satisfaction with encouragement by nursing staff. An investigative report by the Economic Social and Research Institute (ESRI) concluded that Irish mothers needed greater support than was currently being provided if they were to succeed with breastfeeding efforts after discharge from maternity wards. Current research supports the view that breast-fed babies are likely to have lower risks for obesity, diabetes and cardiovascular problems, compared with their formula-fed counterparts, and are less likely to be overfed by having a slower rate of weight gain.
Controversies about the safety and efficacy of tongue-tie division in newborn babies with feeding problems prompted the National Institute for Health and Clinical Excellence (NICE) in the UK to review justification for tongue-tie division, and to provide guidance in this regard to British clinicians back in 2005. NICE concluded that there were “no major safety concerns about division of ankyloglossia” and that “limited evidence suggests that this procedure can improve breastfeeding”.
Benefits of Tongue-Tie Division
My personal experience supports the view that division of ankyloglossia can significantly improve breastfeeding, when latching is impeded, with immediate benefits for infant and mother. Dolby and Associates, in a study of 25 mothers of healthy infants with ankyloglossia, reported a significant decrease in nipple pain after frenotomy (2). Mother's frequently report and improved latch and less discomfort immediately after the procedure is performed .
Not every case of tongue-tie requires intervention, and some babies appear to manage to latch effectively despite the restriction. These babies are likely to thrive since changes in the oral cavity during the first four to five years of life will permit the tongue to grow and narrow, causing the lingual frenulum to receded and stretch to the degree that lingual movements are no longer impeded.
Classification
Tongue-tie may be classified according to its anatomical presentation and severity of stricture, and defined by various classification systems.
In simple practical terms a Type 1, or anterior restriction, binds the tip of the tongue to the floor of the mouth, while Type 4 defines a posteriorly restricted frenulum (Kotlow Diagnostic Criteria). Type 1 restrictions are easier to diagnose and divide, while clinical experience requires the detection and release of a posterior tongue-tie.
A posterior tongue-tie may not be readily identified by a superficial examination of the mouth, and these are often missed by failure to examine the base of the tongue correctly. Careful palpation of the inferior base of the tongue may reveal the restricting frenulum and facilitate its division with improved lingual function. There may be slight bleeding following the surgical intervention, but this invariably ceases when the infant is put to the breast.
Tongue-tie may in some cases be aggravated by a lip-tie, in which a tight upper labial frenulum inhibits the natural flanging of the upper lip and restricts effective latching. In these cases an altered nursing position may facilitate improved latching. Failure to achieve this may require surgical division of the lip tie.
Frenectomy is a low-risk procedure and may on occasions give rise to a small bleed, which invariably resolves when the infant is put to the breast. Mothers are comforted prior to the procedure, and counselled regarding the low risks and potential benefits, and informed that no pain is experienced by the infant. Some infants will even sleep throughout the procedure.
Speech Impairment
It is speculated that untreated tongue-tie may cause speech impediments in later life. While medical opinion is divided on this, there are adults who report articular difficulties because of failure to divide their restricted tongues in infancy. Tongue-tie may restrict the articulation of consonants such as T, D, Z, Th and L .
The emergence of Tongue-Tie Clinics in Ireland is testimony to the growing recognition that the restricted frenulum is more common than suspected, and that relief for these babies and their nursing mothers is now available.
References:
- Arch Otolaryngol Head & Neck Surgery 2000, 126:36-9, Messner, A H
- J Paed Surgery, 2006; 41: 1598-6000
- Arch Otol 1971; 94:948-57