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Unraveling breastfeeding problems tied to ankyloglossia

January 1, 2021

Not all infants with ankyloglossia require frenotomy, according to Anne K. Meyer, M.D., FACS, FAAP

Editor's note:For more coverage of the 2020 AAP Virtual National Conference & Exhibition, visit http://bit.ly/AAPNationalConference2020.

When mothers have trouble breastfeeding their infant, is tongue tie to blame?

Anna K. Meyer, M.D., FACS, FAAP, explained what pediatricians should look for when assessing mothers with breastfeeding problems and infants with suspected tongue ties during the 2020 Virtual National Conference session “Ankyloglossia and Other Ties: What is the Evidence?”

Ankyloglossia is “the presence of a short or tight lingual frenulum that can restrict proper tongue extension and movement, hindering proper breastfeeding abilities in the infant,” according to the AAP Textbook of Pediatric Care.

Of the 4%-11% of newborns with ankyloglossia, many do not have consequences. Some infants demonstrate poor feeding and slow weight gain, and the mother may suffer from severe nipple pain. Recent research suggests that frenotomy may be helpful for clinically significant ankyloglossia.

Dr. Meyer, an otolaryngologist and head and neck surgeon at University of California San Francisco Benioff Children’s Hospital, outlined evidence pediatricians can use to determine whether surgical intervention is necessary.

Nursing mothers no longer rely solely on physicians for information about tongue tie and lip tie, she said. Social media groups have become a larger influence, and information mothers read online often discourages them from going to their pediatricians for help. Mothers may encounter two opposing camps on ankyloglossia, offering extreme solutions that delay appropriate care, she said.

“There’s one camp that says never frenotomy and even has described it as barbaric and another camp that almost seems to think that all frenula should be cut,” said Dr. Meyer, a member of the AAP Section on Otolaryngology-Head and Neck Surgery Executive Committee. “It’s like cesarean sections. There can be too much and not enough.”

Despite a stable U.S. birth rate, ankyloglossia diagnoses rose from 5,000 in 2000 to 33,000 in 2012, and frenotomy rates increased from 1,600 to 12,000.

Often, social media groups lead mothers to high-volume frenotomy providers, she said.

Also contributing to the rising frenotomy rate is a lack of a standardized diagnosis or classification for ankyloglossia. Anterior ankyloglossia, also called classic ankyloglossia, is the only type that exists, Dr. Meyer said.

She called posterior ankyloglossia an inaccurate term that does not have a validated assessment tool or randomized controlled trials to support frenotomy. Loose definitions of posterior ankyloglossia state that the condition is a tight submucosal band of tissue at the base of the ventral tongue that is palpated rather than seen. There also is a dearth of evidence to attribute breastfeeding problems to upper lip tie or buccal ties, she said.

Consumer and professional websites also influence the rising frenotomy rate by listing a range symptoms as reasons to perform a frenotomy, even though the symptoms can be attributed to other causes.

Some symptoms that point to a high likelihood of ankyloglossia are pain for the mother, compressed nipples and a clicking sound made by the infant when nursing. None of these symptoms are exclusive to tongue tie, Dr. Meyer noted.

Dr. Meyer suggested using the Bristol Tongue Assessment Tool (https://fn.bmj.com/content/100/4/F344.full). She also uses the LATCH pneumonic to assess tongue tie: Latch, Audible swallowing, Type of nipple, Comfort and Hold.

She urged pediatricians to observe how the mother holds her infant when breastfeeding, because the cradle hold may not support the infant’s head adequately and can cause a shallow latch. A cross-cradle or football hold improves latch, she said. When observing the breastfeeding pair, it also is important to watch the infant’s mouth, tongue, lips, mandible palate, complete head, neck, chest and auscultation of the airway and heart/lungs.

New mothers and infants are most at risk of frenotomy overtreatment, and this can delay access to a breastfeeding home with psychosocial support. “By and far, the biggest challenge that I see … is whether the family has good access to adequate lactation and maternal support,” she said.

Regarding frenotomy, she advised the following:

  • A laser is not better than scissors for frenotomy.
  • Post-frenotomy stretching is not helpful and may generate more scar tissue.
  • There is inadequate research on frenotomy for upper lip tie.

“Research does support performing frenotomy for classic ankyloglossia for breastfeeding problems,” Dr. Meyer said. “We need to advocate that mothers get more lactation support rather than more frenotomies.”

Registered attendees can access the session through Jan. 31 at https://www.eventscribe.net/2020/AAPexperience/

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