The parents of a 5-day-old infant come in for a preventive care visit. The mother is committed to breastfeeding but says she is having pain when the baby latches. One lactation consultant in the hospital said the baby has a tongue-tie, but another said the baby does not. The mother’s online communities keep asking her if the baby has been “checked for ties.” The family has searched online for information on tongue-, lip- and cheek-ties but are overwhelmed. They ask you to help with the next steps.
Studies show a growing number of infants are being diagnosed with ankyloglossia, a congenitally tight lingual frenulum that limits the motion of the tongue. Performance of frenotomy to release tongue-ties also is rising.
The increased rate of frenotomy is fueled partly by economic incentives for health care providers, which has led to a surge in the number of clinics and specialists offering tongue-tie surgeries. In addition, social media has increased awareness of ankyloglossia, and online communities often pressure parents to seek surgical procedures when breastfeeding difficulties arise.
Many medical professionals, however, have expressed concerns regarding the overdiagnosis of tongue-tie and surgeries that may not always resolve breastfeeding issues.
The AAP has released new evidence-based guidance to help pediatricians care for mothers and infants with breastfeeding problems. It recommends prioritizing nonsurgical interventions and fostering a collaborative care model to help ensure successful breastfeeding outcomes.
The clinical report Identification and Management of Ankyloglossia and its Effect on Breastfeeding in Infants is a multidisciplinary effort from the AAP Section on Breastfeeding, Council on Quality Improvement and Patient Safety, Section on Oral Health, Committee on Fetus and Newborn, and Section on Otolaryngology-Head and Neck Surgery. It is available at https://doi.org/10.1542/peds.2024-067605 and will be published in the August issue of Pediatrics.
Is tongue-tie a problem?
The AAP recommends exclusive breastfeeding for about six months, with continuation for two years or longer as mutually desired by mother and infant. Breastfeeding problems are common, so pediatricians should be able to provide practical advice on techniques or refer to lactation specialists when necessary.
Maternal pain is one of the most common complaints and can occur if the infant’s tongue cannot extend and elevate due to a restrictive lingual frenulum. Pain can lead to poor milk transfer and insufficient growth as well as premature cessation of breastfeeding.
Most difficulties with breastfeeding, including pain, are not due to ankyloglossia, and the differential diagnosis of feeding problems in newborns is extensive.
A pediatrician considering the diagnosis of ankyloglossia should start with the differential diagnosis of poor weight gain and ineffective latch. Feeding problems in newborns should be evaluated in the medical home. Families often seek the help of lactation specialists. Therefore, a team approach is best.
If a restrictive lingual frenulum causes breastfeeding problems that do not improve with lactation support, a diagnosis of symptomatic ankyloglossia can be made. The clinical report includes an algorithm to aid in the evaluation, which requires an observation of breastfeeding to assess the functional dynamic movement of the tongue. Tools to assess the severity of ankyloglossia have been published in peer-reviewed journals, but none have been validated.
Management options
If breastfeeding problems continue after other causes have been evaluated and treated, surgical intervention for ankyloglossia by a trained professional is a reasonable option. Despite the widespread use of lasers for frenotomy, no studies support their use over scissor clipping in infants younger than 6 months.
Parents with breastfeeding problems also face considerable pressure to have labial frenula (lip) or buccal frenula (cheek) addressed. They are normal oral structures, and intervention to release these ties is not supported by evidence.
The Academy of Breastfeeding Medicine and the American Academy of Otolaryngologists-Head and Neck Surgeons recommend frenotomy for tongue-tie under limited circumstances but do not recommend intervention for labial or buccal frenula.
Recommendations
Following are key findings and recommendations in the clinical report:
- Early identification of feeding problems is crucial to support successful breastfeeding outcomes and should take place in the medical home.
- Comprehensive care for infants with tongue-tie requires collaboration with lactation consultants, speech-language pathologists and other specialists.
- Frenotomy should be reserved for cases where significant functional impairments are observed and nonsurgical interventions have failed. The procedure is safe, and poor outcomes are rare. The post-procedure care of the infant should ensure symptoms have improved.
- No evidence supports laser over other methods of frenotomy.
- Increasingly, parents are influenced by online communities advocating for surgical interventions for tongue-tie. It is essential to guide them toward evidence-based practices.
- The evidence supporting frenotomy is limited. While it may alleviate maternal nipple pain, its broader efficacy for other diagnoses remains uncertain.
- There is no support for interventions on labial and buccal frenae.
- Postoperative “stretching” exercises to prevent reattachment are not recommended.
Dr. Thomas is a lead author of the clinical report and a member of the AAP Section on Breastfeeding Executive Committee.
Resources
- Two sessions on ankyloglossia will be presented at the 2024 AAP National Conference & Exhibition in Orlando, Fla. “Identification and Management of Ankyloglossia and its Effect on Breastfeeding in Infants” will be held on Sept. 30, and “Ankyloglossia and Other Ties” will be held on Oct. 1.
- Information for parents on tongue-tie from HealthyChildren.org
