Tongue-tie – to cut or not to cut?

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The midwife asks you to review a 5 day old baby on the postnatal wards. The mum explains that the baby has tongue tie and she’d like it to be released. The midwife agrees –  the baby is having trouble latching on for breast-feeding and this would help. What do you do? Grab a knife and cut; or tell them there’s no indication for unnecessary surgery?

A recent discussion on Mike South’s paeds forum raised the issue of what we should do when parents ask us to release their child’s tongue tie. Needless to say,the paediatric profession is highly divided on this issue. I decided to review the evidence.

 

Tongue-tie, or ankyloglossia, is a congenital short, thick lingual frenulum resulting in reduced mobility of the tongue.

Tongue-tie

How can we assess tongue tie?

The most commonly used tool for assessment is the Hazelbaker Assessement Tool for Lingual Frenulum Function (HATLFF). It is a scoring system looking at:

Appearance

  • appearance of the the tongue when lifted
  • elasticity of the frenulum
  • length of lingual frenulum when the tongue is lifted
  • attachment of lingual frenulum to tongue
  • attachment of lingual frenulum to inferior alveolar ridge

Performance

  • lateralization
  • lift of the tongue
  • extension of the tongue
  • spread of the anterior tongue
  • cupping
  • peristalsis
  • snapback

Each of these categories gets scored at 0, 1, or 2. You can see the full scoring system here.

This gives a total score with a max score of 10 for appearance and 14 for performance (a perfect tongue).

Interpreting the tools depends on how the scores compare in both categories. The key element of understanding the diagnosis, is that the definition of tongue ties rests on performance and function, it is not simply an issue of impaired appearance.

On a less formal note, a good way to recognise tongue tie at a glance it to look for the heart shape in the tongue when they stick their tongue out.

What the problem with tongue-tie anyway?

Some people feel that tongue-tie can cause problems with: breast-feeding; speech; general enjoyment of life.

Breast-feeding

The thinking is that in order to be able to latch on well a baby needs to manipulate its tongue around the areola and the nipple. Babies with tongue-tie have a problem doing this and  this can cause breast-feeding difficulties – incorrect attachment, painful nipples for mum, incomplete milk drainage, poor weight gain, mastitis for mum.

Messner et al (2000) carried out a prospective study to determine the incidence of tongue-tie and its effect on breastfeeding. Although, only a small number (50 out of 1041 newborns) had tongue-tie, those with tongue-tie did have significantly more difficulties with breast-feeding (latch and nipple pain).

An article by Ricke et al (2005) described a case-control study looking at the prevalence of breast-feeding problems in babies with tongue-tie as identified by using the HATLFF. They examined the mode of feeding (breast or bottle) at 1 week and then 1 month. They had 49 tongue-tied babies (and 98 control babies) – around 25% were lost at the follow up stage. They found that at 1 week, tongue-tie babies were three times less likely to be exclusively breastfeeding (although 80% were still doing some form of breast-feeding). And by 1 month, there was no difference in breast-feeding and bottle-feeding between the two groups.

Although the author of the HATLFF was involved in teaching the use of the tool to the researchers in the Ricke et al paper, she was not a fan of the final article (and its conclusion) and Alison Hazelbaker replied in a letter to the journal. Here she stated the many issues she had with the way this study was conducted and the way the researchers used and interpreted her tool.

Speech

It has been suggested that babies with tongue-tie grow up to be children with speech and articulation difficulties. Webb et al conducted a systematic review in 2013. 20 studies were examined and 4 of these looked at speech outcomes following tongue-tie division. There was no difference in articulation errors or speech intelligibility between the groups. There has been a case series reporting self-reported speech improvements post frenotomy.

For those who speak English, it is unlikely to have significant speech implications – the only sounds that require you to press your tongue against your upper teeth are L and TH and there aren’t any sounds that need you to stick your tongue out any further than that.

General enjoyment of life

The list of other potential problems caused by tongue-tie in later life is growing and they have all had their own studies (Lalakea et al, 2003):

  • Intra-oral hygiene (i.e. sweeping tongue around the mouth to clear food debris)
  • Oromotor dysfunction, lower incisor deformity and other dentition problems
  • Licking ice cream
  • French kissing
  • Playing a wind instrument
  • General ridicule from peers

How do we do a frenotomy?

The procedure itself is straightforward. The baby is restrained, the tongue is elevated (you can use a tongue depressor); some topical anaesthetic is applied; and then a small cut is made in the anterior frenulum.

Making the cut is done according to preference. Some people clamp the frenulum first to minimise bleeding and then make a cut; others will make a small anterior cut and then stretch the tongue upwards with the finger thus doing a blunt separate of the remaining tongue-tie.

It’s not a huge procedure, and there are not many adverse effects. Block describes his technique in an article in Pediatric Annals. 

What can go wrong?

Bleeding is the most common complication but this is usually just a few drops and easily stopped with pressure. There has been a reported 3.7% recurrence rate of tongue-tie post frenotomy (Webb et al, 2013).

Two terrifying case studies describe two patients in Nigeria who sustained hypovolaemia secondary to profuse bleeding post-procedure. One had no indication for frenotomy and it had been carried out by a non-medically trained birth attendant; and the other was done using a new razor blade by a community health worker. Both babies were resuscitated successfully and discharged home within a week.

But essentially, if you do it correctly, all will be fine.

Does having a frenotomy improve breastfeeding?

Many studies do show improvement of breast-feeding performance post frenotomy. Ballard et al (2002) looked at around 3000 babies and found 127 with tongue-tie. Their breast-feeding was assessed before and after frenotomy (except for 4 babies who did not have the procedure). All these babies suffered either poor latch or maternal nipple pain prior to frenotomy. In all cases where poor latch had been a problem prior to the procedure, post-frenotomy all the mothers reported improved latch. And in those with nipple pain there was a significant improvement in pain scores.

A more recent review in Archives of Disease in Childhood by Constantine et al (2011) reinforced this. The systematic review included 17 papers and agreed that nipple pain and latch seemed to improve post frenotomy. They also noted, however, that there was a lack of RCTs.

An RCT on 58 patients in 2011, randomised half of their infants with tongue-tie to receive frenotomy and the other half to receive a sham-surgery. The frenotomy group did show a significant improvement in breast-feeding and pain scores.

This year, there was another RCT published (Emond et al, 2014). They took 107 babies (less than two weeks old) with tongue-tie and randomised them to either frenotomy or standard breast-feeding support. At 5 days post-randomisation, 17% of women in the non-intervention arm had opted for a frenotomy. Of those that remained untreated at 5 days, there was no difference in LATCH scores between the two group. But, by the second measurement period (8 weeks) only 15% of non-treatment group had not had a frenotomy, so there was limited useful statistics to be gleaned by that stage in the study.

So, the evidence in Emond et al showed no difference in breastfeeding at five days but, regardless of this, most parents still opted for a frenotomy. Interviews with these families revealed: immediate improvement with frenotomy; general worry around achieving successful breast-feeding; and concern about withholding a simple treatment from their child that may help.

So, what's the verdict?

The studies demonstrate extremely mixed results. There is nothing that clearly shows an improvement in breastfeeding post-frenotomy but it does seem as though babies with tongue-tie struggle more with breast-feeding. In general, mothers seem happier post-procedure with improved self-scoring on pain and latch, and qualitative interviews report immediate improvement. Improving the happiness of new mums also has knock on effects for the baby.

Anyone who has breastfed a baby knows that it is difficult and it is uncomfortable at the beginning. This is even more so if it’s your first child  and you don’t have a clue what breastfeeding should feel like. Many women give up breastfeeding in the first few weeks. And for those who don’t give up, it is often difficult to begin with. Whether or not frenotomy impacts on this process is unclear.

It may be that those who have undergone a frenotomy feel more passionate about persisting with breastfeeding; or even more motivated due to having had an intervention. But it is not evident that less tongue-tie correlates with better breastfeeding.

In the words of the HATLFF author:

“Breast-feeding is a complex set of behaviors involving 2 people. My tool identifies only the deficits of those babies who have difficulty with one aspect of the breast-feeding relationship: the function of the tongue as a result of tongue-tie.”

In other words, even if tongue-tie has some effect on breastfeeding, it’s only a snippet of the whole picture.

However, frenotomy is only a minor procedure with no real risks to the baby, so if the family is keen to go ahead for the multitude of reasons discussed above, I cannot see why as doctors we would put our foot down and deny them this.

References

Ballard, JL, Auer, CE, Khoury, JC, Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002;110;e63.

Block SL, Ankyloglossia: when frenectomy is the right choice, Pediatr Ann. 2012, 41(1):14-6. 

Buryk M, Bloom D, Shope T, Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial, Pediatrics, 2011, 128(2); 280 -288. 

Constantine AH, Williams C and Sutcliffe AG, A systematic review for frenotomy for ankyloglossia (tongue tie) in breast fed infants), Arch Dis Child 2011 96: A62-A63.

Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189–F195.

Hazelbaker AK, Newborn tongue-tie and breast-feeding. J Am Board Fam Pract. 2005, 18(4):326; author reply 326-7.

Lalakea ML, Messner AH, Ankyloglossia: does it matter? Pediatr Clin North Am. 2003 Apr;50(2):381-97.

Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E, Ankyloglossia: incidence and associated feeding difficulties, Arch Otolaryngol Head Neck Surg. 2000, 126(1):36-9.

Opara PI, Gabriel-Job N, Opara KO, Neonates presenting with severe complications of frenotomy: a case series, Journal of Medical Case Reports 2012, 6:77.

Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005,  18(1):1-7.

Webb AN, Webba AN, Hao W, Hong P, The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review, International Journal of Pediatric Otorhinolaryngology, 2013, 77:635–646.

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About 

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa's DFTB posts

5 Responses to "Tongue-tie – to cut or not to cut?"

  1. Henry Goldstein
    Henry Goldstein 3 years ago .Reply

    Great post Tessa; a well rounded appraisal of a clearly controversial area.

    With respect to the views held by different practitioners, Messner & colleagues undertook a survey published in 2000. About 400 each of Otolaryngological surgeons, paediatricians, lactation consultants and speech therapists were surveyed, with a fairly even response rate around the 50% mark for each of the groups.

    The survey enquired about a number of aspects of ankyloglossia and frenotomy, including incidence, complications and surgical management.

    The finding that “Overall, [paediatrician] respondents were significantly less likely than [otolaryngological surgeons] to recommend surgery” is not surprising, but others, such as “Most LC respondents (77%) likewise indicate that ankyloglossia is infrequently encountered in their practice, as it is judged to be a major factor contributing to breastfeeding problems in only 1 – 5% of consults seen.”

    I appreciate these are views from the USA fifteen years ago, but I think that the differences between the groups remain broadly applicable, and may give some insight about why particular views are held by each group.

    The article’s worth reading in its entirety.

    Messner, A H & Lalakea, M L. Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology. 54 (2–3), August 2000, 123–131. http://www.sciencedirect.com/science/article/pii/S0165587600003591

  2. David Fuller
    David Fuller 3 years ago .Reply

    I agree with your conclusions Tessa. The evidence is mixed. Anecdotally it definitely makes a big difference for some babies, but you are right that there are many factors that influence breast feeding and it’s only one. In my experience it is a benign intervention and better tolerated than putting in an IV (which we rarely get concerned about doing).

    • Tessa Davis
      Tessa Davis 3 years ago .Reply

      Great point. We do lots of IVs and even heel pricks on babies without giving it much thought. I think part of the issue is about competency and access. Although all paeds will be happy putting in a cannula, most won’t be comfortable with cutting a tongue-tie. Therefore, it does end up being a bigger deal to go ahead with the procedure.

  3. Ross Fisher
    Ross Fisher 12 months ago .Reply

    The summary of your discussion is that there is no evidence of benefit.

    the “problem” has an interesting geographic distribution in intervention.

    Sticking a pair of scissors into the mouth of an awake baby is not without risk: bleeding and damage to the tongue are real enough and usually not considered by those who do not perform the procedure.

    Sadly, the reality is that what we end up with is operating on the child for the benefit of the mother, the grandmother, the midwife or GP.

    In 20 years of Paediatric surgery I have never had a child referred from speech and language, with a speech impediment, for division of tongue tie.

    I’m always intrigued about strength of opinion of lay people and non operating clinicians telling operators about a procedure they want done. Consider the same for male circumcision.

    • Tessa Davis
      Tessa Davis 12 months ago .Reply

      Thanks for the comment Ross. Completely agree that this intervention has a specific geographic and social class distribution. I’m not sure what the process is for cutting tongue tie in the UK, but in Aus, it’s not only done by surgeons (i.e. there are paediatricians who carry out this procedure too). So it’s not really a case of non-operating clinicians/lay people telling surgeons to do a procedure, but it’s non-surgical doctors deciding that this procedure is in the best interest of their patient and cutting the tongue tie themselves. Personally, I won’t be offering it as a treatment to my patients, but it is commonly done in the area where I worked in Aus and I didn’t come across any bad outcomes. Would be interested to hear the UK experience on this though.

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