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• Symptoms of breastfeeding difficulties are the main indication for lingual frenotomy
  Shaul Dollberg
  Published on: 22 March 2016

• Published on: 22 March 2016

  Symptoms of breastfeeding difficulties are the main indication for lingual frenotomy

  • Shaul Dollberg
  • Other Contributors:
    • Eyal Botzer. Tel Aviv Medical Center

  To the Editors: We have read with interest the article by Ingram et al (1) entitled "The development of a tongue assessment tool to assist with tongue-tie identification". The authors should be commended for simplifying and validating the ATLAF assessment. However, using their tool to decide upon whether or not to carry out lingual frenotomy has neither been proven nor is it justified. Unfortunately, this study, similar...

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  To the Editors: We have read with interest the article by Ingram et al (1) entitled "The development of a tongue assessment tool to assist with tongue-tie identification". The authors should be commended for simplifying and validating the ATLAF assessment. However, using their tool to decide upon whether or not to carry out lingual frenotomy has neither been proven nor is it justified. Unfortunately, this study, similar to most of the current discourse about lingual frenotomy, involves only terms pertaining to the descriptive anatomy of the tongue. Even the erroneously labeled "function items" in Hazelbaker's ATLAF (2) as well as those in the current study are actually descriptions of tongue mobility and not of the function of the tongue during breastfeeding. As our group recently demonstrated by means of an indirect ultrasound analysis, tongue biomechanics during breastfeeding are highly complex (3). No published studies have thus far succeeded in establishing a significant correlation between the description of the tongue by physical examination and the clinical presentation of breastfeeding difficulties. Indeed, the studies by Griffiths (4) and by our group (5), which were specifically designed to correlate anatomy with breastfeeding difficulties, had failed to identify such a correlation. In a recently published prospective study, we described the anatomy of the tongue in a group of non-selected infants without our having prior knowledge of the presence or absence of breastfeeding difficulties (6). We found no correlation between the appearance of the tongue and breastfeeding difficulties as reported by the mother. We therefore suggested that the terminology currently used to describe situations in which the lingual frenulum affects breastfeeding be altered, since the interchangeable terms of ''tongue-tie" "ankyloglossia'', ''sublingual frenulum'', and ''short frenulum" are misleading to both lay people and professionals. Our proposed terminology uses not only descriptive anatomy but also the previously overlooked but indispensable part of every clinical diagnosis, that of the patient's story. We had further suggested that infant and mother dyads who have breastfeeding difficulties that had not been solved by a lactation consultation and that were judged as being due to the infant's lingual frenulum be clinically diagnosed and termed as having ''symptomatic tongue-tie'' (or ''symptomatic ankyloglossia"), while infants with no breastfeeding difficulties and, alternatively, those with breastfeeding difficulties that had been corrected after a lactation consultation should be considered as having an asymptomatic ''sublingual frenulum", which is universally present (6). We believe that the terms ''short frenulum'' and "non-symptomatic tongue-tie" should be abandoned. Using the Bristol Tongue Assessment Tool as a means to decide upon performing lingual frenotomy is, therefore, not appropriate. Not only may the posterior symptomatic frenulum be missed, but based upon current research, we suggest that the decision to perform lingual frenotomy should depend primarily on the clinical picture, e.g., pain and latching difficulties during breastfeeding, and not upon visual inspection of the tongue. These symptoms, together with failure of improvement of these breastfeeding difficulties after professional lactation consultation, should be the almost exclusive medical indication to perform lingual frenotomy in a breastfed infant during the neonatal period.

  Shaul Dollberg, MD Beilinson Medical Center and Eyal Botzer DMD, Tel Aviv Medical Center

  References: 1. Ingram J, Johnson D, Copeland M, et al, The development of a tongue assessment tool to assist with tongue-tie identification. Arch Dis Child Fetal Neonatal Ed. 2015 (Online first) 2. Hazelbaker AK. Tongue-tie morphogenesis, impact, assessment and treatment. Columbus Ohio: Aiden & Eva Press, 2010. 3. Elad D, Kozlovsky P, Blum O, et al. Biomechanics of milk extraction during breast-feeding. Proc Natl Acad Sci. 2014;111:5230-5. 4. Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lact. 2004;20:409-14. 5. Dollberg S, Marom R, Botzer E. Lingual frenotomy for breastfeeding difficulties: A prospective follow-up study. Breastfeed Med. 2014;9:286-9. 6. Haham A, Marom R, Mangel L, et al. Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: A prospective cohort series. Breastfeed Med 2014;9:438-44.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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