Article Text
Abstract
Tongue tie is an increasingly common cause for referral of infants to our general paediatric surgery service. In this article, we will explore the indications for tongue tie division in the newborn child, the practicalities of the procedure and the supporting evidence.
- Infant Feeding
- Paediatric Surgery
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Background
Traditionally cited reasons for not wishing to divide a tongue tie
Until recently, the consensus among paediatricians was that tongue ties did not cause problems and should be left alone.1 This view was summed up by McEnery and Gaines from Chicago: “In observing a very large series of newborn babies, we have never seen a tongue that had to be clipped”.2 In the early 2000s, the procedure was still regarded by many as unnecessary and even potentially unethical.3 However, there is now an increasing body of evidence which supports division in selected infants.
The reasons you might want to divide a tongue tie
The indication for division of tongue tie is where the tie is significantly interfering with the feeding of the infant. In the absence of genuine feeding problems, there is no indication. Between 2% and 5% of newborns will be noted to have a prominent lingual frenulum4 ,5; however, in a cohort of >1000 infants, breastfeeding difficulty was documented in only 25% of ‘tongue-tied’ infants. Typical problems include: poor latch (which includes signs of frustration, like head banging), maternal nipple pain (including ulcerated, bleeding, cracked nipples, mastitis, and distorted or ‘lipstick’ nipple) and frequent or continuous feeds (see box 1).6 If these problems are observed, then, as an intermediate step before surgical review, feeding should be observed by an experienced community midwife or lactation consultant, as expert advice about achieving a good latch may be sufficient to resolve the problem. If the problem with feeding persists and the breastfeeding counsellor thinks the problem is tongue tie, then we would like to see the mother and her baby promptly. There are objective ways of assessing the degree of tongue tie, such as the Hazelbaker Assessment Tool for Lingual Frenulum Function and objective scoring systems to assess breastfeeding, such as the Latch, Audible swallowing, nipple Type, Comfort, Hold (LATCH) Scale.7 However, identification of those babies who will definitely benefit from division is difficult and we advocate an experienced team of breastfeeding support worker and surgeon. Timing of division is debateable, too early and the criticism could be levelled that feeding would have improved spontaneously, too late and breast feeding may have been abandoned by the time of the clinic appointment. Within 2 weeks of birth has been suggested as an optimal time.8
Typical symptoms reported by mother with a tongue-tied baby
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Nipple pain
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Deformity of nipple after breast feeding (lipstick nipple)
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Difficulty with latching (slipping off)
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Clicking noise during feeding
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Long feeds
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Constant feeding cycle (unsatisfied baby)
Is there any objective evidence that tongue tie division is effective?
Numerous cohort studies have been reported as demonstrating benefits of tongue tie division in infants with tongue tie presenting with breastfeeding difficulties. In a cohort of 215 babies reported by the Southampton group, 80% of those undergoing division were reported to be feeding better at 24 h.9 In a cohort of 123 infants with breastfeeding difficulties who underwent division, there was dramatic improvement in latch and in nipple pain (pain scores reduced from 6.9 to 1.2, p<0.001) following the procedure10; indeed, nipple pain appears to be a predictor that division will be successful.11
Geddes et al undertook submental ultrasound scans of the oral cavity in a cohort of infants before and after tongue tie division. For all of the infants, milk intake, milk-transfer rate, LATCH (latch, audible swallowing, type of nipple, comfort and hold) score and maternal pain scores improved significantly after division.12 There have been five randomised controlled trials attempting to evaluate the effects of tongue tie division in infants with feeding difficulty (table 1)7 ,8 ,13–15; none, however, without criticism of the study design.
This is how we do it
Our main contraindication to division of tongue tie is the absence of feeding difficulty; however, common sense should prevail in assessing infants for tongue tie division. A simple history is, of course, mandatory to screen for bleeding diathesis or other significant health problem, the infant must be otherwise well and we are cautious with infants with significant jaundice.
Tongue tie division is a technically simple procedure, we swaddle the infant in a blanket and give some 24% sucrose; the baby's head is held by an assistant across the examination couch with the head towards the surgeon. The baby’s head is steadied by the assistant who should also pull down the lower lip to enable the ‘divider’ to see. The first step is to establish the diagnosis of ankyloglossia and exclude other diagnoses, such as macroglossia or microglossia, fissuring of the tongue, hypertrophy of lingual papillae, congenital lingual cysts and fistulas derived from the thyroglossal duct, cleft palate or the rare bifid or cleft tongue (glossoschissis).
If the lingual frenulum is to be divided, one or two fingers elevate the tongue placing the frenulum under tension (figure 1). The frenulum is divided with sharp, sterile, blunt-ended scissors (figure 2). The baby is fed by the mother immediately afterwards and checked again before leaving the clinic. While some practitioners make note that care must be taken to avoid cutting into the thicker posterior part of the frenulum which carries the blood supply,16 we believe that the absence of a visible frenulum does not always rule out clinically significant tongue tie. ‘Posterior’ or submucosal tongue tie (where the frenulum does not obviously extend forward to the tip of the tongue as in a classical anterior tongue tie) can be better felt than seen and can be associated with breastfeeding difficulty.17 In our view, assessment and division of posterior tongue tie requires specific training and some experience.
The risks of the procedure
Distress occasioned to the baby is limited, particularly if the procedure is undertaken within the first couple of weeks of life and morbidity is low; Hansen and colleagues from Edinburgh reported self-limited bleeding in 2%, pain in 2% and request made for recurrent division in 4% of a cohort of 44 infants.16 In one randomised controlled trial, 5% of mothers reported ‘a small amount of bleeding at home’ after frenulotomy.8 Serious bleeding may occur18 and we believe that the procedure should be concentrated in the hands of those trained in assessment and division and that the procedure should take place within a clinical setting where escalation of care could occur if necessary.
Limitations of the procedure
We advise mothers that the procedure can be expected to make no noticeable difference in breast feeding in up to 20% of infants. Many parents are concerned about speech and language development if their baby has been labelled as having a tongue tie. We feel able to reassure them that, if 5% of babies have a noticeable tongue tie as an infant, not 5% of children have subsequent difficulty with speech and language. There is, therefore, a natural history of the undivided tongue tie in infancy whereby, in the vast majority, it stretches or breaks or simply does not cause a problem with speech. We reassure parents and do not advocate dividing tongue tie just because it is there; but reserve the procedure for an infant with documented feeding difficulty. A recent systematic review confirmed our view; finding no significant data to suggest a causative association between tongue tie and speech articulation problems.19 Other long-term benefits for tongue tie division such as improved cosmesis and enhanced enjoyment of ice creams, etc are anecdotal and unsupported by any evidence.
Conclusion
In summary, we believe that tongue tie can cause difficulty with breast feeding and approximately 80% of infants will respond positively to division, with a low risk of harm. We do not recommend division of tongue tie in infants to prevent future possible speech and language difficulty. Appropriate training must have been undertaken and the procedures should be performed in a setting where escalation could occur rapidly if required. Tongue tie assessment and division in selected infants should form part of an integrated programme to support mothers in adoption and maintenance of exclusive breast feeding where possible.
References
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Commissioned; internally peer reviewed.