A retrospective review of frenotomy in neonates and infants with feeding difficulties

Speech Outcomes of Frenectomy for Tongue-Tie Release: A Systematic Review and Meta-Analysis

OBJECTIVE

Tongue-tie, which is also known as ankyloglossia, is a common condition where the lingual frenulum is unusually tight or short. While most literature investigates the impact of tongue-tie on breastfeeding, recent articles have examined its role in speech production in children. However, these have not previously been reviewed systematically. This study aims to determine the impact of tongue-tie on speech outcomes and assess whether frenectomy can improve speech function.

METHODS

In this systematic review, we conducted a comprehensive search of PubMed/MEDLINE, Cochrane Library, Embase, and speechBITE to analyze primary studies investigating the impact of frenectomy for tongue-tie on speech outcomes. We extracted data regarding patient age, male to female ratio, procedure type, follow-up time, and speech outcomes and ran statistical analyses to determine if frenectomy for tongue-tie leads to improvement in speech issues in pediatric patients. Speech outcomes extracted were subjectively measured based on the interpretation of a speech and language pathologist or parent.

RESULTS

Our analysis included 10 studies with an average patient age of 4.10 years, and average cohort size of 22.17 patients. Overall, frenectomy for tongue-tie was associated with an improvement in speech articulation (0.78; 95% CI: 0.64-0.87; P < .01). Increasing patient age was found to be negatively correlated with post-frenectomy speech outcomes (P = .01). However, this relationship disappeared in the adjusted model.

CONCLUSION

Overall, we conclude that frenectomy is a suitable treatment to correct speech issues in select patients with tongue-tie if caught early in childhood. Despite the limited investigations around speech outcomes post-frenectomy, these results are informative to providers treating tongue-tie.

Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review

It is unclear how effective tongue-tie classification assessment tools are in diagnosing symptomatic tongue-tie and fulfilling lingual frenectomy criteria. The purpose of this systematic review is to determine and evaluate any association between tongue-tie severity, as measured by pre-treatment assessment tools, and post-operative outcome following tongue-tie division. PubMed, EMBASE, and the Cochrane search engines were used to retrieve articles published between 1947 and 2021. Included studies consisted of patients with symptomatic tongue-tie, assessment by either the Coryllos, Kotlow, or Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) classification tool, and tongue-tie division. A total of 205 abstracts were identified; 31 studies met the criteria for a full-text review, of which, only 14 studies met the criteria for data extraction and analysis. Six studies used the HATLFF, 2 studies used the Kotlow, 5 studies used the Coryllos, and 1 study used a combination of both Kotlow and Coryllos methods. Significant heterogeneity was evident across all studies. No statistical correlation between the two variables could be determined. Although tongue-tie division procedures appear to provide benefits in breastfeeding and speech, there are no data to suggest a statistically significant association between the severity of tongue-tie, and the correct identification of patients who would benefit from tongue-tie division. © 2022 Australian Dental Association.

Craniofacial Sleep Medicine: The Important Role of Dental Providers in Detecting and Treating Sleep Disordered Breathing in Children

Obstructive sleep apnea (OSA) is a clinical disorder within the spectrum of sleep-related breathing disorders (SRDB) which is used to describe abnormal breathing during sleep resulting in gas exchange abnormalities and/or sleep disruption. OSA is a highly prevalent disorder with associated sequelae across multiple physical domains, overlapping with other chronic diseases, affecting development in children as well as increased health care utilization. More precise and personalized approaches are required to treat the complex constellation of symptoms with its associated comorbidities since not all children are cured by surgery (removal of the adenoids and tonsils). Given that dentists manage the teeth throughout the lifespan and have an important understanding of the anatomy and physiology involved with the airway from a dental perspective, it seems reasonable that better understanding and management from their field will give the opportunity to provide better integrated and optimized outcomes for children affected by OSA. With the emergence of therapies such as mandibular advancement devices and maxillary expansion, etc., dentists can be involved in providing care for OSA along with sleep medicine doctors. Furthermore, the evolving role of myofunctional therapy may also be indicated as adjunctive therapy in the management of children with OSA. The objective of this article is to discuss the important role of dentists and the collaborative approach between dentists, allied dental professionals such as myofunctional therapists, and sleep medicine specialists for identifying and managing children with OSA. Prevention and anticipatory guidance will also be addressed.

Post Frenotomy Massage for Ankyloglossia in Infants-Does It Improve Breastfeeding and Reduce Recurrence?

OBJECTIVES

Frenotomy is performed in breast fed infants who experience difficulty in latching after failed conservative management for ankyloglossia or tongue-tie. Though parents sometimes enquire about massage after frenotomy, neither published evidence nor clinical consensus supports this. The aim of our study was to assess if there was significant difference in breast feeding or recurrence rate between those infants who had post frenotomy massage and those who did not.

METHODS

A retrospective study was conducted in a tertiary Children's hospital from January 2018 to December 2018. The tongue-tie service consisted of five pediatric surgical consultants, three of whom routinely advice post frenotomy massage. As a result, we had two groups to compare -massage and non-massage group. Total sample size (n = 599) consisted of those who were advised massage (n = 282) and those who were not advised massage (n = 317).

RESULTS

Overall recurrence rate was 4/599 (0.66%) and this did not achieve statistical significance between the two groups. Breast feeding rates were also similar in both the groups. However, it is interesting to note that only 43.5% of those advised massage adhered to the massage regimen.

CONCLUSIONS

Improvement in breast feeding and recurrence after frenotomy were similar between massage and non-massage groups. This confirms the lack of any additional benefit of post frenotomy massage. This study assists clinicians with decision making not to advise massage as it is unlikely to benefit infants with tongue-tie.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

The effect of frenotomy on long-term breastfeeding in infants with ankyloglossia

INTRODUCTION

The World Health Organization has issued guidelines suggesting exclusive breastfeeding for at least six months for all infants. However, one of the main factors interfering with successful breastfeeding is ankyloglossia. Frenotomy may help improve breastfeeding, but evidence on the long-term effects on breastfeeding is lacking. Therefore, this study was conducted to evaluate the effect of frenotomy on breastfeeding and identify factors associated with receiving exclusive breastfeeding for six months.

METHODS

This was a cross-sectional descriptive study conducted using retrospective chart review. Infants diagnosed with anterior ankyloglossia who underwent frenotomy at HRH Princess Maha Chakri Sirindhorn Medical Center between April 1, 2013 and March 31, 2019 were included. Data on both the mothers and the infants were collected. The length and types of feeding at 2, 4, 6, and 12 months were recorded.

RESULTS

In total, 526 infants were included in the study; 322 (61.22%) were male. Their median age on the day of surgery was 2 days (minimum 1 day, maximum 30 days). In total, 7.03% did not receive breastfeeding, whereas 17.96% and 75.01% had received breastfeeding for fewer than and more than six months, respectively. The prevalence of infants exclusively breastfed decreased over time from 81.37% to 55.70%, 33.46%, and 4.38% at 2, 4, 6, and 12 months, respectively. The study did not show any independent factors of neonatal and maternal characteristics associated with being exclusively breastfed for six months.

CONCLUSION

Among infants with anterior ankyloglossia who received frenotomy, 33.46% were exclusively breastfed for six months. The study did not show any independent factors of neonatal and maternal characteristics associated with being exclusively breastfed for six months.

Frenotomy Revision Rate in Breastfeeding Infants: The Impact of Early Versus Late Follow-Up

Purpose: The protocol for postoperative follow-up time after lingual frenotomy in breastfeeding infants with ankyloglossia was changed from 2 weeks to 1 week at our institution. This study examined the impact of this change in practice on frenotomy revision rate. Materials and Methods: A retrospective chart review of breastfeeding infants who underwent lingual frenotomy for ankyloglossia from January 2016 to December 2017 was performed. Subjects were divided into 1-week (1-9 days) and 2-week (10-20 days) follow-up groups. Statistical analyses were performed to investigate the relationship between revision rate and postoperative follow-up time, as well as additional patient characteristics. Results: Of the 369 patients included in the study, 34 (9.2%) underwent frenotomy revision. The individual revision rates of the 1- and 2-week follow-up cohorts were 5.2% and 12.7%, respectively. The difference in revision rate was statistically significant (p = 0.022), and logistic regression revealed the odds of revision for the 2-week cohort to be 2.67 times (95% confidence interval: 1.207-5.918) greater than the 1-week cohort (p = 0.015). Conclusion: This study demonstrates a significant association between a shorter postoperative follow-up time and decreased frenotomy revision rate. With earlier follow-up, manual adjustment can be performed sooner in the postoperative period as needed, which may prevent scarring or healing complications that usually necessitate full revision. Our findings support a shift to a shorter postoperative follow-up time as a means of improving frenotomy outcomes.

How to Treat a Tongue-tie: An Evidence-based Algorithm of Care

Ankyloglossia, or tongue-tie, is characterized by a short or thickened lingual frenulum; this can be associated with impaired breastfeeding, speech, and dentofacial growth. The indications for performing frenotomy, frenuloplasty, or other operative interventions are unclear.

Trends in outpatient intervention for pediatric ankyloglossia

OBJECTIVES

Anecdotally, there has been an increase in ankyloglossia referrals and frenotomy procedures performed in recent years. Many studies have characterized frenotomy indications and outcomes, but none have quantified how the frequency of referrals and interventions have changed over time in the outpatient setting. This study analyzes temporal trends in the diagnosis and intervention of ankyloglossia in a pediatric otolaryngology practice to further clarify how patterns of management of this condition have changed over time.

METHODS

This study was a retrospective chart review of patients evaluated for ankyloglossia in an outpatient pediatric otolaryngology clinic between 2008 and 2018. The chi-square test for trend was used to assess yearly changes in the referral numbers, surgical interventions, and procedure indication prevalence proportions of interest.

RESULTS

Referral numbers and frenotomy procedures increased as a percentage of total office visits from 2008 to 2018 (P = 0.0026, P < 0.0001). The trend in frenotomies was especially pronounced in the 0 to 2-month age group (P < 0.0001) but was not observed in the 2 months to 1-year (P = 0.30) or 1- to 4-year (P = 0.40) age groups. Frenotomy performed for concerns of feeding (P < 0.0001) increased over the study period, but there was no significant increase in procedures performed for speech concerns (P = 0.13).

CONCLUSION

Significant increases in referrals for frenotomy and number of frenotomy procedures performed are demonstrated, especially in young infants for feeding concerns. It is unlikely representative of a true increase in the incidence of ankyloglossia, but rather the result of cultural and clinical factors driving referrals and intervention.

Evaluation of the lingual frenulum in newborns using two protocols and its association with breastfeeding

OBJECTIVE

To characterize the lingual frenulum of full-term newborns using two different protocols and to assess the association of the lingual frenulum with breastfeeding.

METHODS

This non-probabilistic sample consisted of 449 mother/baby binomials. For the anatomo-functional evaluation of the frenulum, the Neonatal Tongue Screening Test and the Bristol Tongue Assessment Tool were used for the evaluation of the lingual frenulum. Breastfeeding was evaluated using the protocol proposed by UNICEF. Scores were created (good, fair, poor) to evaluate every aspect of the breastfeeding to be observed. The results were analyzed through descriptive and inferential statistics and association tests (Pearson's chi-squared and Fisher's exact test).

RESULTS

The study showed that 14 babies had a lingual frenulum alteration, of whom three had difficulties during suction, requiring frenotomy in the first week of life, whereas 11 had no difficulties during breastfeeding. Regarding the breastfeeding evaluation, 410mother/baby binomials had good, 36 regular, and three had bad scores. There was a statistically significant association between the tongue-tie test protocol and breastfeeding (p=0.028) and between the Bristol Tongue Assessment Tool protocol and breastfeeding (p=0.028).

CONCLUSION

Alterations in the lingual frenulum are associated with interferences in the quality of breastfeeding and thus, evaluation of the lingual frenulum in newborns is important.

Clinical Consensus Statement: Ankyloglossia in Children

OBJECTIVE

To identify and seek consensus on issues and controversies related to ankyloglossia and upper lip tie in children by using established methodology for American Academy of Otolaryngology-Head and Neck Surgery clinical consensus statements.

METHODS

An expert panel of pediatric otolaryngologists was assembled with nominated representatives of otolaryngology organizations. The target population was children aged 0 to 18 years, including breastfeeding infants. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus, per established methodology published by the American Academy of Otolaryngology-Head and Neck Surgery.

RESULTS

After 3 iterative Delphi method surveys of 89 total statements, 41 met the predefined criteria for consensus, 17 were near consensus, and 28 did not reach consensus. The clinical statements were grouped into several categories for the purposes of presentation and discussion: ankyloglossia (general), buccal tie, ankyloglossia and sleep apnea, ankyloglossia and breastfeeding, frenotomy indications and informed consent, frenotomy procedure, ankyloglossia in older children, and maxillary labial frenulum.

CONCLUSION

This expert panel reached consensus on several statements that clarify the diagnosis, management, and treatment of ankyloglossia in children 0 to 18 years of age. Lack of consensus on other statements likely reflects knowledge gaps and lack of evidence regarding the diagnosis, management, and treatment of ankyloglossia. Expert panel consensus may provide helpful information for otolaryngologists treating patients with ankyloglossia.

ANKYLOGLOSSIA AND ITS INFLUENCE ON GROWTH AND DEVELOPMENT OF THE STOMATOGNATHIC SYSTEM

Objective:

To critically examine the existing Brazilian and International scientific literature regarding the influence of short lingual frenulum over growth and development of the stomatognathic system, as well as how it impacts the achievement of the shape-function balance.

Data sources:

An electronic literature search was conducted in databases, including MEDLINE/PubMed, Google Scholar, LILACS, SciELO, and ScienceDirect, using the key words “lingual frenum” and “development”, as well as their equivalents in Brazilian Portuguese. The literature search yielded 51 papers published between January 1997 and the present date; 14 articles of clinical trials were selected for meeting the inclusion criteria and were read in full.

Data synthesis:

The integrated literature review supported the proposition that some malocclusions are closely related to the presence of ankyloglossia and, although very few clinical trials on this topic have been published so far, there is a consensus among authors concerning the negative effects of functional imbalances over the stomatognathic system’s proper growth and development. Half of the studies found state that surgical interventions for releasing the lingual frenum are both safe and effective, concerning improvement in breastfeeding scores. Moreover, 4 out of the 14 studies included in this integrated review, report a negative influence of ankyloglossia over the orofacial muscular system.

Conclusions:

There is a consensus among the authors concerning the negative effects of lingual frenulum’s anatomic and functional alterations over craniofacial growth and development. The opinion about the early surgical intervention, however, is not unanimous.

Effect of frenotomy on breastfeeding variables in infants with ankyloglossia (tongue-tie): a prospective before and after cohort study

BACKGROUND

Controversy exists regarding ankyloglossia (tongue-tie) and its clinical impact on breastfeeding, including the benefits, or otherwise, of tongue-tie release (frenotomy). As exclusive breastfeeding rates in Ireland are already considerably low (46% on discharge home from the maternity unit following birth in 2014), it is imperative to protect and support breastfeeding, including identifying the associated effects that frenotomy might have on breastfeeding variables.

OBJECTIVE

To determine the associated effects of frenotomy on breastfeeding variables in infants with ankyloglossia.

METHODS

A prospective before and after cohort study was conducted. Following ethical approval, two self-reported questionnaires were administered to women whose infants were undergoing frenotomy at seven healthcare clinics in the Republic of Ireland. Data on breastfeeding variables prior to the frenotomy procedure and at 1-month post-frenotomy were collected and compared. Descriptive statistics (frequencies and proportions) were used to analyse, separately, the pre- and post-frenotomy data. Inferential statistics (z-test scores for differences between proportions (alpha <0.05) and mean differences (MD) with 95% confidence intervals (CI)) were used for pre- and post-frenotomy comparative analyses.

RESULTS

Ninety-eight women returned the baseline questionnaire, and, of these, 89 returned the follow-up questionnaire. The most common reason for seeking a frenotomy was difficulty with latch (38%). Private lactation consultants were the main person recommending a frenotomy (31%). Rates of exclusive breastfeeding remained similar pre- and post-frenotomy (58% versus 58%), although rates of formula feeding increased two-fold at follow-up. Infants' ability to extend their tongues to the lower lip after frenotomy was significantly increased (p < 0.0001). Almost all participants (91%) reported an overall improvement in breastfeeding post-frenotomy. Pain on breastfeeding was significantly reduced post-frenotomy (MD 2.90, 95% CI 3.75 to 2.05) and overall LATCH scale scores were significantly increased (MD -0.50, 95% CI -0.67 to -0.33).

CONCLUSIONS

This study supports the hypothesis that frenotomy has a positive effect on breastfeeding variables in infants with ankyloglossia. These findings, however, are based on a relatively small number of participants from one country only where breastfeeding rates are low. Further, larger studies are required to substantiate these findings.

Ankyloglossia in Infancy: An Indian Experience

OBJECTIVE

To study the prevalence, clinical presentation and management of infants with ankyloglossia.

METHODS

A retrospective file review of infants less than 6 months of age with a diagnosis of ankyloglossia.

Results

Of the 25786 babies born during the assessment period (2007-2015), 134 (0.52%) had ankyloglossia. Sixty-four (47.7%) infants who presented with breastfeeding difficulties were diagnosed significantly earlier than the asymptomatic group (P<0.05). Of the symptomatic group, 85.9% underwent frenotomy with satisfactory results. Seventy asymptomatic infants were managed conservatively with counselling.

CONCLUSION

Frenotomy seems to be a safe and effective procedure in infants with symptomatic ankyloglossia.

Ankyloglossia (Tongue-Tie)—To Snip or Not to Snip: An Integrative Literature Review

PURPOSE: Ankyloglossia (commonly referred to as tongue-tie), is increasingly being reported as a significant contributory factor to difficulties experienced in establishing the mother–infant breastfeeding relationship. Frenotomy as a management option is contributing to international interest and interdisciplinary controversy. The aim of this article was to identify and examine the evidence in relation to frenotomy to inform practice for newborns diagnosed with symptomatic ankyloglossia.

DESIGN: An integrated literature review, informed by Whittemore and Knafl (2005) was used to identify and evaluate contemporary evidence.

MAJOR FINDINGS: There is a marked difference in opinion between health disciplines regarding frenotomy as a treatment option for ankyloglossia. There is agreement that support from a trained professional such as a lactation consultant prior to undergoing any invasive procedures to treat ankyloglossia is essential. Controversy persists however as to whether the condition will resolve spontaneously without treatment.

CONCLUSION: Although frenotomy does seem to resolve breastfeeding difficulties, little is known regarding long-term consequences for the baby and optimal timing for the procedure. This review indicates a need for education of professionals and standardization of assessment processes along with ongoing research to identify efficacy and optimal timing of frenotomy when used.

Interventions in the Alteration on Lingual Frenum: Systematic Review

Introduction

 Altered lingual frenum modifies the normal tongue mobility, which may influence the stomatognathic functions, resulting in anatomical, physiological and social damage to the subject. It is necessary that health professionals are aware of the process of evaluation, diagnostics and treatment used today, guiding their intervention.

Objective

 To perform a systematic review of what are the treatment methods used in cases of lingual frenum alteration.

Data Synthesis

 The literature searches were conducted in MEDLINE, LILACS, SciELO, Cochrane and IBECS, delimited by language (Portuguese, English, Spanish), date of publication (January 2000 to January 2014) and studies performed in humans. The selection order used to verify the eligibility of the studies were related to: full text availability; review the abstract; text analysis; final selection. Of the total 443 publications, 26 remained for analysis. The surgical approach was used in all studies, regardless of the study population (infants, children and adults), with a range of tools and techniques employed; speech therapy was recommended in the post surgical in 4 studies. Only 4 studies, all with infants, showed scientific evidence.

Conclusion

 Surgical intervention is effective for the remission of the limitations caused by the alteration on lingual frenum, but there is a deficit of studies with higher methodological quality. The benefits of speech therapy in the post surgical period are described from improvement in the language of mobility aspects and speech articulation.

Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments

Background: Persistent nipple pain is one of the most common reasons given by mothers for ceasing exclusive breastfeeding. We aimed to determine the frequency of nipple pain as a reason for consultation, the most common attributed aetiologies, and the effectiveness of the advice and treatment given. Methods: All consultations at the Breast Feeding Centre of Western Australia (WA) were audited over two six-month periods in 2011 (n = 469) and 2014 (n = 708). Attributed cause(s) of nipple pain, microbiology results, treatment(s) advised, and resolution of pain were recorded. Results: Nipple pain was one of the reasons for consultation in 36% of cases. The most common attributed cause of nipple pain was incorrect positioning and attachment, followed by tongue tie, infection, palatal anomaly, flat or inverted nipples, mastitis, and vasospasm. Advice included correction of positioning and attachment, use of a nipple shield, resting the nipples and expressing breastmilk, frenotomy, oral antibiotics, topical treatments, and cold or warm compresses. Pain was resolving or resolved in 57% of cases after 18 days (range 2–110). Conclusion: The multiple attributed causes of nipple pain, possibly as a result of a cascade of events, suggests that effective early lactation management for prevention of nipple pain and early diagnosis and effective treatment are crucial to avoid early weaning.

Tongue-tie division to treat breastfeeding difficulties: our experience

OBJECTIVES

To assess the benefits of frenotomy on breastfeeding in infants, and determine the influence of age.

METHODS

A telephone questionnaire of all patients diagnosed with tongue-tie over 12 months was conducted pre-intervention and 1-month post-intervention. The Infant Breastfeeding Assessment Tool was used to assess breastfeeding.

RESULTS

Of 54 infants diagnosed with tongue-tie, 78 per cent of mothers participated in the survey. Eighty-six per cent of patients underwent frenotomy, with no surgical complications. In the frenotomy group, 81 per cent of mothers reported improvement in breastfeeding, versus 17 per cent in the non-surgical group (p = 0.0074). In the frenotomy group, the mean (±standard deviation) Infant Breastfeeding Assessment Tool score was 3.33 ± 1.51 pre-intervention, versus 9.19 ± 2.44 post-intervention (p = 0.0001). In the non-surgical intervention group, the mean score (±standard deviation) was 4.17 ± 0.75 pre-intervention, versus 6.00 ± 1.73 post-intervention (p = 0.16). For infants who underwent frenotomy, there was a reported improvement in 94 per cent of those aged less than 30 days, versus 68 per cent in infants aged over 30 days (p = 0.092).

CONCLUSION

Frenotomy is a safe, short procedure that improves breastfeeding outcomes, and is best performed at an early age.

[Diagnosis and management of ankyloglossia in young children]

Ankyloglossia is a common condition. Its prevalence is between 3.2% and 4.8% depending on the series and is largely underestimated given the fact of non-diagnosis when the symptoms are limited. It is defined as a short lingual frenulum resulting in a limitation of the lingual mobility. It is due to a defect in cellular apoptosis embryogenesis between the floor of the mouth and tongue. The result is a fibrous and short lingual frenulum. Several classifications were used to make the diagnosis. However, these are the clinical implications, particularly on food and primarily breastfeeding in the baby and phonation in older children that will motivate the management. This is surgical and different techniques are available: infants before the age of 6 months and when the lingual frenulum is still a fine cellular membrane, frenotomy is recommended. Frenectomy with or without frenoplasty is indicated for the older child. The surgery is simple, the results are good and rapidly improving grievances. Complications are rare. Finally, speech therapy is important when there are implications for phonation.

Treatment of ankyloglossia and breastfeeding outcomes: a systematic review

OBJECTIVE

Ankyloglossia is a congenital condition characterized by an abnormally short, thickened, or tight lingual frenulum that restricts tongue mobility. The objective of this study was to systematically review literature on surgical and nonsurgical treatments for infants with ankyloglossia.

METHODS

Medline, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched up to August 2014. Two reviewers independently assessed studies against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics and outcomes and assigned quality and strength-of-evidence ratings.

RESULTS

Twenty-nine studies reported breastfeeding effectiveness outcomes (5 randomized controlled trials [RCTs], 1 retrospective cohort, and 23 case series). Four RCTs reported improvements in breastfeeding efficacy by using either maternally reported or observer ratings, whereas 2 RCTs found no improvement with observer ratings. Although mothers consistently reported improved effectiveness after frenotomy, outcome measures were heterogeneous and short-term. Based on current literature, the strength of the evidence (confidence in the estimate of effect) for this issue is low. We included comparative studies published in English. The evidence base is limited, consisting of small studies, short-term outcomes, and little information to characterize participants adequately. No studies addressed nonsurgical interventions, longer-term breastfeeding or growth outcomes, or surgical intervention compared with other approaches to improve breastfeeding, such as lactation consultation.

CONCLUSIONS

A small body of evidence suggests that frenotomy may be associated with mother-reported improvements in breastfeeding, and potentially in nipple pain, but with small, short-term studies with inconsistent methodology, strength of the evidence is low to insufficient.

Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance

AIMS

Currently there is debate on how best to manage young infants with tongue-tie who have breastfeeding problems. One of the challenges is the subjectivity of the outcome variables used to assess efficacy of tongue-tie division. This structured review documents how the argument has evolved. It proposes how best to assess, inform and manage mothers and their babies who present with tongue-tie related breastfeeding problems.

METHODS

Databases were searched for relevant papers including Pubmed, Medline, and the Cochrane Library. Professionals in the field were personally contacted regarding the provision of additional data. Inclusion criteria were: infants less than 3 months old with tongue-tie and/or feeding problems. The exclusion criteria were infants with oral anomalies and neuromuscular disorders.

RESULTS

There is wide variation in prevalence rates reported in different series, from 0.02 to 10.7%. The most comprehensive clinical assessment is the Hazelbaker Assessment Tool for lingual frenulum function. The most recently published systematic review of the effect of tongue-tie release on breastfeeding concludes that there were a limited number of studies with quality evidence. There have been 316 infants enrolled in frenotomy RCTs across five studies. No major complications from surgical division were reported. The complications of frenotomy may be minimised with a check list before embarking on the procedure.

CONCLUSIONS

Good assessment and selection are important because 50% of breastfeeding babies with ankyloglossia will not encounter any problems. We recommend 2 to 3 weeks as reasonable timing for intervention. Frenotomy appears to improve breastfeeding in infants with tongue-tie, but the placebo effect is difficult to quantify. Complications are rare, but it is important that it is carried out by a trained professional.

Tongue tie: the evidence for frenotomy

Tongue tie or ankyloglossia is a congenital variation characterised by a short lingual frenulum which may result in restriction of tongue movement and thus impact on function. Tongue tie division (frenotomy) in affected infants with breastfeeding problems yields objective improvements in milk production and breastfeeding characteristics, including objective scoring measures, weight gain and reductions in maternal pain. For the majority of mothers, frenotomy appears to enhance maintenance of breastfeeding. Tongue tie division is a safe procedure with minimal complications. The commonest complication is minor bleeding. Recurrence leading to redivision occurs with rates of 0.003-13% reported; this appears to be more common with posterior than anterior ties. There are limited reports indicating that prophylactic frenotomy may promote subsequent speech development; however, evidence is currently insufficient to condone this practice and further good quality research into this area is warranted.

The National Institute for Health and Clinical Excellence, and otolaryngology: review of the evidence

BACKGROUND

The adoption of evidence-based practice is fundamental to good medical care; it ensures that intervention is clinically effective and safe. In a world of limited healthcare resources, consideration of cost-effectiveness must, unfortunately, restrict clinicians' choice. The National Institute for Health and Clinical Excellence has, for over 10 years, developed guidance to achieve a national consensus on best practice.

OBJECTIVES

This review describes the Institute's methodology, examines guidance relevant to otolaryngology and presents more recent research to update the evidence.

Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia?

The aim of this systematic review was to critically examine the existing literature regarding the effectiveness of tongue-tie division in infants with ankyloglossia, using the new grades of recommendations, assessment, development, and evaluation (GRADE) rating system. A clinical question was structured according to patient, intervention, comparison, and outcome, as follows: in infants with poor breast-feeding and ankyloglossia (patient), does frenotomy (intervention), compared to lactation support alone (comparison), improve feeding (outcome)? An electronic literature search was systematically conducted from databases including PubMed, Japana Centra Revuo Medicina (Igaku Chuo Zasshi), CINAHL, and Cochrane Library using the key words "ankyloglossia," "tongue-tie," "frenotomy," and/or "breast-feeding" in English and equivalent terms in Japanese. The literature search yielded four randomized clinical trials, and 12 observational studies for analysis. The quality of the literature was rated in regard to the two most important outcomes (sucking/latching, and nipple pain) and five less important outcomes (milk supply/milk production, continuation of breast-feeding, weight gain, adverse events, and dyad distress) in accordance with the GRADE system. Evidence levels of the most important outcomes were rated either A (strong evidence) or B (moderate evidence), and less important outcomes were rated C (weak evidence); every outcome consistently showed a favorable effect of frenotomy on breast-feeding. The literature review supported an overall moderate quality of evidence for the effectiveness of frenotomy for the treatment of breast-feeding difficulties in infants with ankyloglossia. No major complications from frenotomy were reported.

Parental perception of speech and tongue mobility in three-year olds after neonatal frenotomy

OBJECTIVES

The goal of this study was to evaluate parental speech outcomes and tongue mobility in children with ankyloglossia who underwent frenotomy by an otolaryngologist during the neonatal period.

STUDY DESIGN

Cohort study and retrospective telephone survey.

STUDY SETTING

University Hospital.

SUBJECTS AND METHODS

Neonates previously diagnosed with congenital ankyloglossia were separated into Surgical Intervention (N=71) and No Surgical Intervention (N=15) Groups. A Control Group (N=18) of patients was identified from the hospital medical record database, which were not diagnosed with congenital ankyloglossia. A survey provided by a certified speech pathologist utilized a Likert scale to assess speech perception and tongue mobility by parental listeners. The questionnaire also analyzed oral motor activities and the medical professionals that identified the ankyloglossia shortly after birth. Statistical analyses were performed with the Wilcoxon Rank Sum Test and Fischer's Exact Test in order to determine an effect size=1.

RESULTS

There was significantly improved speech outcomes designated by parents in the Surgical Intervention Group when compared to the No Surgical Intervention Group [p<0.0001, p<0.0001], respectively. Furthermore, parents designated no difference in speech outcomes between the Surgical Intervention Group when analyzed against the Control Group [p=0.3781, p<0.2499], respectively.

CONCLUSIONS

There was a statistically significant improvement in speech outcomes and tongue mobility in children who underwent frenotomy compared to individuals who declined the operation. As a result of the data presented within this study, there appears to be a long-term benefit beyond feeding when frenotomy is performed in newborns with ankyloglossia.

Protocolo de avaliação do frênulo lingual para bebês: relação entre aspectos anatômicos e funcionais

OBJETIVO: verificar quais características do frênulo da língua influenciam nas funções de sucção e deglutição em bebês nascidos a termo, com a finalidade de propor adequações no protocolo proposto por Martinelli et al (2012). MÉTODO: foi aplicado o protocolo de avaliação do frênulo da língua em 100 bebês saudáveis nascidos a termo. Os filmes obtidos na avaliação foram analisados por duas fonoaudiólogas especialistas em MO, com experiência em avaliação de frênulo lingual. Foram aplicados os testes Qui-quadrado seguido do teste exato de Fisher, além da análise de variância, considerando os dados qualitativos e quantitativos, respectivamente. RESULTADOS: nos 16 bebês que apresentaram alteração do frênulo lingual, verificou-se a relação entre: a tendência do posicionamento da língua durante o choro e o tempo entre as mamadas; a forma da língua quando elevada e o cansaço para mamar; bem como a fixação do frênulo na língua e o movimento da língua na sucção não nutritiva. Pela análise dos dados dos bebês com alteração de frênulo lingual, foi possível definir as características indicativas de alteração, que possibilitaram a adequação do protocolo inicial, e a atribuição de escores. CONCLUSÃO: a forma da língua, quando elevada durante o choro, influencia o movimento da língua durante a sucção não nutritiva, e o ponto de fixação do frênulo na língua influencia o ritmo da sucção durante a amamentação. O novo protocolo com escores é uma ferramenta efetiva para avaliar e diagnosticar alterações anatômicas do frênulo da língua e suas possíveis interferências na amamentação.

The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review

OBJECTIVE

To systematically review the outcomes of tongue-tie division procedures in patients with ankyloglossia with the goal of (1) deriving clinically oriented insights into the effect of tongue-tie division procedures and (2) identifying needs in knowledge to stimulate further research.

DATA SOURCES

Medline, EMBASE, and Cochrane databases were searched without any limitations, for studies published between 1966 and June 2012.

REVIEW METHODS

Studies were included (level 4 evidence or above) if subjects of any age had ankyloglossia and underwent tongue-tie release. Outcome measures of interest were any subjective or objective measures of breastfeeding and speech outcomes, or reports of adverse events.

RESULTS

In all, 378 abstracts were generated from the literature searches; 20 studies met the criteria for data extraction and analysis. Of those, 15 studies were observational and 5 were randomized controlled trials. Tongue-tie division provided objective improvements in the following: LATCH scores (3 studies); SF-MPQ index (2 studies); IBFAT (1 study); milk production and feeding characteristics (3 studies); and infant weight gain (1 study). Subjective improvements were also noted in maternal perception of breastfeeding (14 studies) and maternal pain scores (4 studies). No definitive improvements in speech function were reported. The only significant adverse events were recurrent tongue-ties that required repeat procedures.

CONCLUSION

Ankyloglossia is a well-tolerated procedure that provides objective and subjective benefits in breastfeeding; however, there was a limited number of studies available with quality evidence. There are no significant data to suggest a causative association between ankyloglossia and speech articulation problems. Aspects of ankyloglossia that would benefit from further research are described, and recommendations for tongue-tie release candidacy criteria are provided.