Purpose and Goal: CNEP # 2033

  • Understand the effects of tongue tie in the neonate.
  • Learn about the use of frenotomy for treatment of tongue tie.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for successful completion:

  • Successfully complete the post-test
  • Complete the evaluation form

Date

  • March 2016 – March 2018

Learning Objectives

  • Describe the clinical features of tongue tie in the neonate.
  • Describe breastfeeding complications associated with tongue tie.
  • Identify 2 approaches for the treatment of tongue tie in the neonate.

Introduction

  • Tongue tie is a congenital anomaly
  • It results in restricted tongue function
  • It can interfere with successful breastfeeding
  • Treatment of tongue tie is controversial
  • A frenotomy is a one treatment option

History of Tongue Tie

  • Tongue tie is also known as ankyloglossia
  • It is considered a mild congenital anomaly
    • It is not associated with other anomalies
    • It is not associated with a genetic syndrome
  • It occurs due to a persistent lingual frenulum
    • That restricts tongue movements
    • That interferes with tongue function
  • Tongue tie is mentioned in the bible
    • As well as other written documents
    • Documents precede modern literature
  • Tongue tie was thought to interfere with breastfeeding
  • Frenotomies were performed until the mid-20th century
    • By both physicians and midwives
    • Until breastfeeding rates declined
    • Until bottle feeding rates increased
    • Then it disappeared from the literature
  • Tongue tie rarely interferes with bottle feeding
  • Tongue tie and frenotomies resurfaced in the 1990s
  • It is considered a confirmed, common, treatable condition
    • It occurs in 2–10% of the population
    • It occurs more frequently in males
    • It is mostly a sporadic condition
      • But can be a genetic mutation
        • Via X-linked inheritance
      • This occurrence is uncommon

Etiology of Tongue Tie

  • During embryological development
    • During weeks 4 to 7
    • Smooth oral cavity → complex development
  • Complex oral anatomy includes:
    • Mobile, muscular tongue
    • The mobile tongue protrudes freely
      • It develops from tissue buds
      • Buds fuse anteriorly to posteriorly
      • Buds are separate from the mouth
  • Oral cavity development proceeds from:
    • Tissue growth
    • Program cell death
      • Also known as apoptosis
    • Failed apoptosis → persistent frenulum
    • Persistent frenulum → ankyloglossia

Clinical Features of Tongue Tie

  • Tongue tie is an anatomical variation
  • It involves the lingual frenulum
    • It appears as a web of tissue under the tongue
    • It has the potential to limit tongue movement
  • The clinical features of tongue tie include:
    • Abnormally short frenulum
    • Frenulum insertion near tip of tongue
    • Difficulty lifting tongue to upper gums
    • Inability to protrude tongue
      • More than 1-2 mm past lower gums
    • Impaired side to side movement of tongue
    • Notched or “heart shaped” tongue when protruded
  • Tongue tie may present with several different variations
    • It commonly appears as anterior or posterior
    • Anterior tongue tie
      • Most common variation
      • Easily visualized on exam
      • Frenulum tethered to tip of tongue
    • Posterior tongue tie
      • Not as common
      • More difficult to visualize
      • May require manual inspection
      • Frenulum is subtle and hidden
        • Thickened and fibrous
        • Anchored to floor of mouth
  • Tongue tie may vary in severity
    • From severely decreased, restricted mobility
    • To more flexible, less restricted mobility

Tongue Tie and Breastfeeding

  • Breastfeeding requires complex tongue movements
  • Each mother and infant have unique anatomy
    • Each infant must adapt accordingly
    • This requires changes in sucking behavior
  • For successful transfer of milk from the breast:
    • The tongue must:
      • Protrude over the gum line
        • To inhibit the bite reflex
        • To create an airtight seal
        • To produce an intraoral vacuum
      • Manipulate the nipple and areola
        • To positon the nipple
        • To positon the areola
        • To create a relationship between:
          • The hard palate
          • The soft palate
      • Produce an intraoral vacuum
        • To create compression
        • To create suction
        • To assist with milk transfer
  • Restriction of the tongue’s movement in any way:
    • Leads to suboptimal breastfeeding mechanics
  • Tongue tie interferes with breastfeeding in two ways:
    • Ineffective breast emptying
      • Interferes with milk production
    • The development of nipple trauma
  • Any infant who has difficulty breastfeeding:
    • Should be examined for tongue tie
    • Should be evaluated by a lactation specialist
  • Breastfeeding difficulties may be seen:
    • In 12-50% of infants with tongue tie
    • In 3% of infants without tongue tie

Clinical Features in the Breastfeeding Infant

  • Infant signs and symptoms include:
    • Poor latch
    • “Chewing”
    • Clicking sounds
    • Sliding off breast
    • Ineffective milk transfer
    • Poor weight gain or weight loss
    • Hypernatremic dehydration
    • Fussiness or arching away from breast
    • Falling asleep at the breast
  • Maternal signs and symptoms include:
    • Nipple trauma
      • Pain
      • Blisters
      • Cracking
      • Bleeding
      • Scabbing
    • Painful breasts
    • Low milk supply
    • Plugged ducts
    • Mastitis
    • Frustration
    • Disappointment
    • Discouragement
    • Untimely weaning

Potential Complications of Tongue Tie

  • Impaired tongue mobility → several complications
  • Several short and long problems may be seen
  • Tongue tie may be associated with:
    • Breastfeeding difficulties
      • Poor latch
      • Sore nipples
      • Failure to Thrive
    • Speech difficulties
      • Poor articulation is common
      • Does not prevent vocalization
      • Does not delay inset of speech
      • Interferes with speech sounds
        • Sibilants and lingual sounds
        • t, d, z, s, th, n, and l sounds
    • Mechanical problems
      • Inability to lick lips
      • Inability to sweep food off teeth
        • Increased periodontal disease
    • Social embarrassment

Management and Treatment of Tongue Tie

  • There is a lack of consensus about treatment
    • Type of treatment
    • Timing of treatment
  • Conservative treatment includes:
    • Lactation support
    • Otolaryngology support
    • Speech therapy support
  • Definitive treatment includes surgery
    • Frenotomy
      • Most common approach
      • Does not require anesthesia
    • Frenuloplasty
      • Frenotomy with plastic repair
      • Requires general anesthesia
      • Reserved for tongue tie
        • Not improved with frenotomy
        • Very thick frenulum tissue
        • Revisions of previous surgery
  • Indications for surgical intervention
    • Breastfeeding difficulty
    • Poor weight gain
    • Parental concern
  • Goals for surgical intervention
    • Increased tongue mobility
    • NOT improved tongue shape

Frenotomy and Tongue Tie

  • Frenotomy is a safe, effective treatment
  • Frenotomy is also called frenulotomy
  • It is the simple surgical release of the frenulum
    • It frees the tongue
    • Also known as “clipping”
    • It requires specialized training
    • It may or may not require local anesthesia
      • Not generally needed in newborn period
      • A local anesthetic may be used
        • Use of local anesthesia is painful
        • Requires invasive techniques
      • Oral sucrose is an effective alternative
  • Prior to frenotomy it is important to:
    • Assess the infants clotting ability
    • Did the infant receive Vitamin K?
  • Frenotomy is performed under direct visualization
    • The infant is NPO for one hour
    • The infant is swaddled/restrained
    • The infant is given oral sucrose
      • 2 minutes before the procedure
    • The area is illuminated with light
    • The tongue is then elevated
      • With fingers
      • With forceps
    • The frenulum is “clipped”
      • With sterile scissors
    • Pressure is held with gauze
      • For a few seconds
      • Up to a few minutes
  • The infant may breastfeed immediately afterwards
    • Breastfeeding provides comfort
    • Breastfeeding provides pain control
    • Breastfeeding minimizes re-adhesion
      • Provides tongue range of motion
      • Prevents recurrence of tongue tie
  • Studies have shown frenotomy is well tolerated
    • Especially in the newborn period
    • It takes 30 seconds to minutes to perform
  • Post frenotomy care is simple
    • Assessment of pain
    • Assessment of bleeding
  • Complications from frenotomy are rare
    • Potential complications include:
      • Pain
      • Edema
      • Bleeding
      • Infection
      • Ulceration
      • Tongue damage
      • Salivary duct damage
  • Lactation support should continue post frenotomy
    • To support the development of correct latch
    • To support effective transfer of breastmilk
  • Studies have shown good outcomes with frenotomy
    • Improved tongue mobility
    • Improved latch
    • Improved milk transfer
    • Decreased nipple pain
  • New technologies are emerging
    • The use of lasers for frenotomy
    • Laser treatment should minimize:
      • Pain
      • Edema
      • Bleeding
      • Scarring

Summary

  • Tongue tie is a relatively common finding
  • It can interfere with successful breastfeeding
  • Early diagnosis improves neonatal outcomes
  • Treatment with a simple frenotomy
    • Can decrease complications
    • Can improve breastfeeding

References

  1. Isaacson, G.C. 2015. Ankyloglossia (Tongue-Tie) in Infants and Children. Up-To-Date.
  2. Manipon, C. 2016. Ankyloglossia and the Breastfeeding Infant. Advances in Neonatal Care, 16 (2), p. 108-113.
  3. Knox, I. 2010. Tongue Tie and Frenotomy in the Breastfeeding Newborn. NeoReviews, 11 (5), p. e513-3e520.

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