Does My baby Need Tongue-tie Release?

Editor’s Note: In the past 2 decades or so, an epidemic of frenotomy for breastfeeding difficulties has swept the developed world. For example, an 89% increase in the rate of frenotomy was reported in British Columbia, Canada from 2004 to 2013ⁱ; a 420% rise was reported between 2006 and 2016 in Australiaⁱⁱ and a shocking upsurge of 866% was found in the USA during the period 1997 to 2012.ⁱⁱⁱ How valid is the diagnosis of tongue-tie causing feeding difficulties? Is frenotomy a need or demand? What is the evidence of effectiveness of frenotomy in alleviating breastfeeding difficulties? These will continue to be controversial issues until high-quality evidence provides definitive answers. “Do No Harm” remains the fundamental guiding principle for clinicians. In this newsletter, Dr Winnie Chee of Queen Mary Hospital, a designated Baby-friendly Hospital, reviews the subject and shares her team’s experiences.

References:
i. Joseph KS, Kinniburg B, Metcalfe A, et al. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004–2013: a population-based study. CMAJ Open 2016; 4: e33-e40
ii. Kapoor V, Douglas PS, Hill PS, et al. Frenotomy for tongue‐tie in Australian children, 2006–2016: an increasing problem. Medical Journal of Australia 2018; 208(2): 88-89
iii. Walsh J, Links A, Boss E, et al. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997–2012. Otolaryngol Head Neck Surg 2017; 156: 735-740.

Dr Winnie Chee Yuet Yee

FHKAM (Paediatrics),
Associate Consultant, Neonatal Intensive Care Unit,
Queen Mary Hospital & Hong Kong Children's Hospital

Case History

A healthy first time mother gave birth to her full term baby boy with a birth weight of 3.2 kg. He was on exclusive breastfeeding since birth. On day 2, prior to discharge, he was noted to have an excessive weight loss of 9%. His mother also complained of sore nipples. On assessment by a lactation consultant, the baby was found to have poor latch and suckling of the breast. Besides, he was noted to have tongue-tie. The mother was taught to modify the latch and continue breastfeeding. The baby’s body weight caught up upon follow-up a few days later and the latch during breastfeeding was good.

How Common is Tongue-tie?

Tongue-tie (or ankyloglossia) is a congenital condition with abnormally short lingual frenulum which may restrict the mobility of the tongue. During early embryonal development, the tongue is fused to the floor of the mouth. Subsequent cell death and resorption result in a frenulum as the only remnant, which frees the tongue. It is estimated that tongue-tie affects around 2 to 5% of newborns.^1-3 There is no unified classification system for tongue-tie. One of the schemas classifies tongue-tie according to how close to the tip of a tongue the leading edge of the frenulum is attached. The majority of cases involve the attachment of the frenulum to or near the tip of the tongue. In cases where the frenulum is attached to the middle or base of the tongue, they are tighter, less elastic and suggested to be more likely to cause significant symptoms. These are more difficult to visualize and digital examination is needed to determine its tightness and attachment.⁴

How May Tongue-tie Affect Breastfeeding?

Most babies with tongue-tie are asymptomatic, while feeding difficulties have been reported in 12–44% of babies with tongue-tie.^{1, 3, 5-7} During effective suckling, the baby takes in the nipple together with a mouthful of the breast. The tongue extends forward to cup the breast and covers the lower gum, protecting the nipple from damage through rubbing against the lower gum. It is postulated that a baby with tongue-tie cannot advance the tongue over the lower gum during suckling. Chewing is triggered instead which may result in nipple soreness, ulcer or even bleeding. The nipple soreness may set off a sequence of events resulting in feeding difficulties and weight loss. (Table 1)⁴ On the other hand, chewing motion is sufficient to transfer milk from a bottle. Bottle-fed babies are thus less affected by tongue-tie as oral-motor movements differ between bottle feeding and breastfeeding.

Table 1: Possible Presentations of Feeding Difficulties Associated with Tongue-tie

Maternal Presentation

Infant Symptoms and Signs

−            Nipple pain/erosions

−            Painful breasts

−            Low milk supply

−            Plugged ducts

−            Mastitis (blocked ducts)

−            Frustration and disappointment with breastfeeding

−            Untimely weaning

−            Poor latch and suck

−            Clicking sound while nursing

−            Fussiness and frequent arching away from the breast

−            Falling asleep at the breast

−            Ineffective milk transfer

−            Inadequate weight gain or weight loss

−            Irritability or colic

......

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Key Message:

1. Not all babies with tongue-tie require frenotomy.
並非所有患結舌的嬰兒都需要進行結舌手術。

2. Babies with breastfeeding difficulty and tongue-tie require multi-disciplinary assessment and management.
哺乳困難並患有結舌的嬰兒，需要多專業的評估和處理。

3. Frenotomy could be considered if the breastfeeding difficulty in these babies is not improved by latch modification and tongue exercise.
如餵哺輔導及舌頭訓練運動都不能改善這些嬰兒的哺乳問題時，可以考慮結舌手術。

4. Current evidence shows that frenotomy only reduces breastfeeding mothers’ nipple pain but has no consistent positive effect on breastfeeding.
目前證據顯示結舌手術只能減少母親的乳頭疼痛，對母乳餵哺則沒有貫徹的正面效果。

5. Provision of up-to-date clinical evidence for parents to make an informed decision on frenotomy is important.
提供最新臨床證據，讓家長決定是否進行結舌手術最為重要。

Editor-in-Chief: Dr Shirley Leung
Illustration: Ms Iris Leung, 草屋 Iris's Workshop - 畫公仔的草

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Dr Winnie Chee Yuet Yee FHKAM (Paediatrics), Associate Consultant, Neonatal Intensive Care Unit, Queen Mary Hospital & Hong Kong Children's Hospital

愛嬰醫院香港協會，版權所有。 All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.

Dr Winnie Chee Yuet Yee

FHKAM (Paediatrics),
Associate Consultant, Neonatal Intensive Care Unit,
Queen Mary Hospital & Hong Kong Children's Hospital

愛嬰醫院香港協會，版權所有。
All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.