Focus On Subspecialties

©Copyright 2012 AAP News

Volume 33 • Number 1January 2012www.aapnews.org

by Diana R. Mayer, M.D., FAAP

Recent randomized controlled studies have led some experts to takea second look at frenotomy for nursing infants with ankyloglossia.

Lingual frenotomy is a procedure wherein the lingual frenulum isincised without subsequent suturing. Suturing of lingual frenulum tissuegenerally is not needed due to its poor blood supply in infancy and rapidhealing. Sparse, brief post-procedure bleeding is the norm.

Primary care physicians have performed infant frenotomies for cen-turies. However, the procedure fell out of favor in the 20th century inresponse to studies showing little or no improvement in speech later inchildhood. Additionally, problems associated with ankyloglossia in nurs-ing infants may have been concealed by the concomitant emergence ofinfant formula use and plummeting breastfeeding rates in this era. Asbreastfeeding rates began rising in the 1970s, reports of feeding difficultiesassociated with ankyloglossia began resurfacing.

Ankyloglossia, also known as tongue-tie, is defined as an impairmentof tongue movement and function. It almost always is associated witha lingual frenulum; however, the mere presence of a lingual frenulumdoes not always result in ankyloglossia.

An oral motor assessment helps identify nursing infants who willbenefit from frenotomy. This includes evaluating tongue elevation (atleast halfway to the roof of the mouth), protrusion (at least beyond thegum ridge but preferably beyond the lower lip) and lateralization (reflexivemovement of tongue toward the lateral gum line when the gum istouched). These maneuvers have good validity and inter-rater reliability.Another tongue movement known as cupping (tongue “hugging” ofthe areola or of a gloved finger) is thought to have strong validity butpoor inter-rater reliability.

Though assessment tools vary in criteria, one tool suggests that failureof at least one tongue maneuver, in combination with documented feed-ing difficulties, predicts infants who will benefit from the procedure.Feeding difficulties include latch problems, poor milk retrieval andmaternal nipple pain. If left unchecked, infant weight loss, maternalnipple trauma and mastitis become potential sequelae.

Ankyloglossia usually is classified by using the tongue tip as a referencepoint. Anterior tongue tie (94% of cases) exists when the lingual frenulumbegins anywhere from the tip of the tongue to the point just before thetongue underside meets the floor of the mouth. Posterior tongue tieexists when a lingual frenulum is present where the underside of thetongue meets the floor of the mouth.

Nursing infants under 4 months of age with anterior tongue tie andwho have translucent (whitish) lingual frenula would be suitable can-didates for frenotomy performed by primary care physicians.

Recent studies support use of frenotomy in a subset of nursing infantswith ankyloglossia.

One randomized controlled study compared sham and frenotomygroups of young nursing infants with significant ankyloglossia (BurykM, et al. Pediatrics. 2011;128:280-288). A corrected F test determinedthat the subject number in this study was acceptable. Breastfeedingquality scores improved only in the frenotomy group (p=.029). Bothgroups experienced decreased maternal nipple pain, but the frenotomygroup improved significantly more than the sham group (p<.001).

After completion of the initial phase of this study, sham group par-ticipants were offered frenotomy. Following frenotomy in this subsequentcrossover, the original sham group then demonstrated the same degreeof improvement in breastfeeding quality and diminished pain as theoriginal frenotomy group.

Another randomized controlled trial compared frenotomy with 48

Frenotomy for breastfed tongue-tied infants:a fresh look at an old procedure

B. Wilson-Clay, K. Hoover. The Breastfeeding Atlas (4th edition) 2008.

Nursing infants under 4 months of age with anterior tongue tie andwho have translucent (whitish) lingual frenula are candidates forfrenotomy, where the lingual frenulum is incised without subsequentsuturing.

©Copyright 2012 AAP News

hours of intensive feeding consultation (Hogan M, et al. J Paediatr ChildHealth. 2005;41:246-250). All but one infant in the frenotomy groupshowed improvement in feeding (p<0.001). Only one infant in theintensive feeding consultation group improved. A subsequent crossoverof the control group showed improvement in feeding following freno-tomy, resulting in 95% overall feeding improvement.

An intraoral ultrasound study showed that tongue movement improvesfollowing frenotomies done in breastfeeding infants with ankyloglossia(Geddes GT, et al. Pediatrics. 2008;122:e188-e194). The study alsodemonstrated a significant improvement in infant latch (p<.05 ) anddiminishment in maternal pain (p<.05) following frenotomy.

Promising results of these studies have prompted new interest in res-urrecting frenotomy in a subset of nursing infants with feeding difficultiesand ankyloglossia who may benefit from the procedure.

Dr. Mayer is a member of the AAP Section on Breast-feeding. She also is an International Board Certified Lac-tation Consultant.