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Tongue and Lip Tie – what do we know?KANSAS BREASTFEEDING COALITION – 2018 BREASTFEEDING CONFERENCE
KATHY LEEPER, MD, FAAP, IBCLC, FABM
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Slide 2
Disclosures: None
•I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity
•I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation
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Slide 3
Communities Supporting
Breastfeeding Project
Kansas Breastfeeding Friendly
Practice DesignationBoard member 2014-17
Board member
Curriculum development, Trainer
501c3 Lincoln, NE 2001-2014, 2018
FAAP- 1992 IBCLC- 2000FABM- 2008
(IABLE) Institute for the Advancement of Breastfeeding & Lactation Education
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Slide 4
Objectives
•Identify 3 symptoms that can be associated with tongue-tie in a breastfeeding infant
•Identify 2 tools available for assessing the clinical significance of a lingual frenulum
•List 3 indications for clipping a tongue-tie
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Slide 5
Terminology
•Frenulum = Frenum: a small fold or ridge of tissue that supports or checks the motion of the part to which it is attached, in particular a fold of skin beneath the tongue, or between the lip and the gum.
•Frenula = Frena (plural)
•Frenulotomy = Frenotomy (dividing tissue)
•Frenectomy (removing tissue)
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Slide 6
“Founded in 2009, our group is comprised of Medical Doctors, Dentists, Chiropractors, Osteopaths, IBCLCs (International Board Certified Lactation Consultants), Speech-Language Pathologists, Myofunctional Therapists and others.”
Mission StatementThe International Affiliation of Tongue and Lip Tie Professionals (IATP) is a not-for-profit, multi-disciplinary group of healthcare professionals who advocate for research, education, and integrated clinical practice to improve the lives of all people affected by oral restrictions.
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Slide 7
Definition: (from IATP)
Q: What is Tongue Tie?
A: The lingual frenulum (or frenum), is a remnant of tissue in the mid-line between the under-surface of the tongue and the floor of the mouth. …Tongue-tie can thereby adversely affect breastfeeding. Research is urgently needed to elucidate possible implications that tongue-tie and other oral restrictions have on chewing, swallowing, regurgitation, digestion, speech and breathing disorders.
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Slide 8
Incidence?
✓From 2.5% to >10% reported✓POOR definitions limit usefulness
✓This is a problem for ALL studies
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Slide 9 How do we classify?
Griffiths (2005- English surgeon)◦ Characteristic of frenulum – diaphonus, medium, or thick
◦ Shape of the tip of the tongue – dimpled, heart-shaped, or pointed
◦ Percentage of the tongue anchored by the frenulum – 100, 75, 50 and 25
Kotlow (2004-American dentist)◦ Class 1 12 -16 mm “mild”
◦ Class 2 8 -12 mm “moderate”
◦ Class 3 4 - 8 mm “severe”
◦ Class 4 0 - 4 mm “complete”
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Slide 10
Coryllos 2004-American surgeon
• Type 1: from tip of tongue to alveolar ridge• Type 2: 4 mm b/h tip to just b/h alveolar ridge• Type 3: Mid tongue to mid floor of mouth• Type 4 against the base of the tongue; shiny inelastic
characteristic, usually unable to see unless passively elevate tongue
Type 1 & 2 or “classic”= “Anterior”Type 3 & 4 = “Posterior”
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Slide 11
Coryllos Type 1
Yvonne Lafort, MD
Leeper
Leeper
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Slide 12 Coryllos Type 2
Leeper
Leeper
Leeper
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Slide 13 Coryllos Type 3
Leeper Leeper
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Slide 14 Coryllos Type 4
Leeper
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Slide 15 “Hour-glass” insertion
James Murphy, MD
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Slide 16
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Slide 17 IATP: What kinds of problems are caused by tongue-tie?
“In infants, tongue-tie can impair their sucking, especially at the breast. Babies can have minor to severe difficulty coordinating their sucking, swallowing, and breathing. Symptoms can run a wide gamut and may include latch difficulties, nipple pain or damage (although there may also be no pain whatsoever), poor milk transfer, compromised milk supply, inadequate weight gain and failure to thrive, among others.”
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Slide 18 AAP Section on BreastfeedingSummer 2004 :CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDINGBy Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC, Catherine Watson Genna, BS, IBCLC, Salloum, MD, MA
Maternal presentation:· nipple damage / pain
· painful breasts· poor milk removal
· mastitis· low milk supply· plugged ducts
· frustration, disappointment, and discouragement · untimely weaning
Infant symptoms and signs include:• ineffective milk transfer
• weight loss or inadequate gain• fussiness at breast• breast refusal• fatigue with breastfeeding
• difficulty establishing suction to maintain a deep grasp• poor latch • clicking sound while nursing • gradual sliding off of the breast• “chewing” on the nipple• making a mess• messy with bottle
• choking/coughing
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Slide 19
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Slide 20
What else does the literature say?
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Slide 21 Lingual Frenulum literature highlights…
2000 - Ankyloglossia Incidence and Associated Feeding Difficulties. Messner A (Arch Otolaryngol Head Neck Surg) ◦ 25% TT vs 3% Controls had difficulty bf
◦ Incidence TT = 4.8%
◦ 50 babies- none clipped
2002 -Ankyloglossia: Assessment, Incidence and Effect of Frenuloplasty on the Breastfeeding dyad. Ballard (Pediatrics) ◦ 2763 newborns assessed - 3.2% had lingual frenulum
◦ 123 babies had frenotomies (12.8% of babies seen in a bf clinic!)
◦ Maternal pain fell from 6.9-1.2/10
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Slide 22 2005 - Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Hogan M, Westcott C, Griffiths M. J Paediatr Child Health.
• 201 babies had tongue-tie, 88 had bf problems, 57 randomized.• 28 had immediate frenotomy-27 improved.• Of the 29 “controls”, one improved and bf X 8 mos.• 28 were offered frenotomy at 48 hrs; all requested, and 27
improved.
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Slide 23 2008 - Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. PEDIATRICS Geddes (24 Babies)
•Less nipple compression by the tongue post-frenulotomy
•Improved breastfeeding • better attachment
• increased milk transfer
• less maternal pain
•Described the importance of mid-tongue elevation
•In the assessment of breastfeeding difficulties, ankyloglossia should be considered as a potential cause
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Slide 24 Sucking Theory 1986…
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Slide 25 Elad et al 2014
“Analysis of the US movies clearly demonstrated that tongue motility during breast-feeding was fairly periodic. The anterior tongue, which is wedged between the nipple–areola complex and the lower lips, moves as a rigid body with the cycling motion of the mandible, while the posterior section of the tongue undulates in a pattern similar to a propagating peristaltic wave, which is essential for swallowing.”
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Slide 26
Video
“Breastfeeding Ultrasound Slow motion 3 sucks” on YouTube
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Slide 27
2013 – Diagnosing and Understanding the Maxillary Lip-tie – Kotlow, DDS. JHL
2014 - Using topical benzocaine before lingual frenotomy did not reduce crying and should be discouraged. Acta PaediatrConcomitant Lip-Tie (AHRQ)
Other highlights…
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Slide 28 “Tongue-tie” vs “Frenulum”?
•All but one infant (n=199) had an observable or palpable lingual frenulum that was Coryllos type 1 (n=5), type 2 or 3 (n=147), or type 4 (n=47). 7 frenotomies and 5 improved.
•If bf difficulties are not solved by a lactation consultation and judged as being due to the infant’s lingual frenulum => ‘‘symptomatic tongue-tie’’ or ‘‘symptomatic ankyloglossia”
•Infants with no bf difficulties or with bf difficulties that are corrected after a lactation consultation => “asymptomatic sublingual frenulum’’
•The term ‘‘short frenulum’’ should be abandoned.
•Haham A1, Marom R, Mangel L, Botzer E, Dollberg S. Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: a prospective cohort series. Breastfeed Med. 2014;9:438-41.
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Slide 29 Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes.Todd DA, Hogan MJ. Breastfeed Rev. 2015 Mar;23(1):11-6.
BACKGROUND:
In 2011, the Centenary Hospital Neonatal Department guidelines were modified and recommended delaying the division of infant tongue-tie (TT) until after 7 days of life. This paper looks at the effect of these guidelines in practice by comparing patient characteristics and breastfeeding practices before and after the change.METHODS:
Prospective data from mothers and babies who had TT division to compare breastfeeding practices in 2008 and 2011. Data included: gestational age (GA), birth-weight (BWt), gender, age at TT division, degrees of TT and maternal feeding pre/post TT division.RESULTS:
There were no significant differences between the 2 years in the rate of TT division, 115/2471 (4.7%) vs 144/2891 (5.0%) (TT divided/birth number) or GA 39.6 ± 1.2 vs 39.5 ± 1.2 (weeks); BWt 3.48 ± 0.45 vs 3.52 ± 0.50 (kg); and Male:Female 77:38 (2.0:1.0) vs 91:53
(1.7:1.0). There was, however, an increase in the age the TT was divided 6.5 ± 4.5 vs 9.7 ± 6.2 (days) p < 0.0001; and an increased number of mothers unable to continue breastfeeding and providing expressed breastmilk: 4/115 (3.5%) vs 25/144 (17.4%) p = 0.0004 (expressing/divided). A majority (> 90%) of mothers noted an immediate improvement in feeding and decreased nipple pain. No significant complications occurred.
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Slide 30 Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie May 2015Agency for Healthcare Research and Quality(AHRQ); U.S. Department of Health and Human Services
“Mothers consistently reported improved breastfeeding effectiveness after frenotomy, but outcome measures were heterogeneous and short term.”
“Conclusions. A small body of evidence suggests that frenotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain, but with small short-term studies, inconsistently conducted, Strength Of Evidence is generally low to insufficient. Comparative studies reported improvements in some measures of speech, but assessment of outcomes was inconsistent. Few studies addressed tongue mobility and self-esteem issues. Research is lacking on nonsurgical interventions, as well as on outcomes other than breastfeeding.”
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Slide 31 Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossiaand Shortened Maxillary Labial Frenula (Tongue and Lip Tie) 2016
Scott A. Siegel, MD, DDS. Int’l Journal of Clinical Pediatrics
“Of the 1,000 infants, 526 (52.6%) had an improvement of symptoms of reflux within the first week after the procedure. This was significant to the point of either reduction or cessation of H2/PPI medications. Two hundred eighty-three (28.3%) had no change in reflux symptoms, suggesting other cause for reflux, and 191 (19.1%) showed improvement in post-feed irritability and less symptoms of reflux but could not successfully wean off medications.”
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Slide 32 Breastfeeding Improvement Following Tongue-Tie and Lip-Tie (2016)Release: A Prospective Cohort Study. Bobak A. Ghaheri, MD; Melissa Cole, IBCLC; The Laryngoscope
Methods: Study participants consisted of breastfeeding mother–infant (0–12 weeks of age) dyads and/or tethered maxillary labial frenula who completed preoperative, 1 week, and 1 month postoperative surveys
Breastmilk intake was measured preoperatively and 1 week postoperatively.
Results: A total of 237 dyads were enrolled after self-electing laser lingual frenotomy and/or maxillary labial frenectomy. 25% had tongue release only, 75% had tongue + lip release. 3% had “reattachment” requiring second procedure.
Isolated posterior tongue-tie was identified in 78% of infants. Significant postoperative improvements were reported between mean preoperative scores compared to 1 week and 1 month scores of the BSES-SF (P < .001), the IGERQ-R (P < .001), and VAS pain scale (4.8 -> 2.2 -> 1.5 P < .001). Average breastmilk intake improved 155% from 3.0 to 4.9mL/min (P < .001).
Conclusions: Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes.Improvements occur early (1 week postoperatively) and continue to improve through 1 month postoperatively. Improvements were demonstrated in both infants with classic anterior tongue-tie and less obvious posterior tongue-tie. This study identifies a previously under-recognized patient population that may benefit from surgical intervention if abnormal breastfeeding symptoms exist.
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Slide 33 O’Shea et al. Cochrane Review (2017) Frenotomy for tongue-tie in newborn infants.
AUTHORS' CONCLUSIONS:
Frenotomy reduced breastfeeding mothers' nipple pain in the
short term. Investigators did not find a consistent positive effect on
infant breastfeeding. Researchers reported no serious complications,
but the total number of infants studied was small. The small number of
trials along with methodological shortcomings limits the certainty of
these findings. Further randomized controlled trials of high
methodological quality are necessary to determine the effects of
frenotomy.
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Slide 34
54 infants from 7 days- 9 mos (Ave 8 wks)
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Slide 35
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Slide 36
Key Messages:
• “This study was designed to determine how complete release can result in a reduction in persistent breastfeeding difficulties, as most practitioners’ conception of lingual frenotomy is to release the thin anterior band under the tongue.
• Significant postop improvements in bf self-efficacy, maternal nipple pain and symptoms assoc with GER in children who had already undergone lingual frenotomy were realized.
• Our findings introduce the notion that children who have not improved following a previous frenotomy may have further restriction under the tongue that still needs attention.”
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Slide 37 Best way to do a frenotomy?
IATP:
•“The simplest way of performing the procedure is by using a pair of sterile scissors. (Knox I. Tongue tie and frenotomy in breastfeeding newborn. NeoReviews. 2010;11.ISSUE 9)
•Recently, laser devices are used. Obviously, these devices are much more expensive. While clinical reports mount regarding positive outcomes of laser release, research is needed to compare the efficacy of laser with scissors and other tools such as electrocautery.”
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Slide 38 How do you decide when lingual frenotomy may be appropriate?
• If baby cannot latch without pain despite optimal latch/positioning
• If baby cannot remove milk well• Be sure baby is not very underweight before you assess their ability to
suck/remove milk!
•Can use a “system”, such as ◦The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF)
◦Martinelli’s Protocol looking at anatomy and function◦Bristol TT Assessment Tool (BTAT)
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Slide 39 Assessment Tool?
Hazelbaker Tool Lingual Frenulum Function 1993-2012 (HATLFF)
5 Appearance items :◦Of tongue when lifted
◦Elasticity of frenulum
◦Passive length of frenulum
◦Point of attachment of frenulum to tongue
◦Point of attachment of frenulum to maxillary ridge
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Slide 40 Hazelbaker Tool Lingual Frenulum Function
7 Function Items:◦Lateralization
◦Lift of tongue
◦Extension of tongue
◦Spread of anterior tongue
◦Cupping
◦Peristalsis
◦Snap-back
Scoring 0, 1 or 2 on each item:• Emphasis on abnormality of function items• Amir et al 2006 found three function items
had the best inter-rater reliability:• Tongue lift • Extension• Lateralization
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Slide 41 Bristol TT Assessment Tool – 2015
The scores for the four items are summed and can range from 0 to 8. Scores of 0–3 indicate more severe reduction of tongue function.
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Slide 42 PROTOCOL FOR INFANTS: RELATIONSHIP BETWEEN ANATOMIC AND FUNCTIONAL ASPECTS (2013)Protocolo de avaliação do frênulo lingual para bebês: relação entre aspectos anatômicos e funcionais
Roberta Lopes de Castro Martinelli (1), Irene Queiroz Marchesan (2), Giédre Berretin-FelixCEFAC 2013 Mai-Jun; 15(3):599-609
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Slide 43
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Slide 44 Nipple Shield?
44
May feel better, but milk removal islikely poor.
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Slide 45 Laser vs. Scissors??
•No study comparing the two methods.
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Slide 46
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Slide 47
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Slide 48
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Slide 49 Before
Leeper
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Slide 50 Gauze ~ 1 minute
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Slide 51
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Slide 52 Immediately to the breast…
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Slide 53 Submucosal
Leeper
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Slide 54
Leeper
Healing after scissors…
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Slide 55 After laser…
Ghaheri
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Slide 56
Laser…
Dr Ghaheri video
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Slide 57 Frenotomy Decision Tool-Dobrich – 2006-2016(includes LIP)??? NOT validated
Part 1: Evaluation of breastfeeding◦ Evidence of pain and/or poor removal
Part 2: Evaluation of tongue in baby◦ Elevation, cupping, protrusion, lateral movement◦ “pseudoleukoplakia”
Part 3: Evaluation of lips if lip tie present◦ Upper lip folds in, perioral blanching, two-tone lips, lip blisters
*Dr Leeper’s lip-tie evaluation: Point tenderness directly under where baby’s upper lip rests on breast? If cannot relieve with positioning, AND appears very restricted, consider frenotomy…
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Slide 58 Labial frenulum not equal to “Lip Tie”
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Slide 59 Lip tie – laser frenotomy
Larry Kotlow, DDShttps://www.kiddsteeth.com
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Slide 60
“Aftercare”???
Dr Kotlow YouTube video
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Slide 61 IATP: “Listed here are few of the knowledge gaps identified. Please suggest to us more knowledge gaps that need research”
• Indication for frenotomy other than breastfeeding difficulties in the form of maternal nipple pain and latching difficulties.
• Best age to perform frenotomy
• Best tool to perform frenotomy
• Post surgery care protocol
• Adjuvant therapy to lingual frenotomy (body work, etc)
• Indications and Efficacy of lip tie frenotomy (Randomized controlled trial needed)
• Indications for lingual frenotomy in older than newborn age
• Effect of neonatal frenotomy on speech and articulation later in life (prospective follow-up study needed)
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Slide 62 Questions/Comments?
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