Treat classic tongue tie when indicated

Ankyloglossia and nipple pain

Ankyloglossia is a congenital abnormality of the lingual frenulum which significantly restricts movement of the infant’s tongue and has been linked with maternal nipple pain. Prevalence estimates vary between 3-10%, in the absence of agreed definitions and demonstrated overdiagnosis.61 You can find out more about ankyloglossia here.

Although many infants have a prominent and membranous frenulum, which may attach anywhere along the ventral surface of the tongue, a tongue-tie is a variation of frenulum which may attach close to the tip of tongue, often to the alveolar ridge instead of the floor of the mouth, and is assessed clinically as impacting on the infant’s capacity to suckle without causing maternal nipple pain.

Lack of consensus definition of ankyloglossia is a methodological flaw in all investigations into this condition, and there are no studies comparing the effects of optimal fit and hold intervention with frenotomy.

• A small case series of breastfeeding pairs showed that the effects of a brief gestalt intervention on tongue contour, measured by ultrasound imaging, was the same as had been measured elsewhere post-frenotomy.40 A classic tongue-tie typically requires a simple scissors frenotomy.45 62

NDC Clinical Guidelines for Anklylossia in summary

Simple scissors frenotomy is indicated for classic ankyloglossia.

There is no indication for laser frenotomy in non-syndromic infants with classic tongue tie. The diagnosis of posterior tongue tie has been disproved as both an anatomic and functional entity. There are no indications for labial frenotomy, nor buccal frenotomies.

The risks of laser lingual frenotomy include

• Thermal damage to branches of the lingual nerve, resulting in loss of sensation of dorsum of tongue

• Conditioned dialling up with breast or bottle feeds

• Haemorrhage

• Infection.

Infants with syndromic, complicated ankyloglossia require referral to an Ear, Nose and Throat surgeon, who may treat with laser technologies.

The image above is of a baby who had been referred with concern about tongue-tie, but who has a normal variation of lingual frenula. The baby and her mother had fit and hold problems whilst breastfeeding, which resolved with implementation of the gestalt method.

Recommended resources

The hypothesis that nipple pain and damage results from tongue friction, pinching, or compression lacks biological plausibility

Is infant frenotomy for breastfeeding problems an evidence-based solution?

What drives overdiagnosis and overtreatment of restricted oral connective tissues in breastfeeding babies?

How to perform a simple scissors frenotomy. Dr Pamela Douglas, F2F Masterclass Redcliffe 2019