DEFINITION
Tongue tie (ankyloglossia) is a condition where a tight fibrous cord on the underside of the tongue causes a limitation in tongue mobility, and can affect feeding in infancy and speech later in life.
The prevalence of tongue tie is not clear, and estimates range from 0.1% to 10% of newborn babies. It is more common in boys (3:1)
Randomized, controlled trial of division of tongue-tie in infants with feeding problems
Ankyloglossia in breastfeeding infants: the effect of frenotomy on maternal nipple pain and latch
Ankyloglossia: incidence and associated feeding difficulties
Symptomatic ankyloglossia is defined as a restrictive lingual frenulum that causes problems with breastfeeding that are not improved with lactation support.
GOALS OF CARE
Identification of a “significant” tongue tie may be performed by a lactation consultant, or a medical doctor with experience in it’s assessment.
A tongue tie diagnosis will be based on history, and examination findings.
Tongue tie symptoms can be non-specific, and the most common symptoms of tongue tie for the baby are;
• Difficulty latching, or staying on the breast
• Tiring easily
• Clicking noises during feeding
• Fussing, irritability and poor weight gain
Symptoms for the mother may include;
• Nipple pain, damage and nipple shape changes after a feed
• Dwindling supply
These symptoms are unfortunately not exclusive to tongue tie, and for this reason, not all babies with these symptoms improve after tongue tie release.
The signs of tongue tie include;
• A tight cord underneath the tongue that stops the tongue reaching the roof of the mouth, or moving side to side
• A tongue that cannot protrude past the lips
• A tongue that is flat looking, forked or heart shaped on protrusion.
Tongue-Tie Information for Families - The Women’s - The Royal Women’s Hospital - Victoria
OUTCOMES
Between 30 and 90% of breast feeding mothers and babies experience some or all of the symptoms typical of tongue tie. However, only 1 - 10% of infants are found to have anatomic evidence of restriction.
There is no consensus on how to diagnose a tongue tie, and there is poor quality literature on short and long term effects on having it divided.
What is known, is that tongue tie division, when performed by a trained practitioner, is safe. There is a small risk of bleeding (more so if the tongue tie is ‘muscular’ rather than thin and membranous), and there is extremely small risk of oral aversion, and injury to the salivary ducts.
The biggest risk is that the infants feeding may not improve after division.
A recent consensus paper from the American Academy of Paediatrics summarises the literature in tongue tie, and had a number of important additional take aways, including;
• Lip ties do not affect feeding and should not be divided
• There is no evidence that a ‘posterior’ tongue tie exists
• There is no evidence that division with laser is any safer or more effective than the traditional division technique with scissors
Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report
OUR APPROACH
Dr Rob provides assessment of tongue tie, and can offer division in the clinic for suitable cases.
Your child will be examined first to determine if the tongue tie is 1) restrictive, and 2) thin and membranous and safe to divide outside of a theatre setting.
If the tongue tie is thick, there is an increased risk of bleeding, and on a case by case basis the recommended treatment may be observation, and division under general anaesthetic at a later date if symptoms do not improve.
Dr Rob strongly recommends that all newborns have received Vitamin K at birth when a procedure with any risk of bleeding is being performed in the first few weeks of life. While Vitamin K is a personal choice, and the prerogative of the parents and caregivers, it must be understood how this may potentially affect bleeding risk in procedures such as tongue tie release.
After informed consent, Dr Rob gives the infant a sweet liquid (sucrose) for distraction, and divides the tongue tie using sterile scissors and a piece of gauze.
POST OPERATIVE RECOVERY AND CARE
After the tongue tie is divided, the gauze will be pressed gently to the underside of the tongue to help control any bleeding. After a few minutes, the infant should be encouraged to breast feed.
If breast feeding continues to be difficult, then ongoing lactation support is recommended.