The development of a specialist tongue tie assessment clinic for neonates.

OBJECTIVES: Ankyloglossia or tongue tie is a condition where the lingual frenulum restricts tongue movement, negatively impacting breastfeeding. An increasing number of infants diagnosed with ankyloglossia may lead to unnecessary procedures. To limit the overtreatment of this problem, we established a specialist clinic to provide the best available evidence-based care to the mother-infant dyad. METHODS: We discuss the development of a specialist tongue tie assessment clinic in our unit. RESULTS: From January to October 2023, there were 162 visits to the clinic by 157 patients. During this time, there were 96 frenotomies performed. CONCLUSIONS: The mother-infant dyad is a vulnerable patient group. Establishing a specialist tongue tie assessment clinic with otolaryngology and lactation expertise provides the best available evidence-based care.

Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT.

Background: Tongue-tie can be diagnosed in 3-11% of babies, with some studies reporting almost universal breastfeeding difficulties, and others reporting very few feeding difficulties that relate to the tongue-tie itself, instead noting that incorrect positioning and attachment are the primary reasons behind the observed breastfeeding difficulties and not the tongue-tie itself. The only existing trials of frenotomy are small and underpowered and/or include only very short-term or subjective outcomes. Objective: To investigate whether frenotomy is clinically and cost-effective to promote continuation of breastfeeding at 3 months in infants with breastfeeding difficulties diagnosed with tongue-tie. Design: A multicentre, unblinded, randomised, parallel group controlled trial. Setting: Twelve infant feeding services in the UK. Participants: Infants aged up to 10 weeks referred to an infant feeding service (by a parent, midwife or other breastfeeding support service) with breastfeeding difficulties and judged to have tongue-tie. Interventions: Infants were randomly allocated to frenotomy with standard breastfeeding support or standard breastfeeding support without frenotomy. Main outcome measures: Primary outcome was any breastmilk feeding at 3 months according to maternal self-report. Secondary outcomes included mother's pain, exclusive breastmilk feeding, exclusive direct breastfeeding, frenotomy, adverse events, maternal anxiety and depression, maternal and infant NHS health-care resource use, cost-effectiveness, and any breastmilk feeding at 6 months of age. Results: Between March 2019 and November 2020, 169 infants were randomised, 80 to the frenotomy with breastfeeding support arm and 89 to the breastfeeding support arm from a planned sample size of 870 infants. The trial was stopped in the context of the COVID-19 pandemic due to withdrawal of breastfeeding support services, slow recruitment and crossover between arms. In the frenotomy with breastfeeding support arm 74/80 infants (93%) received their allocated intervention, compared to 23/89 (26%) in the breastfeeding support arm. Primary outcome data were available for 163/169 infants (96%). There was no evidence of a difference between the arms in the rate of breastmilk feeding at 3 months, which was high in both groups (67/76, 88% vs. 75/87, 86%; adjusted risk ratio 1.02, 95% confidence interval 0.90 to 1.16). Adverse events were reported for three infants after surgery [bleeding (n = 1), salivary duct damage (n = 1), accidental cut to the tongue and salivary duct damage (n = 1)]. Cost-effectiveness could not be determined with the information available. Limitations: The statistical power of the analysis was extremely limited due to not achieving the target sample size and the high proportion of infants in the breastfeeding support arm who underwent frenotomy. Conclusions: This trial does not provide sufficient information to assess whether frenotomy in addition to breastfeeding support improves breastfeeding rates in infants diagnosed with tongue-tie. Future work: There is a clear lack of equipoise in the UK concerning the use of frenotomy, however, the effectiveness and cost-effectiveness of the procedure still need to be established. Other study designs will need to be considered to address this objective. Trial registration: This trial is registered as ISRCTN 10268851. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme (project number 16/143/01) and will be published in full in Health Technology Assessment; Vol. 27, No. 11. See the NIHR Journals Library website for further project information. The funder had no role in study design or data collection, analysis and interpretation. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Many mothers and babies experience difficulties in establishing breastfeeding. In some babies it is thought that their difficulties may be linked to a condition called tongue-tie, in which a piece of skin tightly joins the middle part of the underside of the tongue to the base of the baby's mouth. This can be treated by an operation to divide the tight part/skin in the middle of the underneath of the tongue. We planned to carry out a trial of 870 babies to find out whether an operation together with breastfeeding support helps more mothers and babies with tongue-tie to continue breastfeeding until the baby is 3 months old compared to breastfeeding support on its own and whether the costs were different between the two groups of mothers and babies. We were only able to recruit 169 babies as the trial was stopped because of slow recruitment, changes to services in the COVID-19 pandemic and a high proportion of the babies in the breastfeeding support group going on to have an operation. There were no differences in the rate of breastfeeding at 3 months between the babies in the group who had an operation straightaway and those in the group that had breastfeeding support alone, or had an operation later. More than four in every five babies in both groups were still breastmilk feeding at 3 months. Three babies who had an operation, around 1 in 50 babies, had a complication of the operation (bleeding, scarring or a cut to the tube that makes saliva). Because of the small size of the study, we cannot say whether an operation to divide a tongue-tie along with breastfeeding support helps babies with tongue-tie and breastfeeding difficulties or has different costs. We will need to try different types of research to answer the question.

Ankyloglossia in Central Australia: Prevalence, identification and management in infants.

PURPOSE: To investigate the prevalence and management of ankyloglossia for infants in Central Australia. METHOD: Retrospective chart review consisting of a medical file audit of infants (n = 493) <2 years old diagnosed with ankyloglossia from January 2013 to December 2018 in the primary hospital in Central Australia. Patient characteristics, reason for diagnosis, reason for procedure and outcomes of procedures routinely recorded in the patient clinical files were recorded. RESULTS: The overall prevalence of ankyloglossia in this population was 10.2%. Frenotomy was performed in 97.9% of infants diagnosed with ankyloglossia. Infants with ankyloglossia were more likely to be male (58% vs 42%), diagnosed and managed with a frenotomy on the third day of life. Most ankyloglossia diagnoses were identified by a midwife (>92%). Most frenotomy procedures were completed by lactation consultants who were also midwives (99%) using blunt-ended scissors. More infants were classified with posterior ankyloglossia than anterior ankyloglossia (23% vs 15%). A frenotomy procedure resolved feeding issues in 54% of infants with ankyloglossia. CONCLUSIONS: The prevalence of ankyloglossia and rate of frenotomy procedures were high when compared to previous reports in the general population. Frenotomy for ankyloglossia in infants with breastfeeding difficulties was found to be effective in more than half of the reported sample, improving breastfeeding and decreasing maternal nipple pain. A standardised approach and validated screening or comprehensive assessment tool for the identification of ankyloglossia is indicated. Guidelines and training for relevant health professionals on non-surgical management of the functional limitations of ankyloglossia are also recommended.

Perfil de serviços públicos que realizam avaliação do frênulo lingual em neonatos no Rio Grande do Norte / Profile of health services that assessthelingual frenulum of newborns in public and maternity hospitals of Rio Grande do Norte state / Perfil de servicios que realizanevaluación del frenillo lingual en neonatos en hospitales públicos y maternidades del estado de Rio Grande do Norte

Introdução:A anquiloglossia é caracterizada pela alteração do frênulo lingual resultando na restrição dos movimentos da língua. A avaliação do frênulo lingual em neonatos é importante para diagnosticar precocemente essa alteração. Objetivo:Traçar perfil de serviços que realizam avaliação do frênulo lingual em neonatos nos hospitais e maternidades públicas do estado do Rio Grande do Norte. Metodologia:Trata-se de um estudo observacional, descritivo e transversal, com abordagem quantitativa. Foram incluídos na pesquisa as maternidades públicas e filantrópicas do estadoque realizam procedimentos obstétricos e assistência materno-infantil. As informações acerca da avaliação do frênulo lingual em neonatos e caracterização desses serviços foram coletadas por meio de um questionário eletrônico. Os dados foram armazenados em planilhas no Excel e analisados através do programa estatístico SPSS versão 23.0, em queforam conduzidas análises das variáveis investigadas.Resultados:Participaram do estudo 23 hospitais e maternidades públicas do estado, econstatou-se que apenas 7 (30,44%) ofertam a avaliação do frênulo lingual em neonatos no próprio estabelecimento, enquantoas demais encaminham para outros serviços. O exame foi implantado nas maternidades entre os anos de 2014 e 2018. A quantidade de profissionais que realizam esta avaliação variou entre 1 e 9 por instituição, e os profissionais envolvidos foram os fonoaudiólogos e cirurgiões-dentistas. A prevalência da anquiloglossia variou de 3,7% a 14,5%. A maioria das maternidades realizam a frenotomia e o profissional que executa é o médico ou cirurgião-dentista.Conclusões:Constatou-se uma baixa oferta da avaliação do frênulo lingual em neonatos no próprio estabelecimento de nascimento. Além disso, essa oferta ainda não acontece de forma universal, principalmente no interior do estado (AU).

Introduction:Ankyloglossia is characterized by alterations in the lingual frenulum resulting in restricted tongue movements. Assessing the lingual frenulum in newborns is important for early diagnosis of this disorder. Objective:Describe the profile of health servicesthat assess the lingual frenulum of newborns in public and maternity hospitals of Rio Grande do Norte state. Methodology:This is a cross-sectional descriptive study using a quantitative approach. Included in the research were public and philanthropic maternity hospitals in statethat perform obstetric procedures and provide maternal and child care. The information about lingual frenulum assessment in newborns and characterization of these health services was collected via an electronic questionnaire. The data were stored in Excel spreadsheets and analyzed using the SPSS version 23.0 program, where analyses of the variables investigated were carried out. Results:A total of 23 public and maternity hospitalsparticipated, only 7 of which (30.44%) assessed the lingual frenulum of newborns on site, while the others referred them to other medical facilities. The examination was implemented in maternity hospitals between 2014 and 2018. The number of professionals who performed this assessment varied between 1 and 9 per institution, and included speech therapists, and dentists. The prevalence of ankyloglossia ranged from 3.7 to 14.5%. Most of the maternity hospitals performed frenotomy, where the procedure was conducted by a doctor or dentist. Conclusions:On-site lingual frenulum assessment of newborns was low in the institutions, and does not occur universally, mainly in the rural areas of the state (AU).

Introducción: La anquiloglosia se caracteriza por la alteración del frenillo lingual que resulta en la restricción de los movimientos de la lengua. La evaluación del frenillo lingual en neonatos es importante para un diagnóstico precoz de este trastorno.Objetivo: Delinear un perfil de servicios que realizanevaluación del frenillo lingual en neonatos en hospitales públicos y maternidades del estado de Rio Grande do Norte.Metodología: Se trata de un estudio observacional y transversal con enfoque cuantitativo. Se incluyeron en la investigación las maternidades públicas y filantrópicas del estadoque realizan procedimientos obstétricos y de atención materno-infantil. La información sobre la evaluación del frenillo lingual en neonatos y la caracterización de estos servicios fui recogido por medio de un cuestionario electrónico. Los datos fueron almacenados en hojas Excel y analizados utilizando el programa estadístico SPSSversión 23.0, donde se realizaron análisis de las variables investigadas. Resultados: Un total de 23 hospitales públicos y maternidades participaron del estudio, en el que se constató que solo 7 (30,44%) evalúan el frenillo lingual en neonatos en establecimiento propio, mientras los demás refieren a otros servicios. El examen se implementó en las maternidades entre 2014 y 2018. El número de profesionales que realizan esta evaluación varió entre 1 y 9 por institución, y los profesionales involucrados fueron terapeutas del habla y odontólogos. La prevalencia de anquiloglosia varió entre 3,7 y 14,5 %. La mayoría de las maternidades realizan la frenotomía y el profesional que la realiza es el médico u odontólogo. Conclusiones: Hubo una baja oferta de avaluación del frenillo lingual en neonatos en el propio establecimiento. Además, esta oferta aún no es universal, especialmente en el interior del estado (AU).

Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review.

It is unclear how effective tongue-tie classification assessment tools are in diagnosing symptomatic tongue-tie and fulfilling lingual frenectomy criteria. The purpose of this systematic review is to determine and evaluate any association between tongue-tie severity, as measured by pre-treatment assessment tools, and post-operative outcome following tongue-tie division. PubMed, EMBASE, and the Cochrane search engines were used to retrieve articles published between 1947 and 2021. Included studies consisted of patients with symptomatic tongue-tie, assessment by either the Coryllos, Kotlow, or Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) classification tool, and tongue-tie division. A total of 205 abstracts were identified; 31 studies met the criteria for a full-text review, of which, only 14 studies met the criteria for data extraction and analysis. Six studies used the HATLFF, 2 studies used the Kotlow, 5 studies used the Coryllos, and 1 study used a combination of both Kotlow and Coryllos methods. Significant heterogeneity was evident across all studies. No statistical correlation between the two variables could be determined. Although tongue-tie division procedures appear to provide benefits in breastfeeding and speech, there are no data to suggest a statistically significant association between the severity of tongue-tie, and the correct identification of patients who would benefit from tongue-tie division. © 2022 Australian Dental Association.

Outcomes of tongue-tie release by means of tongue and frenulum assessment tools: a scoping review on non-infants.

Objective: To evaluate outcomes of the surgical and rehabilitative procedures devoted to release the tongue-tie in non-infants when implementing the most commonly used quantitative/qualitative structured tools for tongue and frenulum assessment. Methods: A scoping review and meta-analysis were conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews. Results: The systematic search retrieved 603 (Pubmed), 893 (Scopus), and 739 (ISI Web of Science) articles from January 2011 to December 2021. A total of 50 articles were retrieved for full-text review of which 7 were selected and included based on inclusion criteria. The majority of treatment options have been found to significantly improve the anatomical limitation of the tongue with clear benefits on descending functionality. Conclusions: The review highlights an overall improvement in terms of clinical and functional outcomes when using validated tongue assessment tools both before and after frenulum release. This highlights the need for their rigorous implementation in research and clinical practice.

Evaluation of Anatomic Features and Assessment Tools to Determine Treatment of Ankyloglossia.

Purpose: To evaluate the use of lingual frenotomy assessment tools and the anatomical features most commonly used by dentists and otolaryngologists to determine if a frenotomy was indicated.
Methods: A nine-question survey was distributed to American Academy of Pediatric Dentistry members and otolaryngologists in the American Medical Association. The survey consisted of three categories: (1) demographics; (2) use of a standardized assessment tool; and (3) assessing anatomical features for frenotomy. Three different cases of ankyloglossia were given to assess which anatomical features were used to determine if a frenotomy was needed.
Results: Subjects included 404 practitioners. The most common frenotomy assessment tool utilized was the Hazelbaker assessment tool, followed by the LATCH and Bristol tongue assessment tools. The anatomical features used by most responders in determining if a frenotomy was indicated were the appearance of the tongue when lifted, tongue protrusion, frenulum length, and frenulum type.
Conclusions: Many practitioners believe frenotomies for ankyloglossia are indicated when there is a functional impairment and an anatomical component. This study suggests that the general appearance of the tongue when lifted is the most common anatomical feature used for assessing the need for a frenotomy.

Frenotomy: from assessment to surgical intervention / Frenotomia: da avaliação à intervenção cirúrgica

ABSTRACT The objective of this study was to demonstrate that frenotomy can help improve breastfeeding, tongue movement, and the mother's comfort, if the assessment criteria are respected and the infant's function and age are observed. Frenotomy was performed on two babies with breastfeeding difficulties who came to CEPAE - Center for Research and Dental Care, in 2018, as part of the course on Early Childhood Interdisciplinary Preventive Care at a Dental School. After anamnesis and clinical examination, the lingual frenulum assessment protocol for babies was applied. The necessary frenotomies were performed with topical anesthesia, scissors, and groove director. The babies were reassessed in follow-up visits 7 days after the procedure. The babies had gained weight and the mothers had found greater comfort and easiness when breastfeeding, after the procedure. It is concluded that the less time it takes from ankyloglossia diagnosis to intervention, the easier it is to resume breastfeeding. Also, the identification of ankyloglossia is more effective, and its intervention more efficient, through an interdisciplinary assessment.

RESUMO O objetivo do estudo foi mostrar que a frenotomia pode contribuir para a melhora da amamentação, movimentação lingual e desconforto materno se respeitados os critérios de avaliação, observando a função e idade do lactente. Foram realizadas frenotomias em dois bebês com dificuldade de amamentação que compareceram ao Cepae - Centro de Pesquisa e Atendimento Odontológico, no curso de Atendimento Interdisciplinar Preventivo na Primeira Infância de uma Faculdade de Odontologia, no ano de 2018. Após anamnese e exame clínico foi aplicado o protocolo de avaliação de frênulo lingual para bebês, sendo realizadas as frenotomias necessárias, com a utilização de anestésico tópico, tesoura e tentacânula. Os bebês retornaram para reavaliação após 7 dias do procedimento. Foram observados ganho de peso dos bebês e maior conforto e facilidade das mães durante a amamentação após os procedimentos. Conclui-se que quanto menor o tempo entre o diagnóstico e a intervenção na anquiloglossia, mais fácil se dá o retorno à amamentação, e que a avaliação interdisciplinar torna a identificação mais eficaz e a intervenção da anquiloglossia mais eficiente.

Factors associated with frenotomy after a multidisciplinary assessment of infants with breastfeeding difficulties.

OBJECTIVE: Frenotomy for ankyloglossia has increased nearly 10-fold over the past few decades despite insufficient evidence that the procedure improves breastfeeding outcomes. There is no universally accepted method for identifying patients who may benefit from the procedure. The objective of this study is to determine if comprehensive feeding evaluations and targeted interventions can identify children who should undergo procedures, and to identify factors associated with lip or tongue frenotomy to treat breastfeeding difficulties. METHODS: This observational quality improvement study followed infant-mother dyads between March 2018 and December 2019 referred to our tertiary care center for breastfeeding difficulties. Speech and language pathologists performed comprehensive feeding evaluations on infants prior to surgical consultation for frenotomy. Infants' oral anatomy and function and their ability to breast and bottle feed were assessed, and techniques for mothers to address feeding difficulties without a procedure were offered prior to surgical consultation. Infants either found success over a short observation period or underwent procedures (lip and/or tongue frenotomy). RESULTS: 153 patients (mean age 47.0 days (stdev 39.0 days, 56.2% male) were referred for surgical division of the lingual frenulum. Following development of a program utilizing pediatric speech language pathologists to perform feeding evaluations prior to surgical consultation, 69.9% of patients subsequently did not undergo surgical procedures. 11 (23.9%) underwent labial frenotomy alone and 30 (65.2%) underwent both labial and lingual frenotomies. Frenotomy was associated with significantly increased worry subscale of the Feeding Swallow Impact Survey (FSIS) and decreased mean Breastfeeding Self Efficacy Scale score (p = 0.0001, p = 0.006, respectively). Tongue appearance was significantly associated with having a procedure, while lip appearance was not. The Bristol Breastfeeding Assessment Tool (BBAT) was lower in children undergoing tongue and/or lip frenotomy (p = 0.0006), while the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) appearance and function scores were lower in children undergoing lingual frenotomy with or without lip frenotomy (p = 0.0008, p = 0.0009, respectively). CONCLUSIONS: The majority of patients referred for ankyloglossia may benefit from nonsurgical intervention strategies based on findings from comprehensive feeding evaluation. Frenotomy is associated with higher maternal feeding-related worry and reduced breastfeeding self-efficacy scores. While tongue appearance is associated with frenotomy, functional assessment is critical for identifying patients who may also benefit from lip frenotomy.

Tongue-tie assessment: clinical aspects and a new diode laser technique for its management.

BACKGROUND Often breastfeeding problems experienced by mothers and their babies may be attributed to the abnormal attachment of the infant's tongue (ankyloglossia) and/or maxillary lip-tie. Proper breastfeeding depends upon an infant's ability to correctly latch onto its mother's breast. If born with oral soft tissue abnormalities such as tongue-tie or lip-tie, it may be almost impossible for the infant to breastfeed. During the oral evaluation of an infant presenting with breastfeeding problems, one factor that is often overlooked and undiagnosed - and thus untreated - is the attachment of the upper lip to the maxillary gingival tissue. CASE REPORT: The case is reported of tongue-tie and breastfeeding difficulties, treated with a novel technique: the diode laser (980 nm).

Ankyloglossia and the Breastfeeding Infant: Assessment and Intervention.

BACKGROUND: Our current culture defines breastfeeding and the use of human breast milk as the preferred criterion standard for infant nutrition. Medical and health professionals have a responsibility to support breastfeeding in the mother-infant dyad. This includes the recognition of anatomical barriers to breastfeeding such as a tongue-tie, ankyloglossia. PURPOSE: The purpose of this article is to enrich and expand the clinical knowledge of health professionals about the physical assessment of ankyloglossia and its impact on breastfeeding. Techniques for assessing anterior and posterior ankyloglossia and interventions across the spectrum are discussed. We also explore maternal emotional experiences of breastfeeding an infant with ankyloglossia. METHODS/SEARCH STRATEGY: A systematic literature search from MEDLINE, CINAHL, and Cochrane databases was performed. The search results consisted of qualitative and quantitative studies performed involving infants with anykloglossia and breastfeeding experiences. Data and findings from the search results were analyzed and reviewed. FINDINGS: Ankyloglossia, commonly referred to as tongue-tied, can result in weight loss, painful breastfeeding, and a cessation of breastfeeding prematurely. Depending on severity, interventions to alleviate breastfeeding difficulties can range from a lactation consultation to surgical intervention. The options for treatment and intervention must be discussed thoroughly with caregivers. IMPLICATIONS FOR PRACTICE: Thorough assessment of the breastfeeding dyad is essential to discovering ankyloglossia and its role in breastfeeding difficulties. Intervening appropriately can prevent negative outcomes associated with ankyloglossia and breastfeeding. IMPLICATIONS FOR RESEARCH: Future studies should be focused on developing universal tools for grading ankyloglossia and the effects of ankyloglossia on speech development. There is also a gap in the knowledge regarding ankyloglossia in the preterm infant and its impact on developing breast and bottle-feeding technique in the neonatal intensive care unit.