JCDA Express Issue 2 2013

Frenectomies for tongue-tied infants

In this edition of JCDA Express, Dr. Geoff Smith, a pediatric dentist practising in St. John’s, Newfoundland, and member of CDA’s Committee on Clinical and Scientific Affairs, brings forward 3 articles that examine the effect of ankyloglossia on breastfeeding and the potential benefits of frenectomies for tongue-tied infants. According to Dr. Smith, dentists are well positioned to increase awareness of this issue and meet the growing demand for frenectomies from mothers who are experiencing difficulties with breastfeeding. “In my experience, mothers are desperate to find someone to perform frenectomies and dentists have the necessary skill set to meet this need,” says Dr. Smith.

Dr. Geoff Smith

Introduction

• Ankyloglossia, or tongue-tie, can contribute significantly to breastfeeding problems. Treatment of ankyloglossia is frenectomy to release the lingual frenum—a relatively simple procedure that dentists are well positioned to perform.
• In most cases, performing a frenectomy results in significant, immediate improvement in breastfeeding for tongue-tied infants.
• Ankyloglossia in infants can be a critical factor influencing a mother’s decision to initiate and continue breastfeeding—it results in restricted range of tongue movement that represents a significant proportion of breastfeeding problems. Given the well known benefits of breastfeeding for both mother and infant, ankyloglossia can present a significant obstacle to mothers committed to breastfeeding.
• However, despite the benefits of frenectomies to breastfeeding infants and mothers, parents may receive conflicting advice about the procedure from pediatricians, surgeons, dentists, lactation consultants, and speech pathologists. Surveys show that only 21% of pediatricians recommend the procedure versus 53% of ENT surgeons and 69% of lactation consultants.¹
• Although some doctors may question the need for frenectomies in favour of waiting to see what happens to the frenum during growth, the papers presented here highlight the risks of delaying frenectomies—including early discontinuation of breastfeeding—for infants and mothers with breastfeeding difficulties. Potential complications associated with the procedure include infection, pain, and bleeding; the studies presented here reported no complications.
• Dr. Smith adds, “I believe that dentists who are willing to perform frenectomies on infants should promote their services to local groups offered at hospital and community health services and La Leche League Canada—this would increase awareness among new mothers about the benefits of frenectomies for tongue-tied infants and offer them guidance in finding treatment.”

How does ankyloglossia interfere with the ability to breastfeed?

Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-94. Epub 2008 Jun 23.

Full-text access to this article has expired.

JCDA Clinical Pearl: Post-frenectomy, infants with ankyloglossia experiencing persistent breastfeeding difficulties showed less compression of the nipple by the tongue, which was associated with improved breastfeeding (defined as better attachment, increased milk transfer and less maternal pain). In the assessment of breastfeeding difficulties, ankyloglossia should be considered as a potential cause.

Key Points:

• This study examined the sucking dynamics of infants with ankyloglossia before and after frenectomy and provides evidence of the procedure’s benefits.
• Mother-infant pairs (n=24) experiencing persistent breastfeeding difficulties despite receiving professional advice were recruited.
• Milk intake, milk transfer, LATCH scores (a numerical scoring system addressing 5 key components of breastfeeding: latch, audible swallowing, type of nipple, comfort and hold) and maternal pain were recorded before and after frenectomy.
• All infants included in the study showed significant improvement in all measures and the mothers’ pain scores were significantly reduced.
• Frenectomy changed tongue movement during breastfeeding and reduced the degree of nipple distortion, which corresponds with successful breastfeeding.

Reasons for Recommending this Article: The use of ultrasound in this study helps illustrate how ankyloglossia interferes with nursing by looking at the mechanics of sucking. The description of infants who compress the tip of the nipple, rather than minimally distorting the nipple as is observed during successful breastfeeding, supports the work of Kotlow² who suggests frenectomy of the labial frenum for those infants whose upper lip is tethered and can’t reach the base of the nipple. 

Are intensive instruction and frenectomies equally beneficial to infants with feeding problems?

Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005;41(5-6):246-50.

Full-text access to this article has expired.

JCDA Clinical Pearl: This randomized, controlled trial has clearly shown that tongue ties can affect feeding and that division is a safe and successful intervention for these infants. When compared to the control group (intensive skilled support of a lactation consultant), the treatment group (frenectomy) demonstrated significantly improved feeding.

Key Points:

• This randomized controlled trial examined the effect of 2 treatments on feeding in tongue-tied infants: referral to a lactation consultant or immediate division of tongue-tie.
• Tongue-tied infants with feeding problems (n=57) were divided into two treatment groups: immediate division of the tongue-tie (intervention) or intensive support, advice and help from a lactation consultant (control).
• Improvements in breast- or bottle-feeding after frenectomy were usually immediate and often dramatic: feeding improved for 27 of 28 infants in the intervention group, either immediately or within 48 hours.
• In contrast, feeding in the control group improved for 1 of 29 infants. The mothers of all 28 infants that failed to improve after 48 hours of intensive instruction requested frenectomy; 27 of 28 showed improvements in feeding after frenectomy (77% immediately, 19% within 48 hours and 4% within 7 days).
• Frenectomy also improved feeding in bottle-fed babies with feeding problems: it allowed them to latch efficiently, feed much faster, dribble less and suck in less air.

Reasons for Recommending this Article: This study clearly shows that frenectomy improves feeding in tongue-tied infants with feeding difficulties. This is the only study that I have read that includes bottle-fed babies in the frenectomy treatment group.

Are frenectomies beneficial for breastfeeding infants and mothers?

Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.

Full-text access to this article has expired.

JCDA Clinical Pearl: Ankyloglossia represents a significant proportion of the identified impediments to successful breastfeeding. It is more common in boys than girls and seems to be genetic in origin.

Key Points:

• This study looked at incidence of ankyloglossia in a population of breastfeeding infants (inpatients and outpatients at a children’s hospital) and the impact of ankyloglossia on breastfeeding infants.
• Ankyloglossia is relatively common in newborns and represents a significant proportion of breastfeeding problems—it was diagnosed in 88 of 2763 (3.2%) breastfeeding inpatient infants and in 35 of 273 (12.8%) of breastfeeding outpatients.
• When offered the frenectomy treatment, 123 of 127 mothers of infants with ankyloglossia opted for the treatment.
• After the procedure, latch improved in all cases and maternal pain levels fell significantly.

Reasons for Recommending this Article: This is a large study with a good discussion of the factors leading to discontinuation of breastfeeding. One important point is that mothers of tongue-tied infants are 3 times as likely to discontinue breastfeeding after 1 week than mothers of infants without tongue-tie.³

References

1. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2–3):123–31.
2. Kotlow L. Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. Eur Archs Paediatr Dent. 2011;12(2):106-112.
3. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005;18(1):1-7.