Breastfeeding and Tongue-Tie- A Professional Consensus Statement
by Anne Eglash MD, IBCLC, FABM
The American Academy of Otolaryngology-Head and Neck Surgery states in their recent report that there has been a great escalation in the number of newborns diagnosed with ankyloglossia since 2003. The Academy therefore convened an expert panel of pediatric otolaryngologists, all of whom treat ankyloglossia (tongue-tie), to develop a clinical consensus statement on the diagnosis, evaluation, and management of tongue-ties in children, based on current evidence and expert opinion.
In addition to establishing statements on lingual frenula, the experts developed key statements on upper lip frenula and buccal frenula.
This is a very important topic, especially during the COVID-19 pandemic, because the consensus statement may have an influence over the whether clipping lingual frenula in breastfeeding infants is considered elective or urgent by otolaryngologists.
The expert group agreed that ankyloglossia is a condition of limited tongue mobility caused by a restrictive lingual frenulum. This means that if the tongue’s movement is not restricted, the presence of the frenulum by itself does not indicate the need for treatment.
There are several other consensus statements, which I will summarize in my comments. First, test yourself.
- Ankyloglossia does not cause sleep apnea.
- Surgery to release buccal frenula should not be performed.
- Breastfeeding difficulties are common in the newborn period and evidence shows that posterior ankyloglossia is a potential contributor to infant feeding problems.
- Posterior ankyloglossia refers to a frenulum that attaches to the posterior aspect of the tongue and restricts tongue mobility.
- Upper lip frenotomy in infants or children with primary dentition will not prevent the occurrence of an upper interincisor diastema (spacing between upper teeth).
- Ankyloglossia does not typically affect speech.
- Retrognathia is a relative contraindication to clipping a tongue-tie.
See the Answer
Abstract
Objective
To identify and seek consensus on issues and controversies related to ankyloglossia and upper lip tie in children by using established methodology for American Academy of Otolaryngology–Head and Neck Surgery clinical consensus statements.
Methods
An expert panel of pediatric otolaryngologists was assembled with nominated representatives of otolaryngology organizations. The target population was children aged 0 to 18 years, including breastfeeding infants. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus, per established methodology published by the American Academy of Otolaryngology–Head and Neck Surgery.
Results
After 3 iterative Delphi method surveys of 89 total statements, 41 met the predefined criteria for consensus, 17 were near consensus, and 28 did not reach consensus. The clinical statements were grouped into several categories for the purposes of presentation and discussion: ankyloglossia (general), buccal tie, ankyloglossia and sleep apnea, ankyloglossia and breastfeeding, frenotomy indications and informed consent, frenotomy procedure, ankyloglossia in older children, and maxillary labial frenulum.
Conclusion
This expert panel reached consensus on several statements that clarify the diagnosis, management, and treatment of ankyloglossia in children 0 to 18 years of age. Lack of consensus on other statements likely reflects knowledge gaps and lack of evidence regarding the diagnosis, management, and treatment of ankyloglossia. Expert panel consensus may provide helpful information for otolaryngologists treating patients with ankyloglossia.
The Academy made it clear that there is not good enough research for a clinical guideline on diagnosis and treatment of ankyloglossia.
The experts did not reach consensus on how to categorize ankyloglossia, nor did they agree on the definition of posterior ankyloglossia.
I believe that this American Academy of Otolaryngology-Heath and Neck Surgery clinical consensus statement will be helpful as a guide for those otolaryngologists who are not as familiar with tongue-ties, are not sure whether to clip a lingual frenulum, and what to do with requests to clip upper lip and buccal frenula.
Here are some other consensus statements, adapted from their list:
- Breastfeeding problems are common early postpartum, and anterior ankyloglossia may be a contributor to infant feeding problems.
- There may be other causes of maternal pain and poor latch that are not due to ankyloglossia.
- When evaluating an infant for ankyloglossia, a thorough infant history and physical exam are important, as well as a breastfeeding evaluation by a specialist who has the skills in evaluating the lingual frenula as part of the feeding exam.
- Before performing a frenotomy, infants should be evaluated for other head and neck causes of breastfeeding problems such as nasal obstruction, airway obstruction, laryngopharyngeal reflux, and craniofacial abnormalities such as cleft palate.
- Informed consent for frenotomy should include the risks of hemorrhage, airway obstruction, injury to salivary structures, oral aversion, scarring and failure to resolve breastfeeding problem(s).
- Topical and injected anesthetics are not recommended before infant frenotomy.
- Presence of an upper lip frenulum is normal in an infant and has an unclear relationship to breastfeeding difficulties.
- Surgery to release a buccal frenulum should not be performed.
- Ankyloglossia does not cause sleep apnea. (In fact, the authors state that anterior tethering of the tongue may serve to prevent posterior collapse of the tongue and frenotomy could worsen sleep apnea).
I recommend reading the full consensus statement, and sharing it with dentists, ENTs, and other physicians/providers who perform frenotomies in your community. The statement still leaves some answers unresolved, such as what to do with posterior tongue ties, and whether post frenotomy exercises are worthwhile. Nevertheless, I value their recommendation of having a breastfeeding expert evaluate breastfeeding before making the decision to perform a frenotomy.
Lois Wattis
Thank you for sharing this useful document. New Zealand dentists have released a similar consensus statement and Australian Dental Association convened a multidisciplinary national panel last year, including neonatologist, pediatrician, midwife, IBCLC, chiropractor, speech pathologist, ENT representatives in addition to expert dental members. Release of this consensus statement is imminent and as representative of Australian College of Midwives I know the content is essentially the same as this document. Importantly, the existence of posterior tongue tie was extensively examined, and informed by the recent research work of Dr Nikki Mills NZ ENT confirmed PTT does not exist and therefore the perceived feeding complications extrapolated from this “anomoly” are incorrect. It is also widely recognized that the worldwide escalation of tongue surgeries in infants and children is associated with apparent PTT, which in fact is not an oral defect at all. Concern about the many adverse outcomes of these unnecessary surgeries including so called lip ties and buccal ties has prompted development of these consensus statements by relevant medical and dental leaders, including midwives and IBCLCs.
Jeanette Panchula
As a La Leche League Leaders since 1975 who had to deal for many years with unresolved breastfeeding pain, I would encourage further studies:
– Some birthing problems can cause issues of the neck, shoulders and back that may initially lead to pain in breastfeeding that is NOT caused by tight frenulum
– Some high palate issues cause horribly painful breastfeeding – and, at times I have seen this connected with tongues which may have caused the development of this issue prenatally, when the palate is soft.
– When specialists collaborate (Osteopaths, chiropractors specializing in craniosacral and movement disorders in infants) pain that might have been erroneously be identified as tight frenulum might be reduced/relieved.
– As an IBCLC since 1985, I cannot diagnose ankyloglossia, but I can report a great deal of relief in mothers who were able to reach out to experts in the field (primarily dentists), who diagnosed and provided appropriate interventions – and also FOLLOWED UP to learn the outcomes of their surgery. I also have observed NO relief when inexperienced or poorly trained physicians attempt minimal interventions, which IF they follow-up – which they rarely do – they then confirm mother still has pain, which “proves” that it doesn’t work, they just did it “because the mother “demanded it”!
Alison Hazelbaker
Bravo! I this this statement is reasonable and better reflects the evidence. Statements like these can hopefully temper the extreme positions being taken by clinicians around the world.
Our clinical management of what people call tethered oral tissues has outstripped the evidence so dramatically that we have strayed into unethical and harmful clinical approaches.
I am happy to see concerns raised over destabilization when unnecessary surgery is performed. I only wish clinicians would take this concern more seriously.
Our eagerness to resolve breastfeeding problems has led us into the one size fits all diagnosis of tongue-tie. Our babies are not better served by this approach!
I look forward to more research that actually clarifies and defines best practice. This statement leads the way by pointing to the subjects that have little to no evidence behind them.