The American Academy of Pediatrics Clinical Report on Ankyloglossia

CQ #306 – August 6, 2024
by Anne Eglash MD, IBCLC, FABM
#LACTFACT
The American Academy of Pediatrics recommends evaluation for infant and maternal conditions before infant frenotomy for ankyloglossia.
Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report
Pediatrics 154(2) August 2024 e2024067605


What are the recommendations from the American Academy of Pediatrics (AAP) on Ankyloglossia Diagnosis and Management?

Ankyloglossia is a medical term for tongue-tie. Lingual frenula are common, and only a fraction of frenula tether sufficiently to cause nipple pain and reduced milk transfer. According to the AAP, there has been a nearly 10-fold increase in the diagnosis of ankyloglossia and rate of frenotomy between 1997 and 2012, with another doubling of these rates from 2012 to 2014. It is unclear how much of this is a true increased incidence, improved diagnostics, or overdiagnosis.

The American Academy of Pediatrics’ Clinical Report addresses the lack of criteria for diagnosing ankyloglossia and the limited research on breastfeeding outcomes after frenotomy. The report reviews the anatomy of ankyloglossia, the physiology of lactation, and provides an algorithm for ankyloglossia evaluation and treatment decision making.

Of note, the report casts doubt on indications for upper lip and buccal frenotomies.

Check out the question to learn more about the AAP Clinical Report’s findings and recommendations!

Please choose accurate statements based on the American Academy of Pediatrics’ Clinical Report on Ankyloglossia. Choose 1 or more:
  1. The report recommends using local anesthesia before performing a frenotomy.
  2. None of the formal scoring systems for ankyloglossia have been validated.
  3. Laser treatment is considered superior to scissors, especially for posterior tongue ties.
  4. Frenotomy to prevent problems with speech or obstructive sleep apnea is not evidence based.
  5. Frenotomy providers should document the receipt of intramuscular vitamin K before the procedure.
  6. Post-op stretches are recommended after a frenotomy.

See the Answer


Correct Answers: B, D, and E (not A, C, or F)

Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report
Pediatrics 154(2) August 2024 e2024067605
Jennifer Thomas, MD, MPH, FAAP, Maya Bunik, MD, MPH, FAAP, Alison Holmes, MD, MPH, FAAP, Martha Ann Keels, DDS, PhD, Brenda Poindexter, MD, MS, FAAP, Anna Meyer, MD, FAAP, Alison Gilliland, MD, FAAP, SECTION ON BREASTFEEDING, COUNCIL ON QUALITY IMPROVEMENT AND PATIENT SAFETY, SECTION ON ORAL HEALTH, COMMITTEE ON FETUS & NEWBORN, SECTION ON OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Abstract

No abstract is available.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

The AAP Clinical Report on ankyloglossia does not recommend routine local anesthesia for frenotomy. Frenotomy is not indicated to prevent speech problems or obstructive sleep apnea. Further, the report does not recommend routine post-op stretches.

While I appreciate the AAP’s attempt to provide a comprehensive algorithm to diagnose and manage ankyloglossia, their Clinical Report on ankyloglossia overlooks a critical component of care: the breastfeeding medicine physician/provider. Breastfeeding medicine physicians/providers possess specialized training to assess the entire dyad. This includes infant oral anatomy and function, maternal breast exam, milk culture, feeding evaluation and differential diagnosis. Many if not most are skilled in frenotomy.

The average pediatrician, family physician, obstetrician, or midwife caring for lactating dyads lacks the expertise to do such a comprehensive evaluation. Non-provider lactation consultants, while valuable, cannot diagnose medical conditions. Consequently, direct referrals to frenotomy providers without comprehensive evaluations risk overlooking maternal/infant health issues and may lead to unnecessary infant oral surgery.

Breastfeeding infants and parents deserve a comprehensive evaluation and treatment plan for lactation-related issues, akin to the care provided for other non-lactation health concerns.



Comments (3)

    Freda Rosenfeld

    Where are studies to prove that the massive cutting of tongue ties that is going on, has actually improved breastfeeding rates. I am afraid that we are over using the procedure with out finding/doing other interventions to improve suck that are less invasive e.g. exercises both oral and to improve neck control .

    As an IBCLC for 34 years I do believe that this procedure is massively over performed, and should only be done when other options have been tried first.
    I see so many babies that have had this procedure and don’t improve or even get worse. when the real root of the problem has never been addressed.

    I think this study is a wakeup call to be more prudent. There will be times that the procedure will make a world of difference–and should be done by a trained thoughtful clinician , but I think it’s a small population

    thanks for listening

    Tricia Shamblin

    Thank you for bringing attention to this important issue. As an IBCLC who is concerned about the rapid increase in these procedures, I appreciate that the AAP is stressing the importance of assessing for any other possible issues first and making sure that the dyad has effective lactation support before the decision is made to seek a frenotomy. However, I still see a lack of outpatient lactation support as a barrier for families.

    I loved your webinar on this topic as well. For those who haven’t seen it yet IABLE currently offers a free webinar on this topic. I thought it was very fair and well balanced.

    Anne Eglash

    Thanks Tricia!

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