Infant with mouth open showing a restrictive frenulum, resulting in the condition often referred to as tongue-tie.

The birth of a baby is a beautiful, exciting, and scary time for new parents. When it comes to the health of a newborn, there are so many aspects of care to consider and so many new things to learn. Breastfeeding can be a primary cause of stress for many first-time mothers. While breastfeeding has proven to provide a baby with optimal nutrition, passive immunity, and mother-infant bonding, getting a baby to successfully latch for breastfeeding can sometimes be challenging and frustrating. Creating the pressure seal that is necessary for successful breastfeeding often requires practice from mom and baby. Sometimes the assistance of a lactation specialist is helpful. For some infants, the struggle to successfully breastfeed may be related to a condition known as tongue-tie (lingual ankyloglossia).

What Is Tongue-Tie?

The tongue naturally has a thin underlying perpendicular membrane called the frenulum. But when this strip of tissue extends to the tip of the tongue and is shortened, it can tether (or “tie”) the tip of the tongue to the floor of the mouth, limiting movement of the tip of the tongue. This limited movement can hinder breastfeeding for the infant and in some cases can interfere with development of normal speech articulation later in life. 

The definition of tongue-tie (lingual ankyloglossia) has been controversial over time, and the frequency of this diagnosis has increased exponentially in recent years. Commonly, it is simply defined as a condition of limited tongue mobility caused by a restrictive frenulum. The ENT providers at CornerStone Ear, Nose & Throat believe that this limited tongue mobility is often blamed for other issues that may not be directly related to the condition. 

What Is Lip-Tie?

Lip-tie (buccal tie/labial ankyloglossia) is often confused with tongue-tie, but there is a difference. A lip-tie occurs when the piece of tissue that connects the upper lip to the gums (the labial frenulum) is too tight or, more commonly, is thickened. This condition may occur in tandem with tongue-tie and should not play a significant role in breastfeeding difficulties. In contrast, more severe deformities such as cleft lip can present definite issues. Surgical division of a thickened or prominent labial frenulum offers little if any benefit to most infants for breastfeeding, as the lips play a relatively passive role in latching onto the breast.

Treating Tongue-Tie

When tongue-tie (lingual ankyloglossia) is diagnosed or suspected, the newborn infant is often referred to an otolaryngologist (ear, nose, and throat specialist) for evaluation and care. If ankyloglossia is confirmed to be present and contributing to difficulty in breastfeeding, some infants may benefit from frenotomy, a procedure in which the lingual frenulum is divided. The physicians of CornerStone Ear, Nose & Throat believe that this procedure should be performed only if a clear benefit of the procedure has been determined and the child has also been previously evaluated for other ENT conditions that could be contributing to breastfeeding difficulties.

Clinical Guidelines

The American Academy of Otolaryngology-Head and Neck Surgery recently published a clinical consensus statement to clarify the diagnosis, management, and treatment of pediatric ankyloglossia. These statements were produced in collaboration with a panel of expert pediatric otolaryngologists and a thorough literature review. 

A Summary of the Clinical Consensus Statements:

  • Ankyloglossia (tongue-tie) is being over-diagnosed in some communities, resulting in a significant number of unnecessary procedures involving the lingual frenulum (frenotomies) and unnecessary concern on the part of some parents and pediatricians.
  • Breastfeeding problems, including poor latch and maternal pain, are common. Anterior ankyloglossia, among multiple other etiologies, can contribute to this difficulty. Evaluation by a lactation consultant is recommended prior to referral to an ENT doctor for consideration of frenotomy.
  • Surgery to release buccal (labial/lip) tie should not be performed. Upper lip-tie is normal in an infant and is an inconsistently defined condition. Upper lip frenotomy does not prevent an enlarged space between upper front teeth later in life, nor does it assist in latching on during breastfeeding. 
  • Ankyloglossia does not cause sleep apnea.
  • The infant should be fully evaluated for other potential head and neck sources of difficulty, such as airway obstruction, reflux, and craniofacial abnormality such as cleft palate, prior to frenotomy.
  • Although frenotomy is generally a safe and well-tolerated procedure when performed by an experienced otolaryngologist, rare complications (such as scarring, hemorrhage, or damage to salivary structures) and relative contraindications (such as blood coagulation disorders, neuromuscular disorders, or abnormally shaped mouth) should be considered prior to the procedure.
  • It is not usually necessary to perform frenotomy on an infant with little to no tongue restriction and no feeding difficulties in order to prevent future speech disorder, although this can be a reasonable elective procedure in selected cases, depending on the child’s anatomy.
  • Painful breastfeeding and/or poor latch is often multifactorial, so it may improve without frenotomy or may not improve with frenotomy
  • Lingual frenotomy should occur as early as possible once the potential for a benefit has been established.
  • There is no specific superior or recommended procedure for frenotomy.
  • In older children, ankyloglossia does not typically affect speech, although it may limit licking ability or dental hygiene. Speech pathology consultation is recommended prior to frenotomy in an older patient.
  • Anesthetic agents are not recommended for lingual frenotomy in infants, though they may become necessary should the procedure be performed on a toddler for other reasons. Special post-procedural care is not typically necessary, although follow-up should be available as needed.
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Category: Pediatrics