DIVISION OF ANKYLOGLOSSIA
Dr. Neville S. Wilson.
Ankyloglossia, commonly called “tongue-tie” is a congenital oral anomaly which may decrease mobility of the tongue and impair breast feeding in infancy.
In some cases this anomaly may cause speech impairment in later life, but medical opinion is divided on this and further studies are required to substantiate this hypothesis. (1).
The evidence, however, is strong for breast feeding benefits following the surgical intervention of ankyloglossia, and the author’s own observations in clinical practice support the rationale for such intervention.
THE FRENULUM :
The fraenum, or frenulum, is a narrow fold of mucous membrane that connects a moveable part of the body to a fixed part, and the lingual frenulum helps to stabilize the base of the tongue without restricting normal tongue movement. It forms the attachment between the underside of the tongue and the floor of the mouth, and is a remnant of the initial attachment of the tongue to the floor of the mouth before birth. (2)
Tongue movements include tip elevation, retraction, grooving and protrusion, and provide for suckling, chewing, eating, drinking, clearing the mouth and for speech function.
In breast-fed infants unrestricted tongue mobility facilitates normal latching and suckling.
An added complication of an unreleased tongue-tie, and ineffective latching, is aggressive chewing of the breast nipple by the hungry infant, leading sometimes to painful nipple ulceration, poor breast emptying, and increased risk for maternal mastitis.
Dolberg and associates, in a study of 25 mothers of healthy infants with ankyloglossia, reported a significant decrease in nipple pain after frenotomy. (3)
The severity of this anomaly may be determined by the position of the frenulum and its degree of thickening, and may present as an anterior, mid-tongue, or posterior attachment to the under surface of the tongue. (2)
In extreme cases, which are rare, the tongue may be tethered to the floor of the mouth.
Ankyloglossia refers to a restricted lingual fraenum, due to consolidation of tissue, and may in some cases reduce mobility of the infant tongue to the degree that effective breast latching is restricted, and efficient supply of breast milk to the infant is compromised.
A consequence, and frequent cause for parental concern, is poor weight gain for the breast – fed infant, shortly after birth, often leading to subsequent consultations with a Lactation Consultant.
Lactation Consultants are registered nurses who have specialised knowledge and skills that are supportive for breast feeding mothers who have a feeding problem, or have concerns about poor weight gain in their breast fed babies.
Lactation Consultants are usually familiar with feeding problems associated with tongue-tie, and are more likely to make referrals to a doctor who offers surgical intervention than other health professionals are likely to do.
In an interesting survey conducted in the USA by Messner, in which over 1500 paediatricians, otolaryngologists, speech therapists and lactation consultants were questioned about the need to surgically divide tongue-tie in affected infants, the paediatricians were the least likely to support the intervention. (4)
DIAGNOSIS AND PREVALENCE OF TONGUE TIE :
Many cases of ankyloglossia are missed because of failure to examine the tongue at birth, or at the 2 week and 6 week post natal examinations.
Furthermore, health professionals often admit to a lack of experience in making the diagnosis, and may rely on a Lactation Consultant to confirm the presence of tongue tie, with recommendations for appropriate management.
There is also conflicting opinion among some health professionals who do not subscribe to the theory of tongue tie as an impediment to infant feeding, and propose that surgical intervention is not required.
This view is not shared by many Lactation consultants, nor by their satisfied clients, who have witnessed the immediate improvement in latching following a surgical release of tongue tie.
The author, having witnessed the degree of feeding difficulty associated with tongue tie, and the immediate relief demonstrated by the feeding infant, following frenotomy, subscribes to the theory that surgical intervention is indicated for breast fed infants with ankyloglossia.
In a prospective study of 62 neonates with ankyloglossia and breastfeeding difficulties, there were significant improvements in weight and breastfeeding at 2 weeks post-freulotomy. (5)
And in a study of 36 mothers with affected babies, paired with 36 mothers of control infants, 25% of Mums with tongue-tied infants reported difficulty with latching and breast feeding, compared to 3% of those not having tongue-tie. Mothers of infants with ankyloglossia reported more breast feeding difficulties than mothers of controls. (2)
The prevalence of tongue-tie is uncertain, and according to Kummer there is large variation in reports, from as low as 1% to as frequent as 97% in newborns. (3)
Messner (2000) and Riche et al (2005) have placed the prevalence of ankyloglossia at between 4% and 5%, but these figures may be unrepresentative of the many cases that are missed due to babies being bottle fed.
Bottle fed babies, unlike their breast fed counterparts, are less likely to experience feeding problems since the latching manoeuver is not required for drinking from a bottle. (6)
For successful nursing to occur the infant must latch onto the Mother’s areola with his/her upper gum ridge and tongue, with successful suckling being effected by forward movement of the jaw and tongue. The tongue also serves to provide a necessary seal, and in conjunction with lower jaw movements, it squeezes milk from the breast ductules.
The milk is then moved to the back of the oropharynx by depressing the posterior part of the tongue and then swallowed. (7) (8).
While feeding problems linked to ankyloglossia are generally acknowledged, many researchers dispute the contention that ankyloglossia causes speech impairment, stating that with growth and development the intact frenulum will recede naturally, permitting free and full range of tongue movement, without impeding speech development. (9)
Other researchers, however, have reported improvements in speech following frenectomy.
Messner and Lalakea studied 30 children aged 1 to 12 years with unreleased ankyloglossia, with a comparative evaluation of speech quality following frenuloplasty in half of these subjects.
They reported 11 cases of abnormal articulation before surgery, and 9 cases of improved articulation after surgery. (2)
Other studies by Messner and Horton offer conflicting results.
Anecdotal evidence suggests that tongue tie has a comparatively limited effect on speech quality, but certain sounds may be restricted by impaired tongue tip mobility, such as T,D,Z,S,Th, & L (10)
In these cases compensatory techniques may be employed by affected children in order to express themselves
It is generally accepted that during the first 4 to 5 years of life, with changes to the oral cavity, the tongue grows and narrows, and the lingual frenulum recedes and stretches, and may even rupture, reducing the earlier restrictions to lingual movement.
This eventuality, however, does not relieve the problem of ineffective latching and suckling in the first few weeks of life.
MECHANICAL & SOCIAL EFFECTS:
Anecdotal evidence of mechanical limitations, such as kissing, licking ice cream, or tongue manoeuvering , have been reported by Lelakea and Messner. (2)
The surgical release of the restricting frenulum may be performed by (a) Frenotomy, which is the snipping of the frenulum during the first few weeks of birth, without local or general anaesthesia. (b) Frenectomy or Frenulectomy, which is surgical revision under GA. (c) Revision by Laser, ususally in older children, (d) Revision by Electrocautery under local anaesthetic.
The author routinely performs FRENOTOMY procedures in newborns, between 2 weeks and 12 weeks of age, and has performed frenulum release in older children with persisting breast feeding difficulties.
Invariably, these procedures are the outcome of referrals by lactation consultants, acting on behalf of anxious mothers who have presented with feeding problems. On occasions, the surgical procedure has been requested by mothers who have conducted their own research and have initiated the request for a tongue tie release to be performed on their affected child.
Frenotomy is an easy and potentially uncomplicated procedure which may be conducted in the Doctor’s rooms without need for an anaesthetic.
The procedure is preceded by a consultation with either, or both, parents during which the birth details and feeding history are documented, and the indications for the intervention explained, with discussion, about any associated risks or complications, and a consent form is duly signed.
Positioning of the infant is determined by the need to secure the head, to avoid movement, and to restrict movement of the arms and legs in older children, in order to minimize movement that may disrupt the operator.
My preference is to have the infant prone on the examination couch, with Mom or Dad standing behind the head of the infant, and securing head and arms with the aid of a wrap around towel.
With the frenulum isolated and defined by using the index fingers of each hand, followed by a grasp between the middle and fore finger of the left hand, the right hand is used to carefully divide the frenulum with a blunt end scissors, being careful not to harm the floor of the mouth or the under surface of the tongue.
Minimal bleeding form the divided frenulum can easily be arrested with a dry cotton swab, and the infant is put to breast immediately following the procedure. Invariably, the outcome is successful, as evidenced by improved feeding, and a highly contented Mum.
Several authors have found that tongue tie can adversely affect infant breast feeding, and that division of tongue tie is safe, successful, and an easy procedure to perform, with significant improvement in breast feeding. (11) (12)
Dr. Neville Wilson.
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