The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding

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Abstract

Objectives

The objectives of this study were to assess the effect of office-based frenotomy on reversing breastfeeding difficulties among infants with problematic ankyloglossia, and to examine characteristics associated with anterior and posterior ankyloglossia.

Methods

Mother's of infants who underwent a frenotomy for ankyloglossia from December 2006 through March 2011 completed a post-intervention web-based survey about breastfeeding difficulties they experienced before and after the frenotomy. Maternal-infant dyads had been referred from health providers to a primary care practice for assessment of ankyloglossia. Infants were subsequently classified as having no ankyloglossia, anterior (Type I or Type II) or posterior (Type III or Type IV).

Results

There were 311 infants evaluated for ankyloglossia and 299 (95%) underwent a frenotomy. Most infants were classified as having Type III (36%) or IV (49%) ankyloglossia compared to only 16% with anterior (Type I and Type II combined). Differences by classification type were found for gender (P = .016), age (P = .017), and maxillary tie (P = .005). Among survey respondents (n = 157), infant latching significantly improved (P < .001) from pre- to post-intervention for infants with posterior ankyloglossia. Both the presence and severity of nipple pain decreased from pre- to post-intervention among all classifications (P < .001). Additionally, 92% of respondents breastfed exclusively post-intervention. The mean breastfeeding duration of 14 months did not differ significantly by classification.

Conclusions

Breastfeeding difficulties associated with ankyloglossia in infants, particularly posterior, can be improved with a simple office-based procedure in most cases. The diagnosis and treatment of ankyloglossia should be a basic competency for all primary care providers and pediatric otorhinolaryngologists.

Introduction

Ankyloglossia, or tongue tie, refers to excessive sublingual frenular tissue resulting from incomplete separation of the tongue from the floor of the mouth during embryogenesis (apoptosis). Anterior ankyloglossia, also described as Type I and Type II ankyloglossia, is characterized by insertion at the tip of the tongue (Type I) or slightly behind the tip (Type II). Posterior ankyloglossia is characterized by a thickened frenulum (Type III) or a submucosal frenulum which is visualized as a flat, broad mound absent of any typical protruding frenular tissue, and restricts movement at the base of the tongue (Type IV) [1], [2]. Most literature refers to the anterior types and rarely reflects the existence and relevance of the posterior types [1], [3].

Maxillary tie, also described as restrictive upper labial frenulum, and ankyloglossia in infants present with interference of breastfeeding, resulting in a characteristic set of maternal and infant symptomatology and physical findings [1], [4]. In infants, ankyloglossia is most often manifest as maternal nipple pain, infant latching difficulties, and poor infant feeding and growth parameters. Infants with maxillary tie have a thicker frenulum that inserts into the papilla and restricts lip splay, resulting in a poor seal and inefficient feeding. These difficulties increase utilization of medical services, breast milk pumping, and accessory feeding methods, which often lead to breastfeeding cessation [5], [6], [7].

Numerous publications [3], [8], [9], [10], [11], [12], [13], [14], [15] exist to support the contention that frenotomy is simple, efficacious, and necessary in achieving the breastfeeding recommendations (i.e., to provide breast milk exclusively for the first six months of life and continued breastfeeding through the first year of life) established by the American Academy of Pediatrics [16], U.S. Surgeon General [17], and World Health Organization [18].

Less well described in the literature is the distinction among infants with different types of ankyloglossia in relation to breastfeeding difficulties and response to frenotomy [3].

Our review of the literature suggests that most researchers primarily studied anterior ankyloglossia. We located only one case series that hinted at the importance of posterior ankyloglossia in relation to breastfeeding failure [3]. The objectives of our study were to assess the effect of office-based frenotomy among infants with problematic ankyloglossia on reversing breastfeeding difficulties and to elucidate differences among infants with anterior and posterior ankyloglossia.

Section snippets

Study design

Women whose infants underwent a frenotomy from December 2006 through March 2011, were asked to complete an 18-item, web-based questionnaire about maternal-infant breast feeding characteristics before and after the intervention. The web-linked questionnaire was offered between December 2010 and May 2011, with three follow-up reminders. Infant date of birth, ankyloglossia classification, date of frenotomy, and referral source were gathered from chart review. The Middlesex Hospital Institutional

Characteristics of all treated infants

Characteristics of all treated infants are shown in Table 1. There were 311 infants evaluated for ankyloglossia and 299 (95%) underwent a frenotomy. Twelve infants did not undergo the procedure due to parental choice or a determination of an alternative explanation. Fifty-four percent of infants who received the procedure were male. The median age at the time of the frenotomy was 35 days (range, 2–323 days).

The majority of infants were classified as having either Type IV (49%) or Type III (36%)

Discussion

The vast majority of problematic breastfeeding problems are corrected by hospital-based and community lactation consultants with well established techniques of positioning. Only a small fraction of dyads seen by consultants were referred for what they felt was ankyloglossia. Thus, the majority of infants in our study presented with persistent breast feeding difficulties that resisted all other means to alleviate maternal pain and inefficient latch. Many infants were also “problematic bottle

Conclusions

This study highlights the significance of maternal-infant breastfeeding difficulties associated with ankyloglossia, particularly posterior ankyloglossia, and demonstrates that a relatively simple, office-based procedure can safely lead to improved breastfeeding characteristics. Due to the increasing rates of breastfeeding one could make the argument that the diagnosis of ankyloglossia in infants should be a basic competency for all primary care providers. Treatment of anterior ankyloglossia is

Conflict of interest

The authors report no financial and personal relationships with other people or organizations that could inappropriately influenced (bias) their work.

Role of the funding source

This study's sponsor, Middlesex Hospital, had no involvement in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Acknowledgements

We thank Betty Coryllos, MD, FACS, FAAP, IBCLC for clinical training on performing frenotomies, and Jennifer Tow, IBCLC, for lactation consulting and support in the early years of our intervention. We are grateful to the mothers and infants who participated in this study.

References (20)

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