INTRODUCTION:
Both historically, and more recently, it has been reported that there has been a rapid increase in the prevalence, diagnosis and treatment of a restrictive tongue-tie.
A restrictive tongue-tie, or ankyloglossia has been identified by NICE (2005) as “A congenital anomaly characterised by an abnormally short lingual frenulum; the tip of the tongue cannot be protruded beyond the lower incisor teeth. It varies in degree, from a mild form from which the tongue is bound by only a thin mucous membrane, to a severe form in which the tongue is completely fused to the floor of the mouth. Breastfeeding difficulties may arise as a result of the inability to suck effectively, causing sore nipples and poor infant weight gain.” More recently, Mills et al (2019) suggest that a frenulum may be classified as fascia within the midline fold beneath the mucosa, fusing connective tissue to the ventral surface of the tongue.
The NICE (2005) definition further limits potential problems to those who exclusively breastfeed. However, a restrictive frenulum does not have a feeding-method preference! It can affect all methods of feeding, inclusive of bottle feeding, the introduction of solid foods, dentition, oral hygiene and potentially speech complications such as pronunciation of certain sounds too. The National Health Service (NHS) provide an informative parent guidance leaflet for the care and management of a tongue-tie restriction which acknowledges bottle feeding complications (NHS 2023). What does not seem to be considered are the cases where breastfeeding is inefficient and so artificial feeding is commenced as a last resort where the root cause has not been identified, and so is an alternative method of feeding only. Maternal feeding choices are therefore limiting and removes their right to feed their infant however they so wish. This may lead to an increase in feelings of guilt, pressure and an impact on maternal mental health. The key is tongue efficiency rather than appearance alone, alongside skilled infant feeding professional support. This would further ensure parental support protecting infant feeding, maternal mental health and prevent any potential risk of over/mis-diagnosis.
CLASSIFICATION/DIAGNOSIS:
There are a number of classification and grading assessments used globally to identify a restricted tongue ‘type’. Generally, this is done visually in accordance to the physical sight of attachment of the lingual frenulum on the underside of the tongue, and the floor of the mouth, its thickness and elasticity. Hazelbaker (2017) acknowledges that there are 7 areas of tongue function to be considered, and that although appearance is taken into account, a visible frenulum without functional restriction is deemed as normal anatomy. Harhan et al (2014) supports this notion stating that an anatomical finding, which is not correlated with breastfeeding difficulties, is not a restrictive frenulum.
Todd & Hogan (2015) identify 4 ‘types’ of ankyloglossia based on appearance, categorised by numbers. Their reclassification of the Coryllos (2004) tool uses a percentage metaphor based on how far forward the lingual frenulum presented, measuring from base of the genioglossus, to the tip of the tongue (<25%=posterior; 25-50%; 50-75%; 75-100%=anterior). Baeza et al (2017) indicate that correct assessment of a tongue-tie is essential in order to help the infant thrive, protection from breastfeeding cessation, and other feeding issues too.
Many healthcare professionals do use an assessment tool to assist them in their suspicion to help confirm a diagnosis or, just as importantly, rule one out. Assessment tools are used in conjunction with the practitioner’s judgement, based on maternal and infant symptoms, feeding behaviours, supply, medical conditions, and medications as part of an overall holistic assessment of the feeding dyad. Tools are not diagnostic as a stand-alone feature; it is there to support holistic assessment of the feeding dyad.
Hazelbaker A (2017) Assessment tool for lingual frenulum function | Kotlow L Scale (2004) | Bristol Tongue Assessment Tool (BTAT) | Tongue Tie and Breastded Babies (TABBY) | Todd & Hogan (2015) |
Visually categorised over 5 different aspects, and given a maximum total score of 10. Additional 7 areas for function assessment with a maximum score of 14. | Classified as a ‘type’. There are 5 main ‘types’ based on where the attachment of the tip of the frenulum is placed in the mouth. | 4 visual aspects that categorise appearance to give a score. Originally based on ATLFF scoring tool. | 12 different images for the assessor to choose and categorise. | Based on Coryllos 2004 scale. Uses a 4 point scale based on the attachment site of the frenulum to the tongue. |
(Figure 1.0 to demonstrate some of the assessment tools available)
There are many signs and symptoms of a tongue-tie in an infant, but they do not necessarily all have to be present and the key is to identify that the root cause of the restriction. This is why an infant feeding specialist, with experience and relevant qualifications is best placed to ensure the symptoms are function related, and not accounted to another cause(s), i.e. oral thrush or positional in origin, as these problems will persist even once any potential restriction is removed.
Maternal nipple pain/nipple trauma; usually caused by the inability to maintain and sustain a wide gape and latch and is common in the infants who struggle with extension and elevation of the tongue.
Clicking; a noise made when the tongue slides back and loses suction (snapback), these infants tend to swallow lots of air, gulping, vomits/posseting after feeds, colic and abdominal discomfort.
Weight: is affected as the tongue is inefficient, it has an un-coordinated rhythm and suck: swallow ratio which results in tiring/exhaustion of the infant quickly, resulting in short but frequent feeds. Weight may falter, but may also increase due to the frequency of feeding times, potential induced oversupply and/or fast flow.
Flow control: of the milk, can be gulping, coughing, breaking the seal, which can also consequently lead to symptoms of reflux.
Dribbling-the inability to create a vacuum seal using a combination of both the palatoglossal muscle and lip tone/closure (Baviaktte et al 2012).
High Palate: Furthermore, Hazelbaker (2010) also recognises that the palate begins its development during embryonic phase and completes by week 12 where the tongue separates itself to form the palate structure. In the case of a tongue restriction the palate can form a higher arch (usually remaining intact) in response to the lack of support to form a symmetrical arch from the tongue body. This results in common symptoms such as reflux, gulping, hiccoughs secondary to aerophagia, and can also affect oral hygiene.
PREVALENCE:
Fernando (1998) acknowledges that being tongue-tied is not a new disorder or diagnosis and Hazelbaker (2010) in her book details evidence of historical records dating back to 1700s in relation to breastfeeding and how the infant’s ability improved once released. In 1918, Koplik suggested a heart-shaped tongue as a ‘type’ requiring excising due to inefficiency to breastfeeding. From 1697 until the 1900’s, midwives would grow their little fingernail, which was sharpened so they could sweep under the tongue with the aim to excise the frenulum immediately and then place baby to the breast. After the 1850’s, surgeons and midwives preferred a conservative approach to ankyloglossia due to advances in hygiene, and cultural choice so frenulotomy incidence reduced (Baxter 2018). Bottle feeding using cow’s-milk based formula latterly became popular (through aggressive marketing strategies)-and although we know that tongue function is prevalent in the bottle-fed infant too; the mechanics of tongue motility differs in bottle feeding. It also took away maternal problems a tongue restriction may cause (i.e. pain, reduction in breast milk supply, increased frequency) masking the signs that only a mother could advocate for her infant. Consequently, formula companies took the opportunity to influence decisions through marketing, resulting in generations of malnourishment with grossly misinformed parents/caregivers believing a formula feed was an advanced innovation that superseded breast milk. Unfortunately, even today, many mothers report being told “If you can’t breastfeed there’s always a bottle” both from well-meaning family members and healthcare professionals alike. In 1985, the first lactation consultants trained through International Board of Lactation Consultant Examiners (IBLCE) and started researching the impact and consequences of not breastfeeding. In 2005 NICE published guidance deeming it a safe procedure with minimal risks. More recently the procedure became regulated, and it is now a requirement that tongue-tie practitioners in England are registered and regulated by Care Quality Commission (CQC, 2019) following clarification in UK law.
DIAGNOSIS:
There are a few ways that parents/caregivers of a tongue-tie restricted infant may receive a diagnosis. Although unfortunately, many are based on assumption or visual appearance, lack of knowledge, poor experiences and opinions. This is evident in the way parents/caregivers present to professionals who are often told a yes or no definitive answer to the question “Is my infant tongue tied?.” Parents/caregivers look to the healthcare professionals expecting them to provide evidence-based responses, yet this is not happening because the healthcare professionals are not receiving the training or education as it is not part of national standard healthcare training, and individual access to specialist training requires funding. This provides a further challenge to new parents/caregivers accessing a diagnosis, unaware of who may support them. This may include:
Hospital infant feeding team,
Hospital midwife at point of delivery,
Community midwife, maternity assistants,
Peer support workers-mother-supporters,
Breastfeeding/chest feeding charities,
Healthcare professional performing newborn examination (NIPE),
Health Visitor,
Word of mouth/family/friends/social media/search engines,
GP review at 6-8 weeks post delivery,
Hospital and community-based infant feeding teams,
Paediatrician/medics.
A more appropriate response may include “I am not trained to assess for a tongue restriction, but I could refer you to our local infant feeding specialist/here is the ATP information website details so this can be further explored”. The Association of Tongue Tie Practitioners (ATP) lists both NHS and private practitioners covering the United Kingdom (UK) in accordance with geographical location. A healthcare professional is best placed to signpost to the professional website as it allows parents the option to see who is local to them allowing for informed choice and autonomy (www.tongue-tie.org.uk/find-a-practitioner).
PROVISION:
Across the UK, parents/caregivers have a limiting choice with NHS services who, have different criteria and waiting lists, set by local Clinical Commissioning Groups (CCGs) or Integrated Care Systems (ICSs). These include the method of feeding, age or weight criteria. Some areas do accept referrals from breastfeeding supporters and health care professionals or to a local infant feeding team who may assess and then refer to an NHS service should a frenulotomy be suspected to be beneficial for their assessment. Parents/caregivers may also self-refer into private services, and the ATP house a directory of regulated providers, but this option is often not always verbalised to them. To list a service with ATP, tongue-tie practitioners must prove their competence and regulation as required in law.
SURGICAL TREATMENT:
Scissor Divide
Griffiths (2004) describes a scissor division as lifting the tongue with the forefinger and holds the infants chin with a thumb. Using sterile blunt-ended scissors, (without anaesthetic) cuts through the membrane to release the restriction. Considerations of this method include:
Quick,
Minimal risk,
No medications or anaesthetic involved,
Instant feeding/sucking post division to release endorphins and oxytocin (natures natural analgesics),
No sutures,
Low cost in comparison to alternative options,
Readily accessible,
UK based practitioners are also healthcare professionals who are trained in infant feeding which allows for a plethora of infant feeding and suck issues to be addressed simultaneously (or in advance of division).
Laser
Kotlow (2004) uses a laser, also without anaesthetic-lifting the tongue to excise with one exposure to laser. Considerations of this method include:
Minimal bleeding,
Minimal infection,
Takes longer to preform/prepare in comparison to scissor,
Removal of tissue rather than incision into it,
Performed by surgeons, few of whom are also trained in infant feeding, and so rely on those specialising in that field,
Cost implications.
Diathermy and electrocautery
Kummner (2005) describes this method utilising a device that passes an electronic current through an electrode which is a metal “needle” heated by the electrical current, that generates heat to cauterise the frenulum and any surrounding blood vessels.
Local anaesthetic is administered,
Advocates for Disruptive Wound Management (DWM),
Uncommon practice in the UK.
ASSOCIATED RISKS:
NICE (2005) acknowledges that division of a restrictive lingual frenulum is a relatively safe procedure with rare incidence of known risks and lists these complications as: bleeding, infection, ulcers, pain, damage to tongue and surrounding tissue and reformation.
Bleeding
Bleeding is a complication of any wound inducing procedure. A frenulotomy procedure is not likened to a blood loss but can be small vessel or capillary related. In the majority of cases only around half a teaspoon of blood loss is expected, it is not an arterial loss, and this usually subsides immediately after the procedure through feeding, which not only provides pressure to the area to stem the bleeding, but also comfort to the infant through stimulating the sucking reflex inducing an oxytocin release.
The estimated risk of continued bleeding is currently suggested to be 1:400, following pressure and feeding management, the risk further reduces to 1:7,000 for those requiring medicated buccal treatment (ATP 2017). A further audit by ATP (2018) suggested the at the required need for medical intervention (sutures or cautery) is 1:76,764, suggesting that prolonged pressure controlling the bleeding stemmed the oozing en-route to hospital. There is a risk of bleeding being caused by inadvertent injury to small vessels or other oral structures too, which are an anatomical anomaly and unpredictable. These cases are believed to be few but there are no studies to suggest its incidence (and it is possible incidence is under-reported). However, the management and control of any bleed is the same regardless of the type/cause.
Infection
It is believed that infection risk to the division site is estimated at 1:12,015 (ATP Complications Audit 2022). All surgical wounds are subject to risk of infection introduction or cross contamination, but by ensuring the practitioner uses an aseptic technique, sterile scissors and gauze, handwashing (and antibodies found naturally occurring in breast milk) all contribute to lowering its risk further.
Ulcers
Following a scissor divide, the wound heals through primary intention, and visually looks like a mouth ulcer. This is part of what is considered the ‘normal’ wound healing process and gradually gets smaller before finally dissolving and dispersing into the mucosa where nothing further can be visualised, and on average takes 7-10 days.
Pain
It is not fully known if the procedure itself is painful. However, as the infant is temporarily restrained and in a potentially unfamiliar environment, the infant may become unsettled after the procedure which may discombobulate the infant, who is then released, comforted and offered a feed. We also know that 8% infants do sleep through the whole procedure (NICE 2005). In young infants there is usually no need for local anaesthetic and may be seen as counter productive because numbing an area results in not being able to feel a feeding -vacuum which may prolong the bleeding timeframe. Numbing gels are believed to be ineffective as swallowed by infants rather than allowing absorption time, rendering ineffective use-but it is also unknown how a gel may react against within an open wound.
Damage to tongue and surrounding tissue
A rare complication is the inadvertent injury from the scissors, controlled by the practitioner, to the ventral tongue surface or surrounding oral structures, which is inclusive of the salivary glands or other fragile oral structures. The scissors do not have the strength to cut through the genioglossus muscle itself, but may damage the lip, tongue, submandibular glands or other oral structures. Treatment would be managing blood loss, but it is not expected to impact long-term function, and this risk is further minimalised by momentary restraint of the infant.
Reformation
Reformation may include a few possibilities. It does not technically “regrow”, but it may present restriction through residual frenula protrusion as the tongue body comes forward. Or through wound scarring which would be restrictive through fibrous and taut formed tissue. Hazelbaker (2014) discusses how the frenulum is very much likened to ligament tissue, rather than membrane, so it would remain relative within the mouth as the infant grows. In these cases, a second scissor divide may be considered but more than that may be viewed as counter-productive (scar overlapping further scar) so in these cases referral to a specialist surgeon or dentist may be suggested. Reformation is thought to affect 1-4% of scissor divides (NHS 2014).
All infants vary on their behaviour/response following the division, and is influenced by many factors including:
availability of maternal milk supply,
timing of the previous feed,
age/alertness of the baby, medical conditions,
environmental factors,
tiredness,
hunger level.
EFFICACY:
There are a number of studies that have been completed, both supporting and dismissing a surgical frenula release. Unfortunately, very few of these are reliable or valid. The general notion is that a surgical release does help with infant feeding complications in the reduction of maternal breastfeeding pain in particular, but further research is needed (Hazelbaker 2010).
SUPPORT & AFTERCARE:
The chosen clinician providing the surgical procedure (frenulotomy) remains the accountable practitioner, and so parents are to be encouraged to access support through their means. Healthcare professionals are responsible for their actions and is linked closely to accountability (Elcock 2018).
Adversely, this may not always be possible. For example, an ENT surgeon offering tongue-tie division may not also be trained in breastfeeding support, particularly when considering them as a dyad rather than the infant being the sole patient (as one). A healthcare professional in this position may instead consider referring to a provider that could, or ensure that the parent/caregiver had access to the skilled support needed. Similarly a parent/caregiver may wish to seek a second opinion, or, should the appointment be for a second divide-the infant may be too old to suit the original provider’s age criteria. Local support largely varies across the UK, fluctuating on access to breastfeeding support where a mother may choose to seek support with attachment and positioning. Although valuable, qualification level and experience can be limited, with many being volunteers with a desire to help rather than professional support, where post tongue-tie division is not within their remit. The matter is usually complex, with training in breastfeeding usually being a basic, minimum standard and not inclusive to bottle fed infants despite there being a robust infant feeding qualification which is accredited and board certified (IBCLC) which is also globally recognised available (Oakley 2021).
WOUND CARE:
Wound stretches and disruptive wound management are commonplace internationally, and very few areas of the UK. Some versions involve stretching through the use of finger pressure against the frenulotomy wound to tear the wound edges with the aim to re-open it to its original ‘diamond’ shape. Some recommend a sweeping motion under the tongue to keep the wound open. The ATP (2022) have categorised levels of wound care instructions, level 1-4 which progress in intervention. Unfortunately robust evidence suggesting efficacy (or not) of this practice is sparse. However, when studying the wound healing process, a division would create an acute wound which predominantly uses secondary intention healing (unless sutures are used).
Brown (2015) describes the 4 phases of normal wound healing
Phase (1) Inflammation: the blood clot/scab formation,
Phase (2) Destruction: the white cells clean the wound and slough production,
Phase (3) Proliferation: new tissue generation-encouraging wound healing from the base of the wound to the surface,
Phase (4) Maturation: wound edges coming together to form wound closure.
Due to this an introduction of stretches or disruptive wound management will cause delay to phases 2 and 3 which will result in the formation of over-granulation. It is defined as an excess of granulation tissue that fills the wound bed to a greater extent than what is required due to the delay in wound healing phases (Jaeger et al 2016).
Ghaheri (2015) insists that the prevention of wound reattachment can only be achieved by actively stretching the wound. Despite this,
UNICEF UK (2019) make a clear statement that “there is no need for any form of wound management-the baby just needs to be fed”.
Ghaheri is not alone in his assumptions. O’Callaghan et al (2013) suggests that fewer revisions are needed when the tongue is elevated to stretch the wound. Currently there is no evidence to advocate the need for wound massage or stretching (ATP 2022).
Kendall-Tackett et al (2017) interviewed tongue-tie specialist professionals who disagree that wound stretches/disruptive wound management should be encouraged and that there are additional risks to doing them such as causing an oral aversion, or pain, due to the repeated uncomfortable/painful digital intrusion. Other risks include bleeding and the introduction of infection. There is of course a very notable difference between wound stretches and tongue function sucking exercises, and commonly the two are confused to mean the same practice.
Tongue suckling exercises do not touch the wound site at all and aim to assist with feeding through tongue strengthening techniques, such as those described by Watson-Genna (2013). Whereas wound stretches and disruptive wound management do touch an open healing wound. Data suggests that wound stretches and disruptive wound management intervention make very little difference (NHS 2014).
MIS-DIAGNOSIS AND OVER-DIAGNOSIS:
A faux tie is when the infant-mother dyad are presenting with stereotypical symptoms of a restrictive tongue-tie, and yet on assessment the tongue function is usually a borderline impairment and visually resembles that of a submucosal frenulum. A submucosal restriction (or type 4) is not usually visually obvious and may present to palpation to the wound bed or to touch. Hazelbaker (2014) believes this is not frenulum, but it is the septum of the genioglossus muscle and that there are knowledge gaps around tongue anatomy and structure. The feeding symptoms can therefore be attributed to other causes (structural restrictions that pull the tongue back into the throat, such as birth trauma –caesarean section or instrumental delivery causing muscular tension by cranial structures through exerted forces as an example). It highlights the importance of using a robust tool by a qualified and experienced practitioner and using a conservative approach to surgical division. As there is not a universally agreed definition of ‘posterior’ or ‘sub-mucosal’ frenulum it is the authors opinion that this is where much confusion is attributed to, but reinforces how skilled infant feeding support as a specialism is paramount to the overall success and outcomes of a frenulotomy procedure.
CONCLUSION:
In conclusion, there is still much learning to be conducted around the frenulum as an anatomical structure, why the restrictive anomaly occurs in some infants, and not all (or none) and a universal system for screening assessment, treatment and expert infant feeding support. Similarly the NICE guidance of 2005 is clearly now quite dated in its guidance, and would benefit from being updated as new research is continually being formulated. Currently, there are healthcare professionals diagnosing and misdiagnosing ankyloglossia where further training required, rather than a holistic infant feeding assessment using evidence based robust assessment tools and skills by a highly skilled, trained and experienced practitioner. They instead are using confusing and ambiguous terminology looking at appearance of the frenulum only and not addressing tongue function collectively. Studies currently suggest that prevalence is on the increase both internationally and in the United Kingdom (UK), but there is nothing to suggest that this is an increase in occurrence, merely an increase in diagnosis. In turn, this may be due to an increase in awareness, and not an increased prevalence. This is why this article aimed to highlight the importance of skilled infant feeding diagnosis and care, to prevent incorrect diagnosis and timely efficient support for the parent-infant dyad.
REFERENCE LIST
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Association of Tongue tie Practitioners (ATP) (2017) “Guideline for the management of bleeding post frenulotomy” Revised edition Association of Tongue Tie Practitioners UK www.tongue-tie.org.uk/bleeding-guidelines.
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