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Tongue During PERSPECTIVES 1211 Arch Dis Child: first published as 10.1136/adc.2005.077057 on 21 November 2005. Downloaded from Congenital anomalies The movements of the tongue during ....................................................................................... infant feeding have been studied by cine-radiography and more recently by ultrasound.12 13 Ultrasound reveals some Tongue tie similarities between the movements made by the baby when either breast D M B Hall, M J Renfrew or bottle feeding,14 but also some impor- tant differences.15 The tongue is pro- ................................................................................... jected further forward in breast 16 Common problem or old wives’ tale? feeding and the human nipple elon- gates during each suck in a way that an artificial teat cannot do.14 During feed- he resurgence of interest in breast tongue tie is an important issue—she ing, the artificial teat, or the nipple feeding has been accompanied by a experienced pain for many weeks while together with some breast tissue, is held Tlively debate about the significance breast feeding her first child, who fully in the mouth with the tongue of ‘‘tongue tie’’ or ankyloglossia. exhibited features said to be typical of covering the lower gum ridge. The Symptoms attributed to tongue tie tongue tie, and has since discussed this nipple is protected from damage and include nipple pain and trauma, diffi- issue widely with lactation specialists pain at the back of the baby’s mouth.16 culty in the baby attaching to the breast, and women having similar problems. The baby’s lower jaw is then elevated, frequent feeding, and uncoordinated The other (DH) accepted that ankylo- compressing the artificial teat, or the sucking. These problems may result in glossia occurs in dysmorphic infants10 breast immediately behind the nipple, the mother deciding to terminate breast and occasionally in otherwise normal while the front of the tongue moves up 11 feeding prematurely, slow weight gain babies, but was sceptical about the to aid the expression of milk. In breast for the baby, and even hypernatraemic high prevalence of the condition now feeding, this is by compression of the dehydration. Speech defects have also being described by several authors. milk ducts under the areola. A wave of been attributed to tongue tie. Strong upward movement of the medial part of views have been expressed by many ANATOMY AND PHYSIOLOGY the tongue progresses backwards, and eminent authors on the subject (box 1). The tongue is a highly mobile organ the expression of the milk is further This paper reviews what is known made up of longitudinal, horizontal, facilitated by negative pressure gener- about tongue movements and the sig- vertical, and transverse intrinsic muscle ated by downward movement of the nificance and treatment of tongue tie. It bundles. The extrinsic muscles are the back of the tongue and the lower jaw is based on two literature reviews, one fan-like genioglossus which is inserted and, in breast feeding, by the active conducted on behalf of NICE12by one of into the medial part of the tongue and expulsion of milk once the let down us (MR) and updated by further the styloglossus and hyoglossus into the occurs. searches of published and grey literature lateral portions. The sub-lingual frenu- In coordinated feeding, the sucking, and conference abstracts. The publica- lum is a fold of mucosa connecting the swallowing and breathing movements tions reviewed for this paper are sum- midline of the inferior surface of the follow in a 1:1:1 sequence. This can marised in table 1. tongue to the floor of the mouth. take several days to become established As our review found little high quality Tongue tie is the name given to the in healthy full term infants. In pre- objective evidence, we begin by making condition arising when the frenulum is term infants and in some term infants http://adc.bmj.com/ explicit the personal experience and bias unusually thick, tight, or short. There a variety of poorly coordinated feed- with which we commenced the review. are many variations and differing ing movement patterns are observed One of the authors (MR) felt that degrees of severity (fig 1). and sometimes persist.17 Antenatal Box 1: Quotes from the past on September 24, 2021 by guest. Protected copyright. ‘‘In observing a very large series of newborn babies, we have never seen a tongue that had to be clipped’’ (McEnery and Gaines, Chicago,1940) ‘‘While tongue tie is not nearly as common as members of the public believe, nevertheless a genuine case is occasionally seen and the condition is not entirely mythical although surrounded by an aura of superstition and old wives’ tales’’ (Cullum, UK, 1959) ‘‘Tongue tie…has been described as a myth of hoary antiquity…but it is probably wrong to suggest that it never causes symptoms. A case is reported in which a tight fraenum ruptured spontaneously during feeding…this baby remained a slow feeder and…(had not been) disabled by his tongue tie’’ (Smithells, London, 1959) ‘‘Tongue tie is a rare but definite congenital deformity’’ (Browne, London,1959) ‘‘Tongue tie is a rare cause of dysarthria, though it is often blamed for slow speech development…most patients who have real limitation of movement as a result of tongue tie have a history of difficult milk feeding’’ (Ingram, Edinburgh, 1968) ‘‘I have never seen feeding difficulties in the first year resulting from tongue tie and I doubt whether it is ever necessary to carry out an operation on it till the age of two or three…There are still doctors who cut the frenulum in the newborn period. This is always wrong’’ (Illingworth, Sheffield, 1982) ‘‘Tongue tie where the tongue is forked can, very rarely, add to the baby’s difficulties in taking the breast with poor protractility’’ (Gunther, UK, 1970) ‘‘To some extent tongue tie is normal in every newborn baby and it should rarely interfere with either sucking or later speech development’’ (Davies et al, UK, 1972) ‘‘True tongue tie is a very rare condition. This condition has been over-diagnosed in the past because of the failure to recognise that the frenum passing from the tongue to the floor of the mouth is normally short in the newborn…Only in infants with severe limitation of the tongue movement and inability to suck is division of the frenum indicated’’ (Turner, Douglas, and Cockburn, UK, 1988) www.archdischild.com 1212 PERSPECTIVES Arch Dis Child: first published as 10.1136/adc.2005.077057 on 21 November 2005. Downloaded from Table 1 Tongue tie; review of literature How cases were Type of study and Author(s) Number and age group studied identified intervention Results Messner et al3 Examined 1041 newborns. Identified 50 Screened by one Observational follow up study 30/36 TT cases and 33/36 controls TT cases (4.8%). M: F ratio 2.6:1 doctor, confirmed by but no intervention breast fed to 2 months (p = 0.29). 36 cases of TT enrolled and 36 controls one colleague 9 cases and 1 control experienced without TT breast feeding difficulties Hogan et al4 Examined 1866 babies. Identified 201 TT Photos to assist staff in Randomised to immediate TT cases treated by frenulotomy; 27/28 cases (10.7% ). M:F ratio 1.6:1. 44% TT postnatal checks frenulotomy or support by marked improvement. Counselled cases cases had problems feeding. 57 TT babies lactation counsellor, at mean managed conservatively; 1/29 entered study (40 breast fed and 17 bottle age 20 days (3–70), median improved fed) age 14 days Ballard et al5 Examined 2763 breast fed in-patient One observer examining 123 cases underwent Latch improved in all, pain scores fell babies and 273 attenders at lactation all babies. ATLFF used frenulotomy at age 1–2 days significantly clinic. M:F ratio 1.5:1. Identified TT in 3.2% in-patients and 12.8% clinic attenders Ricke et al6 Examined 3490 babies, identified 148 TT Nurses assisted by Observational study, no Mothers of TT babies three times more cases (4.24%). M:F ratio 2.3:1. photos, ATLFF by team intervention likely to give up breast feeding by one Enrolled 49 TT babies for study with 2 week; however, 80% TT breast feeding matched non-TT breast fed babies as well at one week. TT and non-TT breast controls feeding in equal numbers at 1 month. Mothers with TT babies reporting more pain at one month but not statistically significant. Small numbers so type II errors possible Ramsay7 Case series Referrals to paediatric Measured nipple tip to hard Distance changed from 7.99 mm to surgeon soft palate junction by 6.49 mm. Milk transfer increased from ultrasound, pre- and post- 3.3 to 7.2 ml/min. At least 7 day frenulotomy interval between frenulotomy and 2nd measurement Messner and Case series of speech problems: 30 Measured tongue Frenulotomy Speech improved. 25 mothers had tried Lalakea8 children age 1–12 protrusion and inter- to breast feed; 21 said no problems incisal distance Fernando9 Case series, n >200 Various; majority Frenulotomy Improved to varying degree. 20% had presenting with speech history of BF problems: 80% did not disorders TT, tongue tie; ATLFF, Assessment Tool for Lingual Frenulum Function. http://adc.bmj.com/ ultrasound studies show that mouth N Division of the frenulum (frenulot- selection of photos (Hogan and collea- and tongue movements are already omy) is a low risk effective treatment gues,4 Ricke and colleagues6). We have well developed in association with N The condition is genetic not found any formal data on observer intra-uterine yawning and crying.18 19 agreement or variation in this process. The method of selection in the study by CASE DEFINITION Masaiti and Kaempf20 is unclear but cases Can tongue tie be defined—and to what were probably selected on the basis of on September 24, 2021 by guest.
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