Healthy Baby Practical advice for treating newborns and toddlers.

Ankyloglossia: When Frenectomy Is the Right Choice Stan L. Block, MD, FAAP

“Out of some little thing, too free a tongue can create an outrageous wrangle.” Euripides in Andoromache (c. 426 B.C.)

nkyloglossia, or tongue-tie, oc- curs on average in about 4% to A5% of babies in most newborn series. Some cases are mild, others severe (Figure 1). It is not life-threatening; it is not associated with any severe sequelae; and it does not cause any cosmetic deformity outwardly in the child. Yet, it is a newborn problem that ev- ery pediatrician needs to be attuned to and know how to manage appropriately.

IMPORTANCE OF BREAST-FEEDING One of our main goals in the post- Figure 1. Ankyloglossia in 1-month-old infant. Note the thickened frenulum. partum period is to encourage breast- Source: Block S. Reprinted with permission. feeding by the mother. Breast-feeding provides major benefi ts to the infant, such as reducing rates of severe infec- But breast-feeding during those fi rst necessary for the mother to continue tions, asthma, obesity, and overall health 10 days postpartum, for a new mother down this challenging, uncertain road. status during the fi rst years of life. If that already fatigued from labor and deliv- The bottle of formula sure looks easy will not convince the mother, I suggest ery, can be one of the most anxious and and painless for her. Once the mother we explain that several studies indicate insecure times of her life. During those successfully endures the 8- to 10-day that breast-feeding probably reduces her initial feedings in the fi rst 2 days, most postpartum breast-feeding milestone, risk for premenopausal breast cancer by newborns quickly fall asleep much of newborn feeding anxiety dissipates tre- 10% to 60%.1-4 the time while nursing. So of course mendously for her. Recently, I even ob- the mother thinks, “He is not getting served this phenomenon in my own two Stan L. Block, MD, FAAP, is a general pediatri- enough.” To that, add the pain mothers intelligent, confi dent daughters, each cian in private practice in Bardstown, KY. often experience when the baby latches of whom breastfed their newborns, Address correspondence to Stan L. Block, MD, on every 2 to 3 hours over the next 48 to despite experiencing much pain and FAAP, via email: [email protected]. 72 hours. And forget about sleep. fatigue. Their newborn feeding angst Dr. Block has disclosed no relevant fi nancial Consequently, internal fortitude, was palpable. But not every mother has relationships. maternal love and instinct, and family access 24/7 to a pediatrician (Dad) or a doi: 10.3928/00904481-20111209-04 and professional reassurance are often nurse (Mom).

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Figure 2. Papoose (a), and instruments and topical anesthesia gel (b). Figure 3. Ankyloglossia in a 3-week-old infant. Source: Block S. Reprinted with permission. Source: Block S. Reprinted with permission.

AFFECT OF TONGUE-TIED much improvement in pain compared One usually needs to use a tongue INFANTS with the sham-surgery group. At the blade twisted sideways to keep the However, when we’re talking about same 2-week evaluation visit, all but mouth open — usually held open by nursing by the tongue-tied infant, the pain one of the sham-surgery mothers (27 your assistant (Figure 3), yet some ba- experienced for even the most dedicated of 28) requested frenectomy for their bies will cry and open the mouth con- mother has been shown to be so over- babies as part of the protocol’s rescue tinuously while in the restraint. Your as- whelming during the fi rst 1 to 2 weeks that remedies for breast pain. sistant will need to stabilize the head as breast-feeding is discontinued in nearly well. Use the tongue elevator to slip the three times as many babies when com- PERFORMING A FRENECTOMY tongue upward gently and fully, expos- pared with those without the condition.5 I recommend performing the proce- ing the membranous frenulum. Most of the literature in the 1980s dure in any newborn whose frenulum With the cotton swab, apply a small and 1990s concerning management of attaches within one-half centimeter or dollop of Hurricane gel to a 1-cm area ankyloglossia has been anecdotal and more of the tip of the tongue, whether or of the mid anterior frenulum. (Make cer- published in lactation or ear, nose, and not they are having diffi culty breastfeed- tain he has no family history of glucose throat journals. ing. I estimate that this comprises about 6 phosphate [G6PD] defi ciency, which For example, in the current literature, 2% of the population. can be a potential problem with topical using ultrasound, Geddes and colleagues The procedure is relatively simple as benzocaine anesthetics.) examined the sucking mechanism of 24 far as outpatient pediatric procedures go. After 20 to 30 seconds, use the curved mother–infant dyads before and after One will need the following (Figures 2a Kelly forceps to clamp and crush about frenectomy. The researchers observed and 2b): three-quarters of a centimeter of the that after frenectomy, milk transfer and 1. Papoose board; thin membranous frenulum horizontally latching on was improved for the in- 2. Tongue elevator; midway between the fl oor of the mouth fants; and in the mothers, the pain of 3. Curved Kelly clamp; and the inferior aspect of the tongue. nursing was diminished.6 4. Band-Aid scissors; (Some may proceed directly to the next More recently, Buryk and col- 5. Hurricane gel for topical anes- step instead. But clamping reduces the leagues undertook a single blind, thesia (and sterile cotton swab). minimal post-operative bleeding, which sham-surgery controlled trial in 58 in- First, obtain an informed consent sig- can be scary for the parents.) Hold the fants who were referred for their nurs- nature explaining the risks (slight bleed- clamp in place for 1.5 to 2 minutes. ing diffi culties.7 The mean age of the ing) and benefi ts (see Discussion), then Meanwhile, offer the baby a sugar nip- infants was 6 days. The frenectomy strap the infant into the Papoose, similar ple or pacifi er. With the small scissors, group of mothers experienced twice as to a circumcision. clip the crushed frenulum segment to

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Figure 4. Before (a) and after (b) frenectomy. Note the slight bleeding. Figure 5. An 8-year-old male with ankyloglossia Source: Block S. Reprinted with permission. who is unhappy with the cosmetic appearance. Source: Block S. Reprinted with permission.

about three-quarters of a centimeter. You will request or need frenectomy (Figure cer epidemiology. Acta Oncol. 1992;31(2): 187-194. are fi nished (Figures 4a and 4b). 5), either when they receive orthodontic 2. Reimer DE. Effect of breast-feeding on risk of Offer the baby back to the mother for a appliances, become self-conscious about breast cancer. CMAJ. 1996;155(7):861. feeding. She will usually immediately no- their inability to stick out their tongue, or 3. Smigel KL. Breast-feeding linked to de- tice the improved feeding mechanics of the when their school peers torment them. creased cancer risk for mother, child. J Natl Cancer Inst. 1988;80(17):1362-1363. baby. And warn her that the small clipped It would be much less expensive, totally 4. Freudenheim JL, Marshall JR, Vena JE, et al. area may ooze some blood for about an non-memorable, and much less painful to Lactation history and breast cancer risk. Am J hour, similar to the bleeding immediately perform the procedure in the newborn than Epidemiol. 1997;146(11):932-938. 5. Ricke LA, Baker NJ, Madlon-Kay DJ, De- noted after the loss of a baby tooth. it would be in an adolescent. As Euripides For TA. Newborn tongue-tie: prevalence and postulated: for teenagers, to “free a tongue effect on breast-feeding. J Am Board Fam DISCUSSION can create an outrageous wrangle.” Pract. 2005;18(1):1-7. 6. Geddes DT, Langton DB, Gollow I, Jacobs The reader may have noticed that I LA, Hartmann PE, Simmer K. Frenulotomy did not exclude the bottle-fed baby in my CPT code – 40819 for breastfeeding infants with ankyloglossia: criteria for surgical indication. I am look- Reimbursement range (including Medic- effect on milk removal and sucking mecha- ing at this problem over the long run. Al- aid) = $200 to $277 nism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-e194. though ankyloglossia is not associated 7. Buryk M, Bloom D, Shope T. Effi cacy of neo- with speech impediments or diffi culties, REFERENCES natal release of ankyloglossia: a randomized most children and adolescents inevitably 1. Kvåle G. Reproductive factors in breast can- trial. Pediatrics. 2011;128(2):280-288.

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