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Tongue and Tie – what do we know? ______KANSAS COALITION – 2018 BREASTFEEDING CONFERENCE KATHY LEEPER, MD, FAAP, IBCLC, FABM ______

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Slide 2 ______Disclosures: None

•I have no relevant financial relationships with the manufacturer(s) of ______any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity

•I do not intend to discuss an unapproved/investigative use of a ______commercial product/device in my presentation

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Slide 3 FAAP- 1992 ______IBCLC- 2000 FABM- 2008

Communities Supporting Breastfeeding Project 501c3 Lincoln, NE 2001-2014, 2018 ______

(IABLE) Institute for the Advancement of Breastfeeding & Education Board member Curriculum development, Trainer ______

Kansas Breastfeeding Friendly Board member 2014-17 ______Practice Designation

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______Slide 4 ______Objectives

•Identify 3 symptoms that can be associated with -tie in ______a breastfeeding infant •Identify 2 tools available for assessing the clinical significance of a lingual ______•List 3 indications for clipping a tongue-tie

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Slide 5 ______Terminology

•Frenulum = Frenum: a small fold or ridge of tissue that ______supports or checks the motion of the part to which it is attached, in particular a fold of beneath the tongue, or between the lip and the gum. •Frenula = Frena (plural) ______•Frenulotomy = Frenotomy (dividing tissue) •Frenectomy (removing tissue) ______

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Slide 6 ______

“Founded in 2009, our group is comprised of Medical Doctors, Dentists, ______Chiropractors, Osteopaths, IBCLCs (International Board Certified Lactation Consultants), - Pathologists, Myofunctional Therapists and others.” ______Mission Statement The International Affiliation of Tongue and Lip Tie Professionals (IATP) is a not- for-profit, multi-disciplinary group of healthcare professionals who advocate for research, education, and integrated clinical practice to improve the lives of all people affected by oral restrictions. ______

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______Slide 7 ______Definition: (from IATP)

Q: What is Tongue Tie? ______A: The lingual frenulum (or frenum), is a remnant of tissue in the mid-line between the under-surface of the tongue and the floor of the . …Tongue-tie can thereby adversely affect breastfeeding. Research is urgently needed to elucidate possible implications that tongue-tie and ______other oral restrictions have on , , regurgitation, , speech and breathing disorders. ______

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Slide 8 ______Incidence? ______✓From 2.5% to >10% reported ✓POOR definitions limit usefulness ✓ This is a problem for ALL studies ______

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Slide 9 ______How do we classify?

Griffiths (2005- English surgeon) ◦ Characteristic of frenulum – diaphonus, medium, or thick ______◦ Shape of the – dimpled, -shaped, or pointed ◦ Percentage of the tongue anchored by the frenulum – 100, 75, 50 and 25

Kotlow (2004-American dentist) ______◦ Class 1 12 -16 mm “mild” ◦ Class 2 8 -12 mm “moderate” ◦ Class 3 4 - 8 mm “severe” ◦ Class 4 0 - 4 mm “complete” ______

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Coryllos 2004-American surgeon ______• Type 1: from tip of tongue to • Type 2: 4 mm b/h tip to just b/h alveolar ridge • Type 3: Mid tongue to mid floor of mouth • Type 4 against the base of the tongue; shiny inelastic ______characteristic, usually unable to see unless passively elevate tongue Type 1 & 2 or “classic”= “Anterior” Type 3 & 4 = “Posterior” ______

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Slide 11 ______Coryllos Type 1 ______

Leeper ______Yvonne Lafort, MD ______Leeper ______

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Slide 12 ______Coryllos Type 2 ______

Leeper ______

Leeper ______Leeper ______

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______Slide 13 ______Coryllos Type 3 ______

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Slide 14 ______Coryllos Type 4 ______

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Slide 15 ______“Hour-glass” insertion ______

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James Murphy, MD ______

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Slide 17 ______IATP: What kinds of problems are caused by tongue-tie?

“In infants, tongue-tie can impair their sucking, especially at the ______breast. Babies can have minor to severe difficulty coordinating their sucking, swallowing, and breathing. Symptoms can run a wide gamut and may include difficulties, pain or damage (although there may also be no pain whatsoever), poor transfer, ______compromised milk supply, inadequate weight gain and failure to thrive, among others.” ______

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Slide 18 AAP Section on Breastfeeding ______Summer 2004 :CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING By Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC, Catherine Watson Genna, BS, IBCLC, Salloum, MD, MA ______Maternal presentation: · nipple damage / pain Infant symptoms and signs include: · painful • ineffective milk transfer · poor milk removal • weight loss or inadequate gain · • fussiness at · • breast refusal ______· plugged ducts • fatigue with breastfeeding · frustration, disappointment, and discouragement • difficulty establishing suction to maintain a deep grasp · untimely weaning • poor latch • clicking sound while nursing • gradual sliding off of the breast • “chewing” on the nipple • making a mess ______• messy with bottle • choking/coughing ______

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Slide 20 ______What else does the literature say? ______

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Slide 21 ______Lingual Frenulum literature highlights…

2000 - Incidence and Associated Feeding Difficulties. Messner A (Arch Otolaryngol Head Surg) ______◦ 25% TT vs 3% Controls had difficulty bf ◦ Incidence TT = 4.8% ◦ 50 babies- none clipped 2002 -Ankyloglossia: Assessment, Incidence and Effect of Frenuloplasty on the ______Breastfeeding dyad. Ballard (Pediatrics) ◦ 2763 newborns assessed - 3.2% had lingual frenulum ◦ 123 babies had frenotomies (12.8% of babies seen in a bf clinic!) ◦ Maternal pain fell from 6.9-1.2/10 ______

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______Slide 22 ______2005 - Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Hogan M, Westcott C, Griffiths M. J Paediatr Child Health. ______• 201 babies had tongue-tie, 88 had bf problems, 57 randomized. • 28 had immediate frenotomy-27 improved. • Of the 29 “controls”, one improved and bf X 8 mos. • 28 were offered frenotomy at 48 hrs; all requested, and 27 ______improved. ______

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Slide 23 2008 - Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on ______Milk Removal and Sucking Mechanism as Imaged by Ultrasound. PEDIATRICS Geddes (24 Babies) •Less nipple compression by the tongue post-frenulotomy ______•Improved breastfeeding • better attachment • increased milk transfer • less maternal pain ______•Described the importance of mid-tongue elevation •In the assessment of breastfeeding difficulties, ankyloglossia should be considered as a potential cause ______

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Slide 24 ______Sucking Theory 1986… ______

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______Slide 25 ______Elad et al 2014

“Analysis of the US movies clearly demonstrated that tongue ______motility during breast-feeding was fairly periodic. The anterior tongue, which is wedged between the nipple–areola complex and the lower , moves as a rigid body with the cycling motion of the , while the posterior section of the tongue ______undulates in a pattern similar to a propagating peristaltic wave, which is essential for swallowing.” ______

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“Breastfeeding Ultrasound Slow motion 3 sucks” on YouTube ______

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Slide 27 ______Other highlights…

2013 – Diagnosing and Understanding the Maxillary Lip-tie – Kotlow, ______DDS. JHL

2014 - Using topical benzocaine before lingual frenotomy did not ______reduce crying and should be discouraged. Acta Paediatr Concomitant Lip-Tie (AHRQ) ______

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______Slide 28 ______“Tongue-tie” vs “Frenulum”?

•All but one infant (n=199) had an observable or palpable lingual frenulum that was Coryllos type 1 (n=5), type 2 or 3 (n=147), or type 4 (n=47). 7 frenotomies and ______5 improved. •If bf difficulties are not solved by a lactation consultation and judged as being due to the infant’s lingual frenulum => ‘‘symptomatic tongue-tie’’ or ‘‘symptomatic ankyloglossia” ______•Infants with no bf difficulties or with bf difficulties that are corrected after a lactation consultation => “asymptomatic sublingual frenulum’’ •The term ‘‘short frenulum’’ should be abandoned. •Haham A1, Marom R, Mangel L, Botzer E, Dollberg S. Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: a prospective cohort series. Breastfeed Med. 2014;9:438-41. ______

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Slide 29 Tongue-tie in the newborn: early diagnosis and division prevents poor ______breastfeeding outcomes. Todd DA, Hogan MJ. Breastfeed Rev. 2015 Mar;23(1):11-6. BACKGROUND: ______In 2011, the Centenary Hospital Neonatal Department guidelines were modified and recommended delaying the division of infant tongue-tie (TT) until after 7 days of life. This paper looks at the effect of these guidelines in practice by comparing patient characteristics and breastfeeding practices before and after the change. METHODS: Prospective data from mothers and babies who had TT division to compare breastfeeding practices in 2008 and 2011. Data included: gestational age (GA), birth-weight (BWt), gender, age at TT division, degrees of TT and maternal feeding pre/post TT division. RESULTS: There were no significant differences between the 2 years in the rate of TT division, 115/2471 (4.7%) vs 144/2891 (5.0%) (TT ______divided/birth number) or GA 39.6 ± 1.2 vs 39.5 ± 1.2 (weeks); BWt 3.48 ± 0.45 vs 3.52 ± 0.50 (kg); and Male:Female 77:38 (2.0:1.0) vs 91:53 (1.7:1.0). There was, however, an increase in the age the TT was divided 6.5 ± 4.5 vs 9.7 ± 6.2 (days) p < 0.0001; and an increased number of mothers unable to continue breastfeeding and providing expressed breastmilk: 4/115 (3.5%) vs 25/144 (17.4%) p = 0.0004 (expressing/divided). A majority (> 90%) of mothers noted an immediate improvement in feeding and decreased nipple pain. No significant complications occurred. ______

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Slide 30 ______Treatments for Ankyloglossia and Ankyloglossia With Concomitant Lip-Tie May 2015 Agency for Healthcare Research and Quality(AHRQ); U.S. Department of Health and Services

“Mothers consistently reported improved breastfeeding effectiveness after ______frenotomy, but outcome measures were heterogeneous and short term.” “Conclusions. A small body of evidence suggests that frenotomy may be associated with improvements in breastfeeding as reported by mothers, and potentially in nipple pain, but with small short-term studies, inconsistently conducted, Strength Of Evidence is generally low to insufficient. Comparative ______studies reported improvements in some measures of speech, but assessment of outcomes was inconsistent. Few studies addressed tongue mobility and self-esteem issues. Research is lacking on nonsurgical interventions, as well as on outcomes other than breastfeeding.” ______

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______Slide 31 ______Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie) 2016 Scott A. Siegel, MD, DDS. Int’l Journal of Clinical Pediatrics ______

“Of the 1,000 infants, 526 (52.6%) had an improvement of symptoms of reflux within the first week after the procedure. This was significant to the point of either reduction or cessation of H2/PPI medications. Two hundred eighty-three (28.3%) had no change in reflux symptoms, suggesting other cause for reflux, and 191 (19.1%) showed improvement in post- ______feed irritability and less symptoms of reflux but could not successfully wean off medications.” ______

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Slide 32 Breastfeeding Improvement Following Tongue-Tie and Lip-Tie (2016) ______Release: A Prospective Cohort Study. Bobak A. Ghaheri, MD; Melissa Cole, IBCLC; The Laryngoscope

Methods: Study participants consisted of breastfeeding mother–infant (0–12 weeks of age) dyads and/or tethered maxillary labial frenula who completed preoperative, 1 week, and 1 month postoperative surveys ______Breastmilk intake was measured preoperatively and 1 week postoperatively. Results: A total of 237 dyads were enrolled after self-electing laser lingual frenotomy and/or maxillary . 25% had tongue release only, 75% had tongue + lip release. 3% had “reattachment” requiring second procedure. Isolated posterior tongue-tie was identified in 78% of infants. Significant postoperative improvements were ______reported between mean preoperative scores compared to 1 week and 1 month scores of the BSES-SF (P < .001), the IGERQ-R (P < .001), and VAS pain scale (4.8 -> 2.2 -> 1.5 P < .001). Average breastmilk intake improved 155% from 3.0 to 4.9mL/min (P < .001). Conclusions: Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes. Improvements occur early (1 week postoperatively) and continue to improve through 1 month postoperatively. Improvements were demonstrated in both infants with classic anterior tongue-tie and less obvious posterior ______tongue-tie. This study identifies a previously under-recognized patient population that may benefit from surgical intervention if abnormal breastfeeding symptoms exist. ______

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Slide 33 ______O’Shea et al. Cochrane Review (2017) Frenotomy for tongue-tie in newborn infants.

AUTHORS' CONCLUSIONS: ______Frenotomy reduced breastfeeding mothers' nipple pain in the short term. Investigators did not find a consistent positive effect on infant breastfeeding. Researchers reported no serious complications, but the total number of infants studied was small. The small number of ______trials along with methodological shortcomings limits the certainty of these findings. Further randomized controlled trials of high methodological quality are necessary to determine the effects of frenotomy. ______

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54 infants from 7 days- 9 mos (Ave 8 wks) ______

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Slide 36 ______Key Messages:

• “This study was designed to determine how complete release can result in a ______reduction in persistent breastfeeding difficulties, as most practitioners’ conception of lingual frenotomy is to release the thin anterior band under the tongue. • Significant postop improvements in bf self-efficacy, maternal nipple pain and symptoms assoc with GER in children who had already undergone lingual frenotomy were realized. ______• Our findings introduce the notion that children who have not improved following a previous frenotomy may have further restriction under the tongue that still needs attention.” ______

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______Slide 37 ______Best way to do a frenotomy? IATP:

•“The simplest way of performing the procedure is by using a pair ______of sterile scissors. (Knox I. Tongue tie and frenotomy in breastfeeding newborn. NeoReviews. 2010;11.ISSUE 9) •Recently, laser devices are used. Obviously, these devices are much more expensive. While clinical reports mount regarding ______positive outcomes of laser release, research is needed to compare the efficacy of laser with scissors and other tools such as electrocautery.” ______

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Slide 38 How do you decide when ______lingual frenotomy may be appropriate?

• If baby cannot latch without pain despite optimal latch/positioning ______• If baby cannot remove milk well •Be sure baby is not very underweight before you assess their ability to suck/remove milk! •Can use a “system”, such as ______◦The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) ◦Martinelli’s Protocol looking at and function ◦Bristol TT Assessment Tool (BTAT) ______

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Slide 39 ______Assessment Tool? Hazelbaker Tool Lingual Frenulum Function 1993-2012 ______(HATLFF) 5 Appearance items : ◦Of tongue when lifted ______◦Elasticity of frenulum ◦Passive length of frenulum ◦Point of attachment of frenulum to tongue ◦Point of attachment of frenulum to maxillary ridge ______

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______Slide 40 ______Hazelbaker Tool Lingual Frenulum Function

7 Function Items: Scoring 0, 1 or 2 on each item: ◦Lateralization • Emphasis on abnormality of function items ______◦Lift of tongue • Amir et al 2006 found three function items had the best inter-rater reliability: ◦Extension of tongue • Tongue lift ◦Spread of anterior tongue • Extension ______◦Cupping • Lateralization ◦Peristalsis ◦Snap-back ______

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Slide 41 ______Bristol TT Assessment Tool – 2015

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The scores for the four items are summed and can range from 0 to 8. Scores of 0–3 indicate more severe reduction of tongue function. ______

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PROTOCOL FOR INFANTS: RELATIONSHIP BETWEEN ANATOMIC AND FUNCTIONAL Slide 42 ASPECTS (2013) ______Protocolo de avaliação do frênulo lingual para bebês: relação entre aspectos anatômicos e funcionais Roberta Lopes de Castro Martinelli(1), Irene QueirozMarchesan(2), GiédreBerretin-FelixCEFAC2013 Mai-Jun; 15(3):599-609 ______

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Slide 44 ______Nipple Shield? ______May feel better, but milk removal is likely poor. ______

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Slide 45 ______Laser vs. Scissors?? •No study comparing the two methods. ______

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Slide 47 ______

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Slide 48 ______

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______Slide 49 ______Before ______

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Slide 50 Gauze ~ 1 minute ______

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______Slide 52 ______Immediately to the breast… ______

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Slide 53 ______Submucosal ______

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Slide 54 ______Healing after scissors…

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______Slide 55 ______After laser…

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Slide 56 ______Laser… ______

Dr Ghaheri video ______

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Slide 57 Frenotomy Decision Tool-Dobrich – 2006-2016 ______(includes LIP)??? NOT validated Part 1: Evaluation of breastfeeding ◦ Evidence of pain and/or poor removal ______Part 2: Evaluation of tongue in baby ◦ Elevation, cupping, protrusion, lateral movement ◦ “pseudoleukoplakia” Part 3: Evaluation of lips if lip tie present ◦ Upper lip folds in, perioral blanching, two-tone lips, lip blisters ______

*Dr Leeper’s lip-tie evaluation: Point tenderness directly under where baby’s upper lip rests on breast? If cannot relieve with positioning, AND appears very restricted, consider frenotomy… ______

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______Slide 58 ______Labial frenulum not equal to “Lip Tie” ______

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Slide 59 Lip tie – laser frenotomy ______

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______Larry Kotlow, DDS https://www.kiddsteeth.com ______

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Slide 60 ______“Aftercare”??? ______

Dr Kotlow YouTube video ______

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______Slide 61 IATP: “Listed here are few of the knowledge gaps identified. ______Please suggest to us more knowledge gaps that need research”

• Indication for frenotomy other than breastfeeding difficulties in the form of maternal nipple pain and latching difficulties. ______• Best age to perform frenotomy • Best tool to perform frenotomy • Post surgery care protocol • Adjuvant therapy to lingual frenotomy (body work, etc) ______• Indications and Efficacy of lip tie frenotomy (Randomized controlled trial needed) • Indications for lingual frenotomy in older than newborn age • Effect of neonatal frenotomy on speech and articulation later in life (prospective follow-up ______study needed)

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Slide 62 Questions/Comments? ______

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