TONGUE-TIE © 2006 SNL All rights reserved Tongue-tie – exploding the myths

Tongue-tie occurs in 4-5% of babies. However, despite this appearing to be a relatively minor condition, there is huge debate about whether tongue-tie is clinically significant and as a result major differences exist concerning the policies for tongue-tie division. This article provides an overview of the different indications for tongue-tie division, and aims to explode some of the myths that have arisen.

Paul R V Johnson nkyloglossia or ‘tongue-tie’ is a similar tongue restriction. These MBChB, MA, MD, FRCS (Paed Surg) Acongenital anomaly caused by an differences have lead to a seemingly simple Reader in Paediatric Surgery, University of abnormally tight lingual frenulum (the condition being associated with a wide Oxford and Consultant Paediatric Surgeon, band of tissue that connects the tongue number of definitions, and as a result, John Radcliffe Hospital, Oxford base to the floor of the mouth) and occurs considerable variability in reported more commonly in males than females1. It incidence diagnosis and management. has been reported to be present to some The principle differences in definition degree in as many as 11% of newborn relate to whether an anatomical or babies, although the more widely quoted functional approach is adopted. incidence is 2-5%2-4. Until the 1950s, tongue-ties were divided routinely2. However, since then there has been much debate amongst healthcare professionals about the clinical significance of tongue- ties and as a result major differences in opinion exist as to whether division of tongue-tie is necessary or not. Indeed, even when it is agreed that tongue-tie division is indicated, controversy also exists over the timing of division, the technique used for division, and even the exact 5 Keywords definition of this condition . In an interesting survey of over 1500 FIGURE 1 Untreated tongue-tie in an older tongue-tie; ankyloglossia; breastfeeding; paediatricians, otolaryngologists, speech child. Note that the frenulum extends to the speech; frenotomy therapists, and lactation consultants in the tongue tip, although no forking of the tongue is present in this case. Key points USA, Messner confirmed major differences in approach to the management of tongue- Johnson, P.R.V. (2006) Tongue-tie – tie, with paediatricians being the least Anatomical definitions exploding the myths. Infant 2(3): 96-99. 4 likely to recommend division . The aim of Anatomical definitions consist of 1. There is considerable variation in this review is to provide an evidence-based descriptions of appearance of both tongue reported incidence, diagnosis and discussion of the indications for tongue-tie and frenulum, as well as absolute management of tongue-tie. division. In particular the relationship 2. The most useful assessment of tongue- measurements. Descriptions include the tie is based on the position of frenular between tongue-tie and breastfeeding, appearance of the tongue when lifted, the attachment to the tongue base, degree speech, oral hygiene, and social tongue elasticity of the lingual frenulum, the of maximal tongue tip protrusion and movement will be addressed. To begin with attachment of the frenulum to the tongue, impairment of activities requiring however, it is important to be clear on the and the attachment of the frenulum to the tongue function. exact definition of tongue-tie. inferior alveolar ridge. Absolute 3. There is evidence that tongue-tie measurements include the length of the division can improve breastfeeding in Defining tongue-tie lingual frenulum when the tongue is lifted, babies with tongue-tie having difficulty In simple terms, tongue-tie is present when as well as the ‘free tongue’ length. The feeding, as well as improving oral the lingual frenulum is attached close to latter forms the basis for the Kotlow hygiene and social tongue function. the tongue tip, resulting in reduced tongue Classification of Ankyloglossia (TABLE 1). 4. Division is usually carried out before movement (FIGURE 1). However, in some One of the problems with this precise three months of age in babies with cases of tongue-tie the attachment of the definition is its impracticality. Measuring feeding difficulties or electively after six frenulum is to the proximal tongue base free tongue length in a screaming newborn months for other indications. but the frenulum is shortened, resulting in can be quite a challenge!

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remember that, as with many aspects of tongue then forms a groove along its Clinically Normal >16 mm medicine, association does not necessarily length that provides a channel to maintain Class I: mean causation. Indeed, many adults breast position, as well as holding the milk Mild Ankyloglossia 12-16 mm report having had tongue-ties present since at the back of the tongue before swallowing Class II: birth with minimal impairment of is initiated. The tongue movement during Moderate Ankyloglossia 8-11 mm function. When then should tongue-tie be suckling involves elevation of the tongue Class III: divided and what evidence is there that tip which traps milk in the front of the Severe Ankyloglossia 3-7 mm division is associated with improved breast, before a wave of compression Class IV: function? passing from the tip to about halfway along Complete Ankyloglossia <3 mm the tongue presses milk from the areola to Breastfeeding the nipple. The pressure within the mouth TABLE 1. Kotlow classification of Over the last couple of decades there has is then reduced by the back of the tongue ankyloglossia (tongue-tie). Based on ‘free been a major drive to encourage babies to dropping to the floor of the mouth tongue’ length. breastfeed6. As a result there has been a enabling milk to be expelled from the greater reluctance to abandon nipple by a combination of compression Functional definitions breastfeeding if difficulties arise. This has and suction. Efficient breastfeeding The simplest functional definition was re-opened the debate as to whether therefore, relies on the baby having an outlined by Wallace as ‘a condition in tongue-tie impairs breastfeeding. adequate length of free tongue tip, having which the tip of the tongue cannot be A number of interesting functional adequate overall tongue movement, and protruded beyond the lower incisor teeth studies have monitored tongue movement also having sufficient flexibility of the floor because of a short frenulum’1. However, during breastfeeding and have of the mouth. Infants with tongue-tie tongue movement is more complex than demonstrated that the tongue is a major attempt to compensate for restriction in simple protrusion and as a result component of the suckling reflex7-10. In these components in a number of ways11. functional assessments have included general terms, the initial function of the First, they use their jaws to increase the tongue lateralisation, tongue lift, tongue tongue is to help draw the breast into a compression on the breast. This is often spread, tongue ‘cupping’ and tongue ‘snap correct position in the baby’s mouth at the also accompanied by a shallow latch onto back’. In an attempt to combine anatomical start of breastfeeding (initial latching). The the breast. The increase in pressure leads appearance and tongue function, Hazelbaker developed an assessment tool Appearance Items Function Items for the lingual frenulum (TABLE 2). In this assessment, five appearance items and Appearance of tongue when lifted Lateralisation seven function items are scored. Significant 2: Round or square 2: Complete ankyloglossia is diagnosed if the total 1: Slight cleft in tip apparent 1: Body or tongue but no tongue tip appearance score is 8 or less and/or the 0: Heart or V-shaped 0: None total function score total is 11 or less. Elasticity of frenulum Lift of tongue Whilst this detailed scoring system 2: Very elastic 2: Tip to mid-mouth enables objective definition, assessment, 1: Moderately elastic 1: Only edges to mid-mouth and diagnosis of tongue-tie, its practicality 0: Little or no elasticity 0: Tip stays at lower alveolar ridge or rises for routine clinical assessment of infants is to mid-mouth only with jaw closure questionable. In clinical practice the most Length of lingual frenulum when useful assessment of tongue-tie is based on tongue lifted Extention of tongue the position of frenular attachment to the 2: >1 cm 2: Tip over lower lip tongue base, degree of maximal tongue tip 1: 1 cm 1: Tip over lower gum only protrusion, and impairment of activities 0: <1 cm 0: Neither of the above, or anterior or requiring tongue function. It is the latter mid-tongue humps Attachment of lingual frenulum to point that is controversial and is the tongue Spread of anterior tongue subject for the remainder of this review. 2: Posterior to tip 2: Complete Indications for division 1: At tip 1: Moderate of partial 0: Notched tip 0: Little or none Most clinicians will agree on the position where a particular infant’s lingual Attachment of lingual frenulum to Cupping frenulum attaches to the tongue and how inferior alveolar ridge 2: Entire edge, firm cup far that infant’s tongue can protrude. 2: Attached to floor of mouth or well 1: Side edges only, moderate cup However, even if frenular attachment is to below ridge 0: Poor or no cup the tongue tip and tongue movement 1: Attached just below ridge Peristalsis significantly restricted, there is no 0: Attached at ridge 2: Complete, anterior or posterior consensus as to whether this actually 1: Partial, originating posterior to tip causes a problem and whether it requires 0: None or reverse dividing. When evaluating the indications for tongue-tie division, it is important to TABLE 2. Hazelbaker Assessment Tool for lingual frenulum function. infant VOLUME 2 ISSUE 3 2006 97 TONGUE-TIE to the mother sensing that the breast is demonstrated a significant improvement in difficulties with these sounds may well being ‘chewed’ and in turn leads to nipple breastfeeding after division of tongue-tie in benefit from tongue-tie division. At least soreness and cracking. As the nipples those babies with feeding difficulties. by optimising tongue movement, speech become painful, the milk reflex slows and Clearly larger controlled trials need to be therapy can be maximally beneficial. It is the baby has to further increase jaw performed in order to answer this question important however, to first fully assess the pressure, establishing a vicious circle of conclusively. However, there is enough data child for other causes of speech difficulties. increasingly painful suckling. Secondly, available to conclude that babies with they use their lips instead of their tongues tongue-tie and significant problems with Oral hygiene/dentition to move milk from the breast. This can be breastfeeding, who have undergone Dentists frequently diagnose tongue-tie as observed when the lips are turned outward assessment by a lactation consultant, part of their regular dental examinations rather than inward during breastfeeding. should be referred to an appropriate and in some countries, lactation specialists This can lead to frequent ‘delatching’ specialist for consideration of tongue-tie principally refer children to dentists for during feeding as well as feeds becoming division. Indeed, in December 2005, a tongue-tie division. However, one of the prolonged, even if latching is maintained. guideline for division of tongue-tie for indications for tongue-tie that is often Clearly, many babies with tongue-tie breastfeeding was issued by the National understated is impairment of oral hygiene compensate well, achieving effective Institute for Health and Clinical Excellence and dentition. The tongue is frequently breastfeeding which results in good weight (NICE) and this concluded: used by all of us for extracting pieces of gain and which is well tolerated by the “current evidence suggests that there are food from between our teeth, and tongue mother. This is not surprising if we no major safety concerns about division movement also ensures movement of saliva consider the spectrum of appearance and of ankyloglossia (tongue-tie) and limited around the mouth. Several groups have function of tongues with tongue-tie. evidence suggests that this procedure can advocated division of tongue-tie if oral However, the important question to improve breastfeeding. This evidence is hygiene is affected17,18, but no prospective, consider, is does division in those who do adequate to support the use of the controlled studies are available. not compensate well, enable breastfeeding procedure provided that normal Problems with dentition have been to subsequently be established? There are a arrangements are in place for consent, reported with tongue-tie including lower number of studies that help answer this. audit, and clinical governance”15. incisor deformity, gingival recession, and The most significant of these is a malocclusions19. However, the evidence is randomised controlled trial in which Speech not strong enough to recommend babies with tongue-tie and feeding One of the other principle reasons that prophylactic division of tongue-tie in order difficulties were randomised to either parents request division of their child’s to prevent malocclusion. Often these tongue-tie division (28 babies) or no tongue-tie is the widely held belief that conditions are associated with additional division but intensive support of a tongue-tie can impair normal speech abnormalities such as deviation of the lactation consultant (29 babies)2. The mean development. However, what is the epiglottis or larynx20. It is widely accepted age of the babies was 20 days (range 3 to evidence for this? In the study by that the tongue can influence face 70) and follow-up was four months. In the Messner4, 60% of otolaryngologists, 50% development and cases of impaired division group, 95% of breastfed babies of speech pathologists, but only 23% of maxillary and mandibular development showed improvement in breastfeeding paediatricians believed that tongue-tie is at being resolved by tongue-tie division have within 48 hours, compared with only 5% least sometimes associated with speech been reported21. in the no division group. This controlled difficulties. The real problem in answering study added further support to a previous this question is that to date there are no Social tongue movement case-series by the same team in which 215 good controlled trials investigating tongue- The tongue is used for a wide variety of infants with tongue-tie and difficulties tie and onset of speech difficulties social activities including licking ice with breastfeeding who underwent tongue- prospectively. creams, playing musical instruments tie division were studied12. In that study, Many published cases of tongue-tie and (particularly woodwind), and kissing. All 80% achieved better breastfeeding within impaired speech are based on the these activities rely on good tongue 24 hours, and 95% of infants could observation that established speech protrusion and elevation and there are a protrude their tongues at three months. difficulties can be associated with tongue- number of reports indicating that these can Interestingly two patients had increased tie in some children, rather than definite be impeded by tongue-tie and in turn difficulty feeding after division. A similar evidence that it actually causes speech improved with tongue-tie division17, 22-24. An case series of 123 babies with tongue-tie by impairment. Certainly tongue-tie does not interesting study, albeit small, of adolescent Ballard et al3 demonstrated that 83% of seem to be the cause of speech prevention and adult patients aged between 14 and 68 babies with failure to thrive resumed or delay3. However, many clinicians believe years with previously untreated tongue-tie, breastfeeding within five days of the that it can cause articulation difficulties in indicated that 93% noted functional procedure and achieved a normal rate of some patients. If the tongue tip is impairment and 57% mechanical growth. There was an 89% improvement completely restricted, then perhaps limitations such as kissing and licking of in maternal comfort during breastfeeding understandably, the articulation of the lips, and that tongue function improved in this series. A smaller case series from sounds ‘t’, ‘d’, ‘l’, ‘th’, and ‘s’ may be both subjectively and objectively in all Oregon13 and a very small (12 patients) affected16. A number of simple articulation patients undergoing division in this prospective cross-over trial of tongue-tie tests have been suggested for assessing group23. Whilst this and other studies are division and breastfeeding14, have also both this17. A child who has tongue-tie and not randomised or controlled, they do

98 VOLUME 2 ISSUE 3 2006 infant TONGUE-TIE suggest that benefit can be achieved by In this older age group, division is 8. Bosma J., Hepburn, L., Josell S.L., Baker K. dividing tongue-tie in a significant number usually performed under a short general Ultrasound demonstration of tongue motions of patients with these indications. It can anaesthetic. In addition to being much during suckle feeding. Dev Med Child Neurol 1990; 32: 223-29. also be reasonably postulated that kinder for the child, this also allows clear 9. Voloschin L.M., Althabe O., Olive H., Diena V., prophylactic division of tongue-tie may visibility of the salivary ducts. A wide Repezza B. A new tool for measuring the suckling prevent these difficulties developing later number of different procedures have been stimulus during breastfeeding in humans: The on, but this stance cannot be supported reported for division of tongue-tie in the orokinetogram and the Fourier series. J Reprod Fertil by clear data. older child including simple linear division 1998; 114(2): 219-24. by scissors or bipolar diathermy 10. Tamura Y., Horikawa Y., Yoshida S. Co-ordination of Timing and technique of division tongue movements and peri-oral muscle activities (frenotomy or frenulotomy), excision of during nutritive suckling. Dev Med Child Neurol The timing of tongue-tie division is largely the frenulum with simple closure of 1996; 38(6): 503-10. related to the indication for division. defect (frenectomy), and excision with 11. Genna C.W. Tongue-tie and breastfeeding. Leaven Clearly if difficulty with breastfeeding is z-plasty repair (frenuloplasty)25. Indeed, 2002; 38(2):27-29. the reason for division, it is important that elaborate variations of these themes have 12. Griffiths D.M. Do tongue-ties affect breastfeeding? J Human Lactation 2004; 20: 409-14. this is performed in the neonatal period to been recommended including the use 26 13. Masiatis N.S., Kaempf J.W. Developing a frenotomy enable prompt re-establishment of of laser and an elaborate four-flap policy at one medical center: A case study approach. 27 breastfeeding and to prevent soreness and z-frenuloplasty . The choice of procedure J Human Lactation 1996; 12: 229-32. cracking of the mother’s nipples. seems to be related to the surgical specialty 14. Dolberg S., Botzer E., Grunis E., et al. A randomised, Therefore, when planning resources for of the person dividing, with plastic prospective, blinded clinical trial with cross-over of this group of patients, it must be surgeons opting for the most complex frenotomy in ankyloglossia: Effect on breast-feeding difficulties. Pediatric Research 2002; 52: 822. appreciated that whilst the condition itself procedures25. However, there is no strong 15. Natonal Institute for Health and Clinical Excellence. evidence that more complex procedures is not life threatening, it cannot be treated Division of ankyloglossia (tongue-tie) for electively. Indeed, any centre providing confer any advantage over more simple breastfeeding. December 2005; 28 neonatal tongue-tie division, needs to be techniques . Complications of tongue-tie www.nice.org.uk/IPG149dustributionlist. able to provide division within a couple of division include bleeding, infection, 16. Kupietzky A., Botzer E. Ankyloglossia in the infant weeks of presentation. damage to the salivary ducts and damage and young child: Clinical suggestions for diagnosis When performed in a baby under three to the tongue substance itself. All these and management. Pediatric Dentistry 2005; 27(1): 40-46. complications should be rare if the months of age, tongue-ties are usually 17. Ketty N., Sciullo P.A. Ankyloglossia with divided without general anaesthesia, and procedure is undertaken carefully. psychological implications. ASDC J Dent Child 1974; can either be performed with blunt-ended 41: 43-46. scissors or bipolar diathermy. Topical Conclusions 18. Young E.C., Sacks G.K. Examining for tongue tie. Clin anaesthesia is applied. The procedure is Tongue-tie affects a considerable number Paediatr 1979; 18: 298. usually well tolerated with no more distress of infants and children. It is perhaps 19. Williams W.N., Waldron C.M. Assessment of lingual function when ankyloglossia (tongue-tie) is to the baby than having an injection. The interesting that such a seemingly simple suspected. J Am Dent Assoc 1985; 110: 353-26. key requirement is that the infant is held as condition can cause such controversy and 20. Mukai S., Mukai C., Asaoka K. Congenital still as possible during the division and that diversity of opinions! However, it is ankyloglossia with deviation of the epiglottis and the procedure is abandoned if undue important that accurate information and larynx: Symptoms and respiratory function in struggling is encountered (this is very rare guidance is given to parents with regard to adults. Ann Otol Rhinol Laryngol 1993; 102(8): in experienced hands) so as not to risk the indications and potential benefits of 620-24. 21. Defabianis P. Ankyloglossia and its influence on damage to the underlying salivary ducts. tongue-tie division, and that appropriate maxillary and mandibular development. (A seven After division with scissors, a small provisions are in place for those infants year follow-up case report). Funct Orthod 2000; amount of bleeding is encountered, but that require division. 17(4): 25-33. this is usually self-resolving. Diathermy 22. Horton C.E., Crawford H.H., Adamson J.E., Ashbell division avoids this. References T.S. Tongue tie. Arch Otolaryngol 1971; 94: 548-57. If feeding in the newborn with tongue- 1. Wallace A.F. Tongue Tie. Lancet 1963; 13: 377-88. 23. Lalakea M.L., Messner A.H. Ankyloglossia: The 2. Hogan M., Westcott C., Griffiths M. Randomized, adolescent and adult perspective. Otolaryngol Head tie is normal and weight gain adequate, it Neck Surg 2003; 128(5): 746-52. is customary for most clinicians to wait controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005; 24. Wright J.E. Tongue-tie. J Paediatr Child Health until after the age of six months before 41(5-6): 246-50. 1995; 31(4): 276-78. division. One reason for this is that a 3. Ballard J.L., Auer C.E., Khoury J.C. Ankyloglossia: 25. Brinkmann S., Reilly S., Meara J.G. Management of number of tongue-ties will resolve Assessment, incidence, and effect of frenuloplasty tongue-tie in children: A survery of paediatric ‘spontaneously’, often by getting stretched on the breast-feeding dyad. Paediatrics 2002; surgeons in Australia. J Paediatr Child Health 2004; 40: 600-05. or caught on a tooth. However, if tongue- 110(5): e63. 4. Messner A.H., Lalakea M.L. Ankyloglossia: 26. Kato J., Jayawardena J.A., Wijeyeweera R.L., Moriya tie is still present after this and the child Controversies in management. Int J Paediatr K., Takagi Y. Application of a CO2 laser for oral soft fulfils the criteria for division and the Otorhinolaryngol 2000; 54(2-3): 123-31. tissue surgery in children in Sri Lanka- introduction parents are keen for division, there is little 5. Lalakea M.L., Messner A.H. Ankyloglossia: Does it of a laser through activities of aid to a developing point in delaying division beyond one year matter? Peadiatr Clin North Am 2003; 50: 381-97. country. Kokubyo Gakkai Zasshi 2002; 69(1): 34-38. of age. It is imperative however, that the 6. UNICEF. Towards a national breastfeeding policy. 27. Heller J., Gabbay J., O’Hara C., Heller M., Bradley J.P. UNICEF UK Baby Friendly Initiative, 1997. Improved ankyloglossia correction with four-flap Z- parents clearly appreciate the relative 7. Ardran G., Kemp F., Lind. A cineradiographic study frenuloplasty. Ann Plast Surg 2005; 54(6): 623-28. indications for division and can give truly of breastfeeding. Br J Radiology 1958; 31(363): 28. McBride C. Tongue-tie. J Paediatr Child Health 2005; informed consent. 156-62. 41: 242. infant VOLUME 2 ISSUE 3 2006 99