番茄社区

Pediatricians and other specialists have an important role in identifying ankyloglossia and its effect on breastfeeding in infants, according to a clinical report and set of recommendations from the American Academy of Pediatrics (AAP).

While the AAP recommends exclusive breastfeeding for about 6 months with possible continuation for 2 years or longer, ankyloglossia, a condition present at birth and commonly referred to as tongue-tie, can impede breastfeeding, noted Jennifer Thomas, MD, MPH, of Advocate Aurora Health in Milwaukee, and colleagues in .

Ankyloglossia "restricts the tongue's range of motion because of a short or tight band of tissue called the lingual frenulum, which tethers the bottom of the tongue's tip to the floor of the mouth," the authors explained. This "may interfere with breastfeeding by not allowing the infant to extend and elevate their tongue to grasp the nipple with suckling."

Currently, there are no uniform accepted diagnostic criteria for the condition, and there is a lack of consensus on treatment, they wrote. Nevertheless, diagnoses and frequency of performing a frenotomy -- a procedure that involves cutting the lingual frenulum -- have recently increased.

A trio of studies from , , and found that the frequency of tongue-tie diagnoses in newborns ranges from 1.7% to 10.7%. In the U.S., there was reportedly a nearly 10-fold increase in diagnoses from 1997 to 2012 -- with a further doubling from 2012 to 2016 -- as well as a similar pattern in the rates of frenotomy.

"There has been a marked increase in the amount of babies being diagnosed with tongue and other 'ties,' and pediatricians are concerned about the increase and are looking for guidance as to how to help the families when they come in for care," Thomas told 番茄社区 in an email.

"We think some of the increase is from increased awareness, mostly through social media, but also because 83% of mothers initiate breastfeeding (according to the ) and getting a procedure to make breastfeeding easier is very tempting," Thomas added. "The problem is that sometimes it doesn't fix the breastfeeding issue and, in rare cases, can make it worse. Because of a lack of consensus as to how to treat this, there is a lot of overdiagnosis and overtreatment."

Though a number of tools for assessing the severity of ankyloglossia have been published in peer-reviewed journals and encourage scoring of observed tongue movement, none of these tools have been validated, Thomas and co-authors noted.

Furthermore, recent reviews of several small randomized trials of frenotomy indicated that the studies did not determine whether the procedure resulted in longer-term breastfeeding success and resolution of maternal pain.

"We do not have an accepted definition of tongue-tie, and none of the scoring systems used for classifying the degree of severity are reliable or valid," Thomas said. "This is also a functional diagnosis, which means that instead of only focusing on the infant, we need an assessment of maternal anatomy and what the latch looks like. The practice of cutting the ties proceeded with very little research, which is why this clinical guidance is necessary."

Among the recommendations included in the report were that infants with ankyloglossia and normal feeding do not need intervention, and that frenotomy for other problems or to prevent future issues (e.g., speech articulation or obstructive sleep apnea) is not evidence-based.

Additionally, posterior tongue-tie lacks agreement from experts, and should not be used as a reason to perform surgery on an infant, the authors noted. Furthermore, labial and buccal frenae are normal oral structures and do not require surgery to improve breastfeeding, and sucking blisters are normal in newborns, and not suggestive of pathology.

In cases of suboptimal breastfeeding, which is a complex issue, "multidisciplinary communication and management between lactation specialists, feeding therapists, surgeons, and pediatricians are paramount for the best outcome for the family," Thomas and colleagues wrote.

As for newborns with possible symptomatic ankyloglossia, they need breastfeeding support while in the hospital, post-discharge follow-up, and monitoring of weight gain. Surgical intervention for symptomatic ankyloglossia versus laser treatment "can reasonably be offered after other causes of breastfeeding problems have been evaluated and treated," they added. Though evidence is not strong, frenotomy may decrease maternal nipple pain, which is an important part of successful breastfeeding.

Frenotomy should be performed by a trained professional, who should discuss alternatives, risks, and benefits of the procedure; provide pain control options; document previous receipt of intramuscular vitamin K; and provide information on post-surgical care and follow-up.

Attention to the prevention of surgical complications, hemorrhage risk, pain mitigation, and evidence-based post-surgical care are also important, Thomas and team noted, adding that stretching exercises are neither evidence-based nor recommended.

"Further research including a standardized approach to identifying and classifying ankyloglossia, long-term outcome measures, and a good description of the natural history of ankyloglossia by severity, including long-term risk of feeding problems, is needed," they concluded.

Comment