One medical condition associated with breastfeeding problems is ankyloglossia, or tongue-tie, a congenital anomaly in which a child is born with an abnormally short and/or thick lingual frenulum that limits the movement of the tongue. It has been associated with difficulty breastfeeding due to trouble latching on, associated nipple pain, infection, and poor milk supply in mothers, as well as discontinuation of breastfeeding and inadequate weight gain and other health issues such as oral hygiene concerns, speech problems, and developmental and social consequences. Ankyloglossia has a hereditary link, but not all cases are explained by genetics. A review of studies reporting on prevalence of ankyloglossia in the United Kingdom and USA suggested that rates likely fall between 4 to 10%, occurring more commonly in males, though inconsistency in diagnostic procedures may contribute to variation in estimates. There is no clinical standard for diagnosing ankyloglossia, but assessment tools such as the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), which is considered comprehensive, but difficult to use, and the Bristol Tongue Assessment Tool (BTAT), which is simpler and aims to ease implementation, are cited in the literature. Diagnoses may also be made using subjective clinical judgement by practitioners with varying levels of experience or expertise. The condition can entail mild immobility or be as severe as fusion of the entire tongue to the floor of the mouth. The condition can be anterior or posterior, and may be comorbid with other issues such as upper lip-tie.
To correct ankyloglossia, splitting of the tongue-tie, termed frenectomy (also commonly referred to as frenotomy or frenulotomy), is often proposed. It can be conducted using a laser, scalpel, or surgical scissors, and the laser procedure is suggested to be more accurate, and provide greater patient-perceived success, and hemostasis. Frenuloplasty (also called Z-plasty) is a type of tongue-tie release often conducted with anesthetic in which more precise incisions and closure of the wound in a specific pattern occurs, with the aim of lengthening the anterior tongue. Simple release is a procedure in which the frenulum is detached without any wound closure or alteration, usually without anesthetic. Based on population data from British Columbia, the rate of frenotomy increased by 89% from 2004 to 2013, rising from 2.8 to 5.3 per 1000 live births. This suggests a possible increased awareness, interest in frenotomy, and increase in diagnostic capacity.
There is disagreement across specialties regarding whether a tongue-tie should be divided to facilitate breastfeeding, and under what circumstances. Ankyloglossia is not the only cause of breastfeeding issues, and in cases of comorbidities or alternative primary causes, frenectomy may not result in resolution. Un-split lingual frenulum may physically adapt (i.e., stretch with age) over time and breastfeeding quality may improve without intervention. The Canadian Paediatric Society has communicated that under most circumstances, tongue-tie is an incidental anatomical finding without significant consequences for the quality of breastfeeding, and that surgical intervention may not be warranted unless difficulty breastfeeding or other clinical concerns present themselves. The National Institute for Health and Care Excellence in the UK released guidance in 2005 which reported that current evidence was suggestive of no major safety concerns with frenectomy, and that there was limited evidence that it might improve breastfeeding. Considering uncertainties regarding the clinical effectiveness and appropriateness of the procedure, and the development of new technologies and methods of conduct, this report aims to review the current clinical evidence regarding the effectiveness of frenectomy in newborns and infants with ankyloglossia, as well as evidence-based guideline recommendations for the use of this procedure.
Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that the Canadian Agency for Drugs and Technologies in Health (CADTH) could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.
