Ankyloglossia (tongue -tie): Latching on to the evidence

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The benefits of breastfeeding are many. And the pressure on moms to breastfeed — and to continue breastfeeding — is high. But what happens when moms run into problems with breastfeeding? What if the baby can’t latch properly? What if it hurts? Moms in these situations can be quite anxious to find the cause of the problem and to fix it. And there are many interventions aimed at common breastfeeding problems that have the goal of promoting breastfeeding success. What can be difficult, however, is to know whether these interventions actually work to improve breastfeeding, and if they are safe for moms and babies.

One medical condition often linked with breastfeeding problems is called ankyloglossia — what many of us would call tongue-tie. Normally, the bottom of the tongue is attached to the floor of the mouth with a band of tissue called the lingual frenulum. But some babies are born with an abnormally short or thick frenulum so that their tongue isn’t as free to move. How common tongue-tie is, isn’t certain because many people may go undiagnosed. But studies suggest that somewhere between 4 and 10 per cent of the population have the condition. Tongue-tie seems to be more common in boys and can sometimes run in families. How severe the tongue-tie is can vary from mild immobility to the fusion of the entire tongue to the floor of the mouth. Although it doesn’t always cause problems, tongue-tie can prevent a child from being able to stick out their tongue, they may have difficulties talking or swallowing, and it may make breastfeeding more difficult by preventing a good latch onto the nipple. An improper latch can in turn lead to nipple pain or infection, poor milk supply, poor weight gain in babies, and the discontinuation of breastfeeding.

Diagnosing tongue-tie isn’t always as straightforward as some may think, and there are different screening and assessment tools to help clinicians. However, the diagnosis is most commonly made after a health care provider simply examines a baby’s mouth and tongue, and parents themselves may recognize the condition in their babies.

Tongue-tie can be relatively easy to treat. A simple procedure called a frenotomy separates the tongue from the floor of the mouth. This can be done with or without anaesthesia and is performed with surgical scissors, a scalpel, or a laser. A more complicated procedure called a frenuloplasty can be done under general anaesthesia if the tongue and floor of the mouth need repair as well, or if the frenulum is too thick. During a frenuloplasty, multiple incisions are made requiring dissolvable stitches. Both procedures are quite safe and complications such as serious bleeding and infection are rare.

But even though procedures to correct tongue-tie are relatively simple and low-risk, are they really necessary to help with breastfeeding? Should every baby with tongue-tie undergo a procedure to fix the condition, or should it be reserved only for those who are also experiencing breastfeeding issues? The health care and breastfeeding communities aren’t all in agreement — some feel that all babies should have tongue-tie corrected as soon as it’s diagnosed. And, in fact, the rate of frenotomies does appear to be increasing, at least in some regions of Canada. But others believe that the frenulum can stretch over time and that only rarely is a release of a tongue-tie truly necessary.

To answer the questions about tongue-tie procedures and breastfeeding, the health care community turned to CADTH — an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures — to find out what the evidence says. The CADTH Rapid Response service gathered the evidence and identified two systematic reviews, one randomized controlled trial, and four non-randomized studies that would help to answer the questions. No evidence-based guidelines on treating tongue-tie were found, but three guidance documents were included in a systematic review.

The available evidence shows that frenotomy for tongue-tie is a safe procedure for newborns and infants and that it does, according to moms, appear to improve breastfeeding — at least in the short term. But whether fixing tongue-tie reduces nipple and breast pain, improves feeding problems, improves infant growth, or increases continuation and duration of breastfeeding over the long term is uncertain because there isn’t a lot of good evidence.

So what does this mean for breastfeeding moms and their babies? Knowing the evidence can help breastfeeding moms and their families, together with their health care providers, make the treatment decision that is the best for them. Some families may decide to treat the tongue-tie as soon as it’s diagnosed. Another family may decide to wait and see if breastfeeding problems develop — at which time they may go ahead with the procedure. Still another family might decide to opt out of treating tongue-tie altogether. Knowing the evidence doesn’t mean everyone will make the same decision — but it does mean everyone can make an informed decision that is right for them.

If you’d like to learn more about the evidence on treating tongue-tie or browse our other freely available Rapid Response reports, please visit www.cadth.ca/RapidResponseReports. And if you would like to learn more about CADTH, visit our website www.cadth.ca, follow us on Twitter @CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth.ca/contact-us/liaison-officers.

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