Basics
Description
Anatomic variation of the tongue in which the lingual frenulum is unusually tight and short. Also known as tongue-tie. This condition may result in impaired tongue mobility with early breastfeeding problems, maternal nipple pain, and, later, speech problems. �
Epidemiology
- Incidence ranges from 1.7 to 5% of newborns in various studies.
- About half of breastfeeding infants with ankyloglossia will have difficulty feeding or cause maternal nipple pain during feeds.
- Incidence of speech articulation disorders due to ankyloglossia is unknown.
- Male-to-female ratio of 3:1.
Risk Factors
- Pedigree analysis suggests significant hereditary component, possibly X-linked.
- Studies show 40-50% of patients with ankyloglossia had a relative with the same condition and an inheritance rate of about 21%.
- Rarely, mutations in the T-box transcription factor TBX22 may lead to heritable ankyloglossia with or without cleft lip, cleft palate, or hypodontia.
- Rarely, may be associated with Opitz syndrome or orodigital facial syndrome
- No known environmental risk factors
Pathophysiology
- Newborns with ankyloglossia
- Are often asymptomatic but problems can occur with breastfeeding
- May have poor or ineffective latch or may cause maternal nipple pain due to poor tongue mobility and prolonged feeding times
- Later in childhood, the effect of ankyloglossia is controversial.
- May cause problems with articulation of certain sounds that require tongue to reach teeth, palate, and lips (e.g., "t,"� "d,"� "z,"� "s,"� "th,"� "n,"� "l"�)
- Not a cause of speech delay
- May also result in mechanical problems including difficulty with oral hygiene (inability to lick lips), inability to lick ice cream cone, play wind instruments, or French kiss
Diagnosis
- Diagnosis based on physical appearance and functional impairment of breastfeeding or speech
History
- Maternal report of difficulty with infant latch or nipple pain while breastfeeding
- Report of inability of infant/child to extrude tongue beyond alveolus/teeth
- Ankyloglossia varies in severity. Some children can protrude tongue past alveolus/teeth but not past lower lip and still have difficulties.
Physical Exam
- Commonly missed finding on newborn exam because the mouth is usually not open.
- Examiner should pass the small finger, pad-side down, under the infant's tongue to feel for resistance at the site of the lingual frenulum.
- Examiner should also visualize the floor of mouth and lingual frenulum using tongue depressors, Q-tips, or fingers to open the mouth or by observation of the infant crying.
- Visualization of the tongue will show
- Abnormally short frenulum, inserting at or near the tip of the tongue
- Difficulty lifting tongue to upper alveolus/palate
- Inability to protrude tongue beyond lower alveolus/teeth
- Notching or heart shape of tip of tongue when protruded
- Note: Some children can protrude tongue past alveolus/teeth but not past lower lip and still have difficulties.
Diagnostic Tests & Interpretation
Imaging
- No imaging indicated
- Functional ultrasound of tongue movement during breastfeeding has been used experimentally to quantify milk transfer.
Diagnostic Procedures/Other
- Mothers of infants with ankyloglossia and difficulty breastfeeding should meet with lactation consultant to rule out other potential causative factors,
- Children with speech articulation difficulty should meet with speech therapist for therapy and to assess for other causes.
Differential Diagnosis
- Consider other causes of poor breastfeeding including inexperience, poor positioning, or poor suck.
- Consider other causes of speech articulation difficulties including incoordination and neuromuscular disease.
Treatment
General Measures
- Observation if there is no functional impairment of breastfeeding or speech
- Surgical treatment if functional impairment is present
- Treatment is frenotomy-incision of lingual frenulum.
- For most healthy newborns, this may be performed in an outpatient setting. Topical lidocaine and oxymetazoline on a cotton ball are applied before and after incision with sterile scissors. Infants with a thick frenulum should have the procedure performed in the operating room setting to avoid bleeding.
- For older children unlikely to cooperate, and any patient with medical comorbidities or coagulopathy, the procedure should be performed in the operating room under general anesthesia.
Ongoing Care
Follow-up Recommendations
- Infants should be seen about one week after frenotomy to assess feeding and weight gain.
- Older children should be seen about 6 weeks after surgery to assess function and to determine whether a revision procedure for scar formation is needed.
Prognosis
- Infants treated for tongue-tie have an excellent prognosis.
- <1% require repeat frenotomy and local flaps may be required.
- Frenotomy has been shown to be effective for improving infant breastfeeding problems and weight gain and maternal nipple pain while breastfeeding. There are 5 randomized controlled trials with similar positive results.
- Breastfeeding rates in infants treated with frenotomy for ankyloglossia appear similar to healthy infants (approximately 40-45% at 6 months and 25% at 12 months).
- There is anecdotal clinical evidence that frenotomy improves speech articulation problems. However, studies evaluating this are of low quality, with lack of randomization and small sample sizes. Further studies are needed.
- Complications have rarely been reported including severe infection or severe bleeding. Severe bleeding was associated with untrained individuals performing the surgery.
Additional Reading
- Buryk �M, Bloom �D, Shope �T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011;128(2):280-288. �[View Abstract]
- Dollberg �S, Botzer �E, Grunis �E, et al. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg. 2006;41(9):1598-1600. �[View Abstract]
- Han �SH, Kim �MC, Choi �YS, et al. A study on the genetic inheritance of ankyloglossia based on pedigree analysis. Arch Plast Surg. 2012;39(4):329-332. �[View Abstract]
- Opara �PI, Gabriel-Job �N, Opara �KO. Neonates presenting with severe complications of frenotomy: a case series. J Med Case Rep. 2012;6:77. �[View Abstract]
- Webb �A, Hao �W, Hong �P. The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol. 2013;77(5):635-646. �[View Abstract]
Codes
ICD09
- 750.0 Tongue tie
- 779.31 Feeding problems in newborn
ICD10
- Q38.1 Ankyloglossia
- P92.8 Other feeding problems of newborn
SNOMED
- 67787004 tongue tie (disorder)
- 206568009 Difficulty in feeding at breast (finding)
FAQ
- Q: What is the appropriate time to perform frenotomy in breastfeeding newborns with ankyloglossia?
- A: Optimal timing is not known. A reasonable approach is to allow enough time to establish that there is a problem with breastfeeding caused by the ankyloglossia. Some infants with ankyloglossia will not have problems. Usually, this issue is evident in the first 2 days of life. Newborns with identified breastfeeding difficulty should have frenotomy performed quickly to allow for continued breastfeeding. Delay may cause some mothers to abandon breastfeeding due to pain or difficulty. Optimal timing is probably between 2 and 7 days of life.
- Q: In infants with ankyloglossia who are either bottlefeeding or breastfeeding with no difficulty, should frenotomy be performed to help "prevent"� future problems with speech or functional difficulties?
- A: Data regarding speech/functional outcome in these children are not known at present.
- Q: Who does frenotomies?
- A: ENT or oral surgeons most commonly perform the procedure. In areas where access to these specialists is difficult, general pediatricians, family practitioners, neonatologists, or newbornists may perform the procedure after sufficient training and appropriate credentialing. The procedure is not difficult. It can be done in the inpatient or outpatient setting. It is billed under the CPT Code 41010 (frenotomy).
- Q: What are the postoperative instructions after frenotomy?
- A: For all patients after frenotomy: acetaminophen for pain. Although complications are rare, patients should go to an emergency department if bleeding, infection, or swelling occurs. For older children, avoid citrus; spicy; or hard, scratchy foods for 1 week after the procedure.