Congenital Tongue-Tie and Its Impact on Breastfeeding - New ...

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Page 2Breastfeeding: Best for Baby <strong>and</strong> MotherThe American Academy of Pediatrics (AAP)offers the Breastfeeding: Best for Baby <strong>and</strong> Mothernewsletter as a member benefit of the AAPSection on Breastfeeding. Information about theAAP Breastfeeding Promotion in Physicians’Office Practices (BPPOP-Phase II) program alsois included. The newsletter is intended as a forumfor sharing information about breastfeeding<strong>and</strong> AAP breastfeeding initiatives to facilitatenetworking among AAP members. The AAPprovides this newsletter through its Departmentof Community Pediatrics Division of CommunityHealth Services.Comments <strong>and</strong> questions are welcome <strong>and</strong> canbe directed to:American Academy of PediatricsDivision of Community Health Services141 Northwest Point BlvdElk Grove Village, IL 60007-1098Phone: 800/433-9016, ext 7821Fax: 847/434-8000E-mail: lactation@aap.orgWeb site: www.aap.orgAAP StaffBetty Crase, IBCLC, RLC, ManagerCyndy Rouse, Division AssistantThomas F. Tonniges, MD, Director, Departmentof Community PediatricsNewsletter EditorNancy Powers, MDChairperson, Communications CommitteeAAP Section on BreastfeedingAAP Chapter Breastfeeding Coordinator, KansasElectronic mailing lists are available for AAP ChapterBreastfeeding Coordinators, members of theBPPOP-Phase II program, <strong>and</strong> members of the AAPSection on Breastfeeding. Contact program staff forinformation regarding participation.The recommendations listed in this newsletter <strong>and</strong>in the mentioned publications do no indicate anexclusive course of treatment or serve as a st<strong>and</strong>ardof medical care. Variations, taking into accountindividual circumstances, may be appropriate. Thisnewsletter <strong>and</strong> the materials mentioned within thisnewsletter discuss titles published by organizationsother than the American Academy of Pediatrics.Statements <strong>and</strong> opinions expressed in these publicationsare those of the authors <strong>and</strong> not necessarilythose of the American Academy of Pediatrics.Any part of this newsletter may be reproduced fornoncommercial educational purposes.© 2004 American Academy of PediatricsCONGENTIAL TONGUE-TIE [CONTINUED FROM P 1]© 2004 Catherine W Genna © 2004 Catherine W GennaClassicmiddle of the floor of the mouth <strong>and</strong> is usuallytighter <strong>and</strong> less elastic.Type 4 is essentially against the base of the tongue,<strong>and</strong> is thick, shiny <strong>and</strong> very inelastic.SimpleClassic heart shaped tongue caused by restricted central tongue tip elevation. This presentation is actuallysometimes less symptomatic than the tighter, shorter frenula that present as flattened (simple) or bunchedtongue .Types 1 <strong>and</strong> 2, considered “classical” tongue-tie,are the most common <strong>and</strong> obvious tongue-ties, <strong>and</strong>probably account for 75% of incidence. Types 3 <strong>and</strong>4 are less common, <strong>and</strong> since they are more difficultTypes 3 <strong>and</strong> 4 may require a digital examto visualize are the most likely to go untreated.Type 4 is most likely to cause difficulty with bolus h<strong>and</strong>ling <strong>and</strong> swallowing, resulting in moresignificant symptoms for mother <strong>and</strong> infant (see section on Diagnostic Assessment).Oral-motor Movements That Differ Between Bottle <strong>and</strong> BreastfeedingAn infant can obtain milk from a bottle without the wide gape <strong>and</strong> consistent suction needed fora good breast latch. If the tongue-tied infant cannot maintain the tongue over the lower gumduring sucking, the “phasic bite reflex” (chewing) is triggered. 24 This chewing motion is sufficientto transfer milk from the bottle, but is clearly problematic at breast. Bottle feeding allows milkto drip into the mouth without effort, thus requiring less tongue muscle effort (such as tonguegrooving, cupping <strong>and</strong> depression) than needed for breastfeeding (Hartman, P, oral communication,2003). Breastfeeding requires well-defined peristalsis from the front to the back of thetongue as well as tongue–palate synchronization. Some tongue-tied infants cannot even managea bottle.Diagnostic AssessmentPhysical examination <strong>and</strong> observation of breastfeeding should be conducted, with particularattention to the following items:• Assessment of range of motion of the tongue should include the degree of extension of thetongue beyond the lower dental ridge <strong>and</strong> lip, 13 elevation to palate with mouth wideopen, 10,13 <strong>and</strong> transverse movement from one corner of the lips to the other withouttwisting the tongue. Elevation seems to be the most important tongue movement forbreastfeeding <strong>and</strong> should be weighted most heavily in the assessment. 8,20,25• Thorough evaluation of adequacy of latch <strong>and</strong> effectiveness of milk transfer are important.The amount <strong>and</strong> rate of milk transfer from the breast can be determined by test-weighing[continued on p 3]
Page 3Breastfeeding: Best for Baby <strong>and</strong> MotherCONGENTIAL TONGUE-TIE [CONTINUED FROM P 2]Box APresentation of<strong>Tongue</strong>-tie++++++++++++++++++++++The presentation of symptomatic tonguetiemay vary widely, including symptoms<strong>and</strong> signs in both infant <strong>and</strong> mother.Maternal presentation is commonly characterizedby:• nipple pain <strong>and</strong>/or erosions• painful breasts• low milk supply• plugged ducts• mastitis• frustration, disappointment, <strong>and</strong>discouragement with breastfeeding• untimely weaningInfant symptoms <strong>and</strong> signs include:• poor latch <strong>and</strong> suck• clicking sound while nursing (poorsuction)• ineffective milk transfer• inadequate weight gain or weight loss• irritability or colic• fussiness <strong>and</strong> frequent arching awayfrom the breast• fatigue within one to two minutes ofbeginning to nurse• difficulty establishing suction tomaintain a deep grasp on the breast• gradual sliding off the breast• “chewing” of the nipple• falling asleep at the breast havingtaken less than an optimal feed, asproven by “test weight” on a digitalscale (experience of authors)Bunched tongue-tieRollunder tongue-tiethe infant with an appropriate digitalscale <strong>and</strong> st<strong>and</strong>ardized protocol. (SeeBox B.)• Evaluate the efficiency of bolus h<strong>and</strong>ling(ability to hold milk on the groovedtongue for a controlled swallow that iswell coordinated with breathing). 1,2,8Cineradiography <strong>and</strong> close observationhave been the primary tools. Signs ofimperfect coordination between swallowing <strong>and</strong> breathing include increasingnasal congestion over the course of afeed, gulping sounds, decreasing respiretion rate during sucking, sucking in unusually short bursts (fewer than 10-15sucks per burst) <strong>and</strong> even short bouts ofapnea. 24 If the infant nurses, transfersmilk, <strong>and</strong> breathes well over a three tofive minute period, this is good clinicalevidence of normal suck-swallowbreathingcoordination.• Observe the degree of fatigue <strong>and</strong> irritability shown by the infant (especiallyimportant in posterior tongue tie, whichis less apparent to the examiner), during<strong>and</strong> after feeding, often expressed as jaw<strong>and</strong> tongue tremor, fussiness <strong>and</strong> archingaway during feeding or needing to feedagain <strong>and</strong> again after short periods ofrest).• Document the degree of nipple pain <strong>and</strong>nipple skin erosion of the mother.• Examine for any other contributing orconfounding issues including occult cleftsof the palate, facial deformity, muscularor neurological deficit, thrush, etc.<strong>Tongue</strong>-tie is seen relatively frequently inassociation with other birth defects. 2,6,14The Surgical Treatment of <strong>Tongue</strong>-tieFrenotomy is a simple, safe <strong>and</strong> effective surgicalprocedure. It improves comfort, effectiveness<strong>and</strong> ease of feeding for the mother<strong>and</strong> infant, thereby increasing the exclusivity<strong>and</strong> duration of breastfeeding for affecteddyads. (Benefits/outcomes other than forimproved breastfeeding are beyond the scopeof this article).A simple “snip” with a blunt ended scissors isusually all that is needed <strong>and</strong> bleeding is minimal.It is less traumatic than ear piercing, <strong>and</strong>much less invasive <strong>and</strong> painful than circumcision.The author usually prefers to use topicalbenzocaine on a small cotton swab to eachside of the frenulum <strong>and</strong> has used this in infants<strong>and</strong> young children from 0-5 years withgood results <strong>and</strong> without side effects. Immediatelyafter the frenotomy is done, the infant isplaced back on the breast, <strong>and</strong> the latch adjusted.There is usually immediate improvementin milk transfer <strong>and</strong> maternal comfort.10,12-16,20,21Fortunately, complications are minimal.Rarely, the release does not help breastfeedingbut does help with speech later on. It isnot harmful to the baby. Occasionally theremight be enough bleeding to stain half of a2 x 2 gauze pad instead of the more usual fewdrops.Usually there seems to be no pain <strong>and</strong> breastfeedingin the immediate post operative periodis sufficient analgesia for the nursling.[continued on p 4]
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