Tongue Tie Talk

Ankyloglossia

By Claire Carter

October 2017

Tongue Tie

Lingual Frenulum

Definition

• Ankyloglossia Greek for “crooked tongue”

• Lingual frenulum, membrane attached

underneath the tongue restricting range of

movement

• Tongue maybe restricted in forward protrusion,

lateral movement and elevation affecting feeding

• May result in feeding speech and oral/dental

hygiene problems Watson Genna(2002)

Incidence

• Messener et al (2000)……4.8%

• Griffiths (2000)……………10%

• Male to female ratio of 2.6:1.0

• (Messner et al, 2000)

• Family history in 50% of cases

• (LCGB, 2001)

Does it really matter?

• In Messner’s study (2000) of 1041 neonates,

4.8% (50 babies) were defined as having

tongue-tie. Of these, 25% were described by

their mothers as having breastfeeding problems

as opposed to 3% in the control group.

• In Fernando’s study (1998) of 200 babies with

tongue-tie, 20% of mothers had difficulty

breastfeeding and “nipple problems that

occurred were often serious enough to stop

them breastfeeding.”

Breastfeeding does matter • Breast feeding very important to wellbeing of

infant and mothers (WHO/Unicef 2003)

• Reduces the risk of hospital admissions for GI

and Respiratory infection (Quigley et al 2007)

• Reduces ear infection (Fewtrell 2004) and urinary

infection (Marild et al 1990)

• Long term reduction blood pressure, diabetes

cholesterol and cognitive development (Horta et al 2007)

• Women give up due to painful nipples, unable to

latch properly and insufficient milk (Bolling et al IFS 2005)

Maternal and Infant Challenges

MOTHER BABY

Sore or damaged nipples Difficulty in latching or maintaining the latch

Nipple pain while feeding Clicking noises while feeding

Mastitis/breast infections (from poor

drainage)

Fussiness at the breast

Diminished milk supply Frequent or prolonged feeding

Exhaustion from frequent feeding Prolonged physiological jaundice

Psychological effects from Failure to

establish breastfeeding

Colic due to poor attachment

Excessive early weight loss/failure to gain weight

Reproduced courtesy of LCGB from leaflet

“Breastfeeding and Tongue-tie”(2001)

Ros Escott, with permission Trisha Whisker, with permission

Hazlebaker’s assessment tool for lingual frenulum function

Appearance Items Function Items Appearance of tongue when lifted Lateralization

Round or square – 2 Complete – 2

Slight cleft in tip - 1 Body of tongue but not tongue-tip – 1

Heart or v shaped - 0 None - 0

Elasticity of frenulum Lift of tongue

Very elastic – 2 Tip to mid-mouth – 2

Moderately elastic – 1 Only edges to mid-mouth – 1

Little or no elasticity – 0 Tip stays at lower alveolar ridge or rises to

mid-mouth only with jaw closure – 0

Length of lingual frenulum when

tongue lifted

Extension of tongue

> 1cm – 2 Tip over lower lip – 2

1cm – 1 Tip over lower gum only – 1

<1cm – 0 Neither of the above or anterior or mid-

tongue humps – 0

Attachment of lingual frenulum to

tongue

Spread of anterior tongue

Posterior to tip – 2 Complete – 2

At tip – 1 Moderate or partial – 1

Notched tip – 0 Little or none – 0

Attachment of lingual frenulum to

alveolar ridge

Cupping

Attachment to floor of mouth or well below

ridge – 2

Entire edge, firm cup –

Attached just below ridge – 1 2 Side edges only, moderate cup – 1

Attached at ridge – 0 Poor or no cup – 0

Peristalsis

Complete anterior to posterior – 2

Partial, originating posterior to tip – 1

None or reverse motion – 0

Snapback

None – 2

Periodic – 1

Frequent or with each suck - 0

BTAT Scoring system

Ingram J, et al. Arch Dis Child Fetal Neonatal Ed 2015;100:F344–F348.

doi:10.1136/archdischild-2014-307503

Bristol Tongue

Assessment Tool

(BTAT)

0 1 2 Score

Tongue tip

appearance

Heart shaped Slight cleft/notched Rounded

Attachment of

frenulum to lower

gum ridge

Attached at top of

gum ridge

Attached to inner

aspect of gum

Attached to floor

of mouth

Lift of tongue with

mouth wide

(crying)

Minimal tongue lift Edges only to mid-

mouth

Full tongue lift to

mid-mouth

Protrusion of

tongue

Tip stays behind

gum

Tip over gum Tip can extend

over lower lip

What can you do ?

• If concerned about any baby’s feeding

• Refer locally BfN list found in the PCHR

• If frenulum suspected refer to RBH BFC

0118322 7295 OR email rbb-tr.CAT1@nhs.net

• Meantime encourage expressing to safeguard

the supply

Referral procedure

Feeding problem with Tongue Tie identified

Royal Berkshire Hospital (RBH)

Midwife/Health Visitor (HV) support with positioning and attachment & signpost to peer support at local drop

in group. Encourage mother to safeguard her milk supply by expressing milk as necessary.Many West Berkshire, Wokingham and Reading mothers can access the Breastfeeding Network Peer Support Project by phoning 0750 146 6818

or email: reading.mum@breastfeedingnetwork.org.uk (for all areas mentioned above)

Baby over 6 weeksGeneral Practitioner (GP) or HV referral to Mr W

Flannery Paediatric Surgeon, RBH for assessment

and probable tongue tie release.

Fax 0118 322 7147 or phone 0118 322 3051

OR email rbb-tr.CAT1@nhs.net subject heading

Tongue Tie PatientsGP ensure 6/52 check completed prior to procedure

Baby under 6 weeksParent self-refer to Royal Berkshire Hospital

Breast Feeding Clinic (BFC) for assessment.

If Frenulotomy is needed an appointment will

then be made for the procedure.

Ring 0118 322 7295

For more advice contact RBH Infant feeding team: 0118 322 8314 infantfeeding.team@royalberkshire.nhs.uk

Other centres offering assessment and treatment of Tongue Tie listed at www.babyfriendly.org.uk

Local HV & /or continued peer support as necessary. Record in Personal Child Health Record and electronic record

.

Patient Information Leaflet

•

RBH audit results

• 1430 snipped since 2008 - March 2017

• 3% averages 200/year snipped by midwives

• Average 60% still BF at 3M

• Recent parent surveys reported that they wanted it

done as soon a possible

• Now weekly clinics

• Now cover in Mr Flannery’s absences

Take Home Messages

• Feeding assessment on all babies

• Support Feeding

• Safeguard supply

• Refer to BFC/Mr Flannery for further

assessment

• Decision to snip is based on feeding

assessment in presence of tongue tie

• Continued Support

• Ballard J, Auer C, Khoury J (2002) Ankyloglossia: Assessment Incidence and Effect of Frenuloplasty on the

Breastfeeding Dyad. Available from: http://www.paediatrics.ofg/cgi/content/abstract/110/5/e63; (last accessed Mar 10)

BTAT Scoring system

Ingram J, et al. Arch Dis Child Fetal Neonatal Ed 2015;100:F344–F348. doi:10.1136/archdischild-2014-307503

• Bolling K, Grant C, Hamlyn B (2007) Infant Feeding Survey 2005 London: Information Centre

• DH Infant Feeding Survey 2010 London: Information Centre

• Fernando C (1998) Tongue-tie from confusion to clarity. A guide to the diagnosis and treatment of ankyloglossia.

Sydney: Tandem Publications

• Fewtrell MS (2004) The Long-term benefits of having been breastfeed. Current Paediatrics 14:97-103

• Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartman PE, Simmer K. (2008) Frenulotomy for Breastfeeding Infants

with Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound .Paediatrics 122;e188-

e194

• Griffiths DM. (2004) Do tongue ties affect breastfeeding? Journal Human Lactation 20(4):409-414

• Hazelbaker AK (1993) The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation Consultant

Private Practice. CA: Pacific Oaks College Thesis

• Horta BL, Bahl R, Martines JC,(2007) Evidence on the long-term effects of breastfeeding: systemic review and meta-

analysis. Geneva:WHO

• Lactation consultants of Great Britain (2001) Breastfeeding and Tongue-tie. www.lcgb.org/.uk

• Marild S, Jodal U, Hanson LA. (1990) Breastfeeding and urinary tract infection. Lancet 336(8720):942

• Messner AH, Lalakea M, Aby J, Macmahon J, Blair E. (2000) Ankyloglossia: incidence and associated feeding

difficulties. Archives of Otolaryngology-Head Neck Surgery 126(1):36-39

• Newcomb PA, Storer BE, Longneck MP. (1994) Lactation and a reduced risk of premenopausal breast cancer. New

England Journal of Medicine 330(2):81-7

• NICE (2006) Routine Postnatal care of women and their babies. London NICE

• Paton LM, Alexander JL, Nowson CA (2003) Pregnancy and lactation have no long-term deleterious effects on

measures of bone mineral in healthy women: a twin study. American Journal of Clinical Nutrition 77(3):707-14

• Quigley MA, Kelly YJ, Sacker A. (2007) Breastfeeding and hospitalisation for diarrheal and respiratory infection in the UK

Millenium Cohort Study. Paediatrics 119(4):e 837-42

• Rosenblatt KA, Thomas DB. (193) Lactation and risk of epithelial ovarian cancer: The WHO Collaborative Study of

Neoplasia and Steroids Contraceptives. International Journal of Epidemiology 22(2):192-7

• Watson-Genna C (2002) Tongue Tie and Breastfeeding Available

at:http://.illi.org/llleaderweb/LV/LVAAprMay02p27.html(accessed Mar 10)

• Wooldridge MW. (1986) The anatomy of infant sucking. Midwifery 2(4):164-171

• WHO/UNICEF (2003) Global Strategy for infant and young child feeding Geneva: WHO

References