Assessment of Ankyloglossia
All newborn infants, whether healthy or ill, should have a thorough examination of the oral cavity that assesses function as well as anatomy. This examination should include palpation of the hard and soft palate, gingivae and sublingual areas in addition to the movements of the tongue, and the length, elasticity and points of insertion of the sublingual frenulum.
When breastfeeding difficulties are encountered and a short or tight sublingual frenulum is noted, the appearance and function of the tongue may be semi-quantified using a scoring system such as the Hazelbaker (see Table 1 in the original guideline document). The Hazelbaker scale has been tested for interrater reliability and validated in a sample of term neonates. Hazelbaker scores consistent with significant ankyloglossia have been shown to be highly correlated with difficulty with latching the infant onto the breast and maternal complaints of sore nipples. Alternatively, ankyloglossia may be qualified as mild, moderate or severe by the appearance of the tongue and of the frenulum.
Assessment of the Breastfeeding Dyad
Breastfeeding complications due to ankyloglossia can generally be placed into broad categories of those due to maternal nipple trauma and/or failure of the infant to breastfeed effectively. Specific complaints include difficulty latching or sustaining a latch, infant becoming frustrated or falling asleep at breast, prolonged feedings, a dissatisfied baby, gumming or chewing at the breast, poor weight gain, or failure to thrive. Maternal complaints include traumatized nipples, severe unrelenting pain with feeding, inability to let down due to pain, incomplete breast drainage, breast infections, and plugged ducts.
The physician should interview the mother to ascertain her degree of confidence and comfort while breastfeeding. This can be done semi-quantitatively by using a scoring system such as the LATCH Score or a similar tool. The LATCH score has been shown to correlate with breastfeeding duration but only due to sub-scores for breast comfort.
If the mother describes any nipple pain, the physician may wish to use a pain scale in order to semiquantify her perception of the degree of her pain. This serves to follow trends in the severity of pain, which may help in determining the effectiveness of an intervention.
The infant should be weighed and the rate of weight gain since birth should be assessed. The physician should observe the mother and infant while breastfeeding, to assess the effectiveness of the feeding and provide assistance as appropriate. Problems including an inadequate or non-sustained latch and ineffective feedings should be noted. Test weights may be useful in assessing milk transfer. The infant should be weighed prior and after breastfeeding without a change in clothing or diaper; the difference between the weights in grams indicates the amount of breastmilk consumed in milliliters.
The mother's nipples should be examined carefully for creases, bruises, blisters, cracks, or bleeding. Areolar edema and erythema should be noted as possible signs of nipple infection. A family history of bleeding diatheses should be elicited.
Management of Ankyloglossia
Conservative management of tongue-tie may be sufficient, requiring no intervention beyond breastfeeding assistance, parental education, and reassurance. For partial ankyloglossia, if a tongue-tie release is deemed appropriate the procedure should be performed by a physician or pedodontist experienced with the procedure, otherwise a referral should be made to an ear, nose and throat specialist or oral surgeon. Release of the tongue-tie appears to be a minor procedure, but may be ineffective in solving the immediate clinical problem and may cause complications such as infant pain and distress and postoperative bleeding, infection, or injury to Wharton's duct. Complications, however, are rare.
Frenotomy or simple incision or "snipping" of a tongue-tie is the most common procedure performed for partial ankyloglossia (see "The Frenotomy Procedure" in the original guideline document). It should be recognized that postoperative scarring may further limit tongue movement. Excision with lengthening of the ventral surface of the tongue or a z-plasty release is a procedure with less postoperative scarring, but carries the additional risks of general anesthesia.
Management of Maternal and Infant Complications of Ankyloglossia
If nipple damage or infection is present, a problem-specific treatment program should be instituted. Mastitis and yeast infections should be treated according to established guidelines.
Some mothers may need nipple rest for one to several days to allow healing to occur before reinstituting feedings at the breast. These mothers should be encouraged to express their breast milk in order to maintain their milk supply, and to feed their milk to the baby by an alternate method.
Suppressed lactation should be addressed and every attempt made to re-establish the mother's milk supply. Infants who have been gaining weight slowly or failing to thrive may need to receive supplements of expressed breast milk or formula temporarily.
Follow-up for resolution of maternal and infant complications of ankyloglossia should take place by the mother's and/or infant's primary health care provider within 3 or 4 days of the frenotomy.
