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LatchingOnToaBetterUnderstandingofTongueandLipTies

ErikBauer,MDPediatricENTofAtlanta,P.C.

EmoryBreastfeedingConference

March12,2018

Tongue‐tie(Ankyloglossia)

AcademyofBreastfeedingMedicinedefinition

“asublingualfrenulum(bandunderneaththetongue)whichchangestheappearanceand/orfunctionoftheinfant’stonguebecauseofitsdecreasedlength,lackofelasticityorattachmenttoodistalbeneaththetongueortooclosetoorintothegingivalridge”

Doestonguetieaffectbreastfeeding?

1041infantsscreenedforankyloglossiaatWBC Incidence4.8%,M:Fratio2.6:1

Breastfeedingproblems(nipplepainlastinglongerthan6weeksand/ordifficultyofthebabylatchingontothebreast)reportedin: 25%ofinfantswithankyloglossia 3%ofcontrols

Conclusion:ankyloglossiaisassociatedwithBFdifficultyinselected infants,whileothersareabletocompensate…let’sexplorewhy.

Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E.Arch Otolaryngol Head Neck Surg. 2000 Jan;126(1):36‐9. Ankyloglossia: incidence and associated feeding difficulties.

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TongueEmbryology

Tonguedevelopsbetween4‐7weeksofpregnancy

Contributionsfromall4pharyngealarchesandtheirnerves

Fusionofbilateraltissuebudsfromfloorofthemouth(musclelayerunderthetongue)

Budsfusefrombacktofront

Apoptosis(programmedcelldeath)separatestonguefromFOM

Thefrenulumisaremnantofthisprocesswithavariabledegreeofpersistence

MechanicsofBreastfeeding

Upperlipflangesabovenippletoreachareola,wideningthemouthgape

Theinfantmovesthetongueforwardtograspanddrawthenippleandareolaintothemouth

Fronttomid‐dorsaltongueliftsthenippleagainstthehardpalateandmustformanairtightsealwithminimalcompression

Tonguebasedropsdown,expandingthechambertocreatenegativepressureandextractingmilkfromthebreast

Someinfantswithlatchrestrictionareunabletograspthenipple/breast,whileothersattachpoorlycausingnipplepainordamage

Ultrasoundimagingofinfantswallowingduringbreast‐feeding.GeddesDT,ChadwickLM,KentJC,Garbin CP,HartmannPE.Dysphagia.2010Sep;25(3):183‐91.

AnatomyofBreastfeeding

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MechanicsofBreastfeeding:AnatomicConsequence

Mostimportantsinglemechanicalfactorforlatchingsuccess:Totalsurfaceareaofcontactbetweenbaby’smouthandnipple/areola

RestrictedLatchFeedingPattern

Consequenceoflossofsuctionwithinadequateseal

Troubleestablishinglatch,shallowlatch,frequentseparation

Biting,pinchingor“chomping”nipplewithgumridges

“Lipstick”compressionorblanchingofnipple

Nipplepain,crackingorblistering;pluggedductsormastitis

Clickingandairswallowing,gassyafterfeeds,frequentspitup

Ineffectivemilktransfer,breastnotdrainedafterfeed

Prolonged,frustratingfeedsandlittlerestbetweenfeedings

Frequentsuspectedthrushthatdoesnotrespondwelltotypicaltreatments

Poorweightgaininbaby,poormilkproductioninmother

MultifactorialElements

Manyfactorsotherthantongueandliptiesmaycontributetobreastfeedingdifficulties

InfantFactors Higharchedorcleftpalate Recessedjaw Coordination/strengthofsuck,tonguemuscle Oromotortone Airway/breathing(suck/swallow/breathecoordination)

MaternalFactors Decreasedmilksupply

Breasthypoplasia/insufficientglandulartissue(IGT) Stress/hormonalissuesaffectingletdown Short,flatorinvertednipple

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PregnancyandDeliveryImpactBreastfeeding

Notallcausesofpoorbreastfeedingarestructural/anatomic

Manycausesoflowmilkproductionorineffectivebreastfeedingcanbeidentifiedandmanaged hypothyroid Insulindysregulation PCOS Fertilitystruggles Alcoholandtobaccouse Postpartumdepression Medications,herbs,andnaturalremedies

SummationofFactors

EvaluateFrenuluminContext Theseverityofbreastfeedingdifficultydoesnotcorrelateperfectlywithanatomicalseverityoftongue‐tieperse

Ifallotherfactorsfavoreffectivebreastfeeding,thebabymayfeedwellevenwithvisibleankyloglossia

Ontheotherhand,ifotherfactors(particularlythehigharchedpalate)aresuboptimal,treatingthefrenulummaybehelpfulevenifthetonguetieitselfappearsverymild

Thetongueandliparethemosttreatableanatomicfactorsaffectingbreastfeeding

Allotherthingsbeingequal,MOREcontactsurfaceareaisbetterthanLESS.

Therefore,thefeedingpattern,nottheexam,dictatestheneedandlikelybenefitoffrenulectomy

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SchematicofBFdifficulty

Breastfeedingdifficulty

Structurallatchrestriction

Classicalanteriorankyloglossia

Normalinfanttongue

Tongueelevatescompletelyatthetip,reachespalatewithmouthatleasthalfwayopen,nolateralcurling

http://www.cwgenna.com/qhcontent.html

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Anterior(Type1)Tongue‐Tie

Frenuluminsertsattonguetip;obviousheart‐shapedindentationwithprotrusionandlateralcurling/cuppingwithelevation,variabledegreeofrestrictiondependingonlength,height,laxityoffrenulum

http://www.cwgenna.com/qhcontent.html

Anterior(Type2)Tongue‐Tie

Stillavisiblemucosalfrenulum,butinsertsposteriortotip,maynotbeobviousunlesstongueiselevated

Posterior(Type3)Tongue‐Tie

Nomucosalfrenulum,buttightattachmentisvisiblewithattemptedelevationandeasilypalpable

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Posterior(Type4)Tongue‐Tie

• Novisiblefrenulumunlessfloorofmouthcompressedwithgroovedirectorortonguedepressors

• Poortonguetipelevationevident,lateralcurling• Often“relativeankyloglossia”withshorttongue,inadequate

mobilitytocompensateforhighpalate/otheradversefactors

LabialTie

• Usuallyassociatedwith“posteriortongue‐tie”• Labialfrenulumthickened,insertsonorbeyondgumline• Lipcannotflangeupovernipple,limitingdepthoflatch

FrenulectomyProcedure

Toleratedwellin‐officeuntilatleast3,upto6monthsofage

Infiltratelocalanesthetic(1%lidocainewithepinephrine)toreducepainandbleeding

Elevatetongue(and/orlip)andexposefrenulumwithgrooveddirector

Clamptodispelvesselsandstabilizeband

Sharplyreleaselingualand/orlabialfrenulumwithscissorsorlaser

Oxymetazoline/silvernitrateasneededtoreduceanybleeding

Bleedingisthemostsignificantrisk:Suturerarelynecessary(<0.5%)butshouldbeavailable

Immediatebreastfeedingaftertreatmenttosoothebabyandgetfeedbackfrommom

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Whentodoit Anatomyisnotirrelevantbutisnottheprimaryconcernintreatment

decision.Favorreleasewhenfeedingpattern(function)andexamaresuggestiveofstructurallatchrestriction,evenwhentongue‐tieisitselfnotobvious

Recommendedevenwithnormalfeedingiftightenoughtopotentiallyaffectspeech(i.e.anteriortype1‐2)

Noturgentunlessunabletobottlefeed,buttheearlierthebetter

maladaptivecompensatorymaneuvers

decreasedmilksupply

generalanesthesiarequiredinolderinfantsandchildren

Parentaloptionorwaitingperiod,especiallyinequivocalcases

Goalistoworkwiththebaby’sanatomytotreatthetreatablefactorsandachievemaximumsaferelease

DecisionAlgorithm

Latch Restriction Feeding Pattern

Under 6 months

Tip restriction (type 1‐2)

YES

NO

YES

YES

In‐office (local) Lingual/labialfrenulectomy

OR (gen anes) Lingual ± labialfrenulectomy

No procedure needed

NO

NO

TimingofFrenulectomy

Reviewof302infantswhounderwentfrenotomy

91mothersinf/utelephonesurvey

80%strongbenefit,82%restarted/continuedbreastfeeding

86%successin1st weekoflife,74%afterwards

Oncetonguetieisdiagnosed,earliertreatmentisbetter

SteehlerMW,SteehlerMK,HarleyEH.Aretrospectivereviewoffrenotomyinneonatesandinfantswithfeedingdifficulties.InternationalJournalofPediatricOtorhinolaryngology 76(9)(2012Sep),1236‐40.

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ImmediateResults

Randomizedcrossovertrial

57infantsenrolledwithbreastfeedingdifficultyandanteriortongue‐tie 29controlsassignedtolactationconsultation:1improved(3.4%)enoughtodeclinefrenulectomyat48h

28immediatefrenulectomy:27improved(96%)

28whofailedLConlyarmthenunderwentfrenulectomy:27improved(96%)

60%stillbreastfeedingat4months

HoganM,WestcottC,GriffithsM.Randomized,controlledtrialofdivisionoftongue‐tieininfantswithfeedingproblems.JPaediatrChildHealth.2005May‐Jun;41(5‐6):246‐50.

Frenulectomy&BreastfeedingOutcomes

62feedingpairsreferredafterfailuretoimprovewithlactationconsultationtooptimizepositioningandlatch

Uncontrolledprospectivecohortstudywithquestionnaireonpresentationandat3months

KhooAKKetal.NipplePainatPresentationPredictsSuccessofTongue‐TieDivisionforBreastfeedingProblemsEur JPediatr Surg 2009;19:370– 373

ImprovedBreastfeeding

• Presentationwithnipplepainmostpredictiveoflong‐termsuccess(OR5.8[95%CI1.1– 31.6].)

• 78%stillbreastfeedingat3months• 52%haddifficultyscoreof0(nobreastfeedingproblems)post‐tx

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UltrasoundConfirmation

24infantswithankyloglossiaexperiencingpersistentbreastfeedingdifficultiesdespitelactationadvice

Ultrasoundimagestakenfrombelowthejaw,beforeandafterfrenulectomy,showedimprovedbreastfeedingasdefinedby

Decreasedjawexcursion(i.e.lessbiting/chomping) Lesscompressionofthenipplebythetongue Betterattachmentwithlessfrequentseparation Increasedmilktransfer Alsoassociatedwithlessmaternalpain

GeddesDT,LangtonDB,GollowI,JacobsLA,HartmannPE,SimmerK.Frenulotomy forBreastfeedingInfantsWithAnkyloglossia:EffectonMilkRemovalandSuckingMechanismasImagedbyUltrasoundPediatrics2008;122:e188–e194

AdditionalReportedBenefits

Increasespost‐frenotomyin: meaninfantmilkintake(50.5ml→69.1ml) meanmilktransferrate(5.6ml/min→ 10.5ml/min)

meanmaternal24hr milkproduction(455ml→ 615ml)

GeddesDT,LangtonDB,GollowI,JacobsLA,HartmannPE,SimmerK.Frenulotomy forBreastfeedingInfantsWithAnkyloglossia:EffectonMilkRemovalandSuckingMechanismasImagedbyUltrasoundPediatrics2008;122:e188–e194

Anteriorvs.PosteriorTongue‐TieSuccessRates

311infantsevaluatedforfren,299(95%)treated

16%TypeI/II,36%TypeIII,49%TypeIV

37%alsolabial(21%TypeI/II,30%TypeIII,48%TypeIV)

Amongthosewiththesepre‐interventionproblems: Nopost‐interventionlatchdifficulty:100%ant,50%post

Nomaternalnipplepain:79%ant,60%post

Frenulectomycanbesuccessfulinbothgroupsbutmoreposteriortiemorelikelytoberefractorytotreatment

O’Callahan C,Macary S,ClementeS.Theeffectsofoffice‐basedfrenotomyforanteriorandposteriorankyloglossiaonbreastfeeding.InternationalJournalofPediatricOtorhinolaryngology77(2013)827–832

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LipTie/PosteriorTongueTie

Retrospectivereviewof618patientsfromadedicatedbreastfeedingdifficultyclinicin2014

47%‐ anteriorankyloglossiaalone19%‐ posteriorankyloglossia6%‐ bothanteriorankyloglossiaandupperlip‐tie5%‐ posteriorankyloglossiaandupper‐liptie2%‐ upper‐liptiealone.21%‐ “noanomaly”

Anteriorankyloglossia:78%reportedsomedegreeofimprovementinbreastfeedingafterfrenotomy.

Posteriorankyloglossia,91%reportedsomedegreeofimprovementinbreastfeedingafterfrenotomy.

Upperlip‐tiereleasealsoledtoimprovedbreastfeeding(100%).Pransky SM,LagoD.,HongP.Breastfeedingdifficultiesandoralcavityanomalies:Theinfluenceofposteriorankyloglossiaandupper‐lipties.InternationalJournalofPediatricOtorhinolaryngology79(2015)1714–1717

LipTie/PosteriorTongueTie

Prospectivecohortstudyof237dyadsfromadedicatedbreastfeedingdifficultyclinicin2014‐15

78%hadposteriortonguetie

75%lip/tonguerelease,25%tongueonly,0.4%liponly

3%requiredrevisionprocedures

Preop,1week,and1monthpostopsurveys BreastfeedingSelf‐Efficacy(BSES‐SF):42.9→52.3→56.5 Visualanalogscale(VAS)fornipplepainseverity:4.6→2.2→1.5 InfantGastroesophagealReflux(I‐GERQ‐R):16.5→13.2→11.6 Breastmilkintakeandtransferratepre‐ /1wk post3.4→4.9ml/min Allchangesstatisticallysignificantatp<0.001

Ghaheri BAetal. BreastfeedingImprovementFollowingTongue‐TieandLip‐TieRelease:AProspectiveCohortStudyLaryngoscope,127:1217–1223,2017

LipTieRecommendations

Morerecentlyrecognizedcontributortolatchrestriction

Nostudiesaddressinglabialfrenulectomyisolatedfromtreatmentoftonguetie,astheytypicallycoexistandaretreatedtogether

Improvedflangingofupperlipallowswidermouthopening,deeperpositionofnipple/areolawithinmouth,increasedcontactsurfacearea andmoreeffectivetonguefunction;“everylittlebithelps.”

5‐10secondsadditionalproceduretime;noadditionalriskorrecoverytime;avoidanceofpotentialsecondprocedure

ThereforeIfavorlipreleasealongwithlingualfrenulectomyunlesslipflangingisclearlyunrestricted

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Post‐treatmentcare

Firstfeednotalwayssuccessfulduetonumbnessand/orpain;firstgoalistosoothebaby

30‐50%immediateresponserate,80%willhaveimprovementwithinfirst3‐5days

Infantacetaminophenasneeded

Lip/tonguestretchingtohelpreducere‐scarring

Bottlesupplementationasneededtorestmomand/orbaby

LCvisitabout3‐7daysoutishelpfulinconsolidatingimprovementsandaddressingpositioningissues

Post‐treatmentCare

Skintoskintoreducepainandimprovecoordination

Laid‐backbreastfeeding

Kindnessduringstretches

Continuefollowupwiththerapists(especiallyLC,mayalsoincludeST/OT,somefindsuccesswithCST)

Expectprogresswithregressions(“twostepsforward,onestepback”)

ThankYou!