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James G. Murphy MD, FAAP
This condition, commonly known as tongue-tie, has been recognized to some degree for centuries. At the beginning of the last century in the US, this entity was noted at birth and was dealt with swiftly and effectively in the delivery room. Hospitals had equipment for this included in the delivery instrument tray. But that was when everyone was breastfed. As formula replaced breastfeeding this tongue membrane became a far less important problem since the tongue has a much-reduced role with a rubber bottle nipple. Fortunately, breastfeeding is increasing, returning our society to the optimal form of nutrition for newborn infants, human milk (Liquid Gold). The sometimes-severe limitation of tongue movement is a barrier to obtaining a painless, effective latch in a small number of infants and thus interferes with the establishment and continuation of breastfeeding.
Current medical teaching about ankyloglossia is highly variable, but the majority of physicians are taught that the lingual frenulum is never or almost never a problem because, it is said, it stretches as the child grows; the tongue thins and elongates forward of the frenulum; or, it breaks on its own (since few adults are tongue-tied). This dictum of medical education has no scientific basis and no studies to support it, yet it persists in the current era of evidence-based medicine.
Unfortunately, there is no universally agreed upon definition of ankyloglossia. A general definition is: a membrane present at birth that connects the tongue to the floor of the mouth and may have an adverse effect on breastfeeding, speech and dental/facial development. Physicians feel they know it when they see it; NOT! I just saw a 4 y/o with speech problems and an obviously restrictive lingual frenulum whose medical record carried my notation on the newborn exam: "Tongue is OK, not ankyloglossia". Oops, that was before I joined the San Diego County Breastfeeding Coalition, spoke to, and listened carefully to, well-informed lactation specialists and Academy of Breastfeeding Medicine physicians, and realized that I did not have much correct information about this problem at all. In medical school on day one, medical students are told that much of what they will learn over the next 4 years is wrong but that it is not clear which information is incorrect. Thus they are advised that medical education is life long, adding new information and correcting old information. We have unlearned some of what is true as well.
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In my experience, ankyloglossia is generally of three classes, each of which has its own corrective procedure:
A thin membrane from the root of the tongue to a point on the underside of the tongue in the midline between the root and the tip of the tongue. While very thin and with few or no blood vessels or nerves, it can firmly restrict tongue movement, although I recently examined a newborn who had this type frenulum all the way to the tip of the tongue, and he breastfed beautifully. Frenotomy of this type membrane results in little to no bleeding. Anesthesia is often used but felt to be optional by some experts.
A thick membrane in the same location as #1 but with many blood vessel and nerves. Anesthesia is needed to horizontally separate this membrane with brief (<10 minutes) of bleeding from the edges of the relatively diamond shaped defect in the membrane thus created. The wound heals along the underside of the tongue and along the floor of the mouth effectively in the newborn without sutures. In older children this wound requires suturing of the edges along the bottom of the tongue and the floor of the mouth.
A very broad thick membrane or complete fusion of the tongue to the floor of the mouth, both of which require general anesthesia to manage and involve complex surgical repairs.
(Note: Dr Coryllos describes a 4th type which lies at the root of the tongue, is a short, thick membrane usually overlooked that restricts tongue movement. I have not yet encountered this type of problem.)
Thus, thick or thin, long or short, it is almost impossible to tell if any given frenulum will be a clinical problem from visual inspection alone. An "Assessment Tool for Lingual Function®"1 has been developed to rate the tongue mobility at various ages. This tool, to my knowledge, has not yet been validated in a large study. Functional clinical assessment is still the best approach to this problem. A skilled Lactation Consultant (LC) may be able to teach the mom and infant to latch without pain and achieve effective milk transfer despite the frenulum.
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