Ankyloglossia (Tongue-tie)

Frenulum linguae.jpg
https://en.wikipedia.org/wiki/Ankyloglossia

Introduction

Tongue-tie is a condition in which the lingual frenulum is either too short or anteriorly placed limiting the mobility of the tongue. No clear definition has been identified, however, as there is no universally applied criteria for the diagnosis of ankyloglossia.

Early in fetal development, the tongue is attached to the floor of the mouth. With cell death and atrophy, the only attachment is the frenulum. Tongue-tie results when the frenulum is too short, which may limit the movement of the tongue to varying degrees.

Ankyloglossia affects 1.7% to 4.8% of all infants.

Physical exam will easily demonstrate the short or anteriorly placed lingual frenulum. When there is an attempt to stick the tongue out, there may be a V shaped notch at the tip.

Years ago it was routine to clip the frenulum at the time of delivery. Midwives had a long sharp nail to cut the frenulum and obstetricians would inspect the mouth and cut the frenulum immedialtely after the delivery. It was felt that tongue-tie was associated with speech abnormalities especially lisping and inability to pronounce certain sounds. However, current research has not supported this.

Why is ankyloglossia concerning? 

  • Breastfeeding difficulty, speech articulation impairment, and dental problems 
  • In light of the above complications, particularly breastfeeding difficulty, Ballard et al. recommends that the routine neonatal examination should include inspection of the newborn’s tongue and its mobility in order to inform parents of children with ankyloglossia of potential feeding, speech, and dental problems.
    • Primary concern is interference with breastfeeding
      • Typically presents as difficulty latching onto the breast and inadequate milk transfer,  --> leading to prolonged feedings and poor weight gain. In addition
      • Sore nipples, pain with feeding, and incomplete breast drainage
  • Speech:  As children begin to speak, the condition may affect speech articulation, particularly sounds that require fine movements of the tip of the tongue, such as t, d, l, th, and s. However, ankyloglossia does not cause speech delay.
  • Dental problems: Because of its compromised mobility, the tongue may tend to rest near the floor of the mouth, creating a space between the lower incisors over time. In addition, children who are unable to move their tongue laterally and posteriorly to clean their teeth may be at risk for caries and calculus accumulation. 

Management

  1. Physician education
  2. Parental education and reassurance
  3. Monitor for appropriate weight gain if exclusively breastfeeding, consider frenotomy
  4. Complete fusion requires surgery

References

  1. Buryk M., Bloom D., Shope T. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics August 2011
  2. Mayer, D. Frenotomy for breastfed tongue-tied infants: a fresh look at an old procedure. AAP January 2012.
  3. Forlenza G et al. Ankyloglossia , Breastfeeding, and Failure to Thrive.  Pediatrics June 2010
  4. Ballard J., Auer C., Khoury J. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad.  Pediatrics November 2002.

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