All Tied Up! Influences of Oral Frenulae on Breastfeeding and their Recommended Management Strategies

Background: Recently, there has been an increased awareness of the role of the labial and lingual frenulae on a neonate's ability to latch and breastfeed efficiently. This critical review explores the (i) oral physiology of a baby nursing (ii) factors that can decrease a baby's ability to nurse efficiently, the problems these cause and their management and the (iii) relation between poor nursing efficacy and the risk of early childhood caries (ECC) Study design: An expansive search of the literature was performed using four electronic databases. Results and conclusions: Most studies assessing the role of labial and lingual frenulae on breastfeeding were of a low quality. The relation between ECC and poor nursing efficacy was found to be largely speculative. Hence, the results of these studies should be interpreted with caution. Despite the limited quality and external validity of the current evidence, in cases where breastfeeding difficulties are identified, surgical management of labial or lingual frenulae may provide some subjective improvements in breastfeeding outcome.

tongue tie, lip tie, ankyloglossia, frenotomy, breastfeeding

1. Akre J. Infant feeding: the physiological basis. World Health Organization; 1990.

2. NHMRC. Infant feeding guidelines. Dietary guidelines for children. Canberra: NHMRC. 2012.

3. AIHW. In: Australian national infant feeding survey: indicator results. 2011. Canberra: AIHW.

4. Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-e194.

5. Simpson JA, Weiner ESC, Oxford University P. The Oxford English Dictionary. Oxford; Oxford; New York: Clarendon Press ; Oxford University Press; 1989.

6. Nyqvist KH, Sjödén P-O, Ewald U. The development of preterm infants’ breastfeeding behavior. Early Hum Dev.;55(3):247-264. 1999.

7. Geddes DT, Kent JC, Mitoulas LR, Hartmann PE. Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev ;84(7):471-477. 2008.

8. Sanches MTC. Clinical management of oral disorders in breastfeeding. J Pediatr (Rio J).;80(5):s155-s162. 2004.

9. Woolridge MW. The ‘anatomy’of infant sucking. Midwifery. 1986;2(4):164-171.

10. Waller H. Clinical studies in lactation. W. Heinemann; 1938. 11. Howard CR, Howard FM, Lanphear B, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics. ;103(3):e33-e33. 1999.

12. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics;135(6):e1458-e1466. 2015.

13. Webb AN, Hao W, Hong P. The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol. 2013;77(5):635-646.

14. Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Arch Dis Child ;71(4):365-369. 1994.

15. Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. The Cochrane Library. 2007.

16. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int.;30(4). 1999.

17. Hong P, Lago D, Seargeant J, Pellman L, Magit AE, Pransky SM. Defining ankyloglossia: a case series of anterior and posterior tongue ties. Int J Pediatr Otorhinolaryngol;74(9):1003-1006. 2010.

18. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am;50(2):381-397. 2003.

19. Kotlow L. Infant reflux and aerophagia associated with the maxillary lip-tie and ankyloglossia (tongue-tie). Clinical Lactation ;2(4):25-29. 2011.

20. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck;126(1):36-39. 2000.

21. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract;18(1):1-7. 2005.

22. Amir LH, James JP, Donath SM. Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed Jm;1(1):1. 2006.

23. Ngerncham S, Laohapensang M, Wongvisutdhi T, Ritjaroen Y, Painpichan N, Hakularb P, et al. Lingual frenulum and effect on breastfeeding in Thai newborn infants. Paediatr Int Child Health.;33(2):86-90. 2013.

24. Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia Methodologic review. Can Fam Physician;53(6):1027-1033. 2007.

25. Duffy EP, Percival P, Kershaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breast feeding rates. Midwifery ;13(4):189-196. 1997.

26. Williams WN, Waldron CM. Assessment of lingual function when ankyloglossia (tongue-tie) is suspected. J Am Dent Assoc;110(3):353-356. 1985.

27. Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact;17(1):20-23. 2001.

28. Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg;41(9):1598-1600. 2006,

29. Riordan JM, Koehn M. Reliability and validity testing of three breastfeeding assessment tools. J Obstet Gynecol Neonatal Nurs;26(2):181-187. 1997.

30. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics;128(2):280-288. 2011.

31. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2):123-131.

32. O’Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol;77(5):827-832. 2013.

33. Pransky SM, Lago D, Hong P. Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol;79(10):1714-1717. 2015.

34. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatr Dent ;27(1):40-46. 2005.

35. Brookes A, Bowley DM. Tongue tie: The evidence for frenotomy. Early Hum Dev.;90(11):765-768. 2014.

36. Berry J, Griffiths M, Westcott C. A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding.Breastfeed Med;7(3):189-193. 2012.

37. Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, et al. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed. 2014;99(3):F189-F195.

38. Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013:0890334413491325.

39. Coryllos E, Genna CW, Salloum AC. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby:1-6. 2004.

40. Wiessinger D, Miller M. Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact ;11(4):313-316. 1995.

41. Douglas PS. Rethinking “posterior” tongue-tie. Breastfeed Med;8(6):503-506. 2013.

42. American Academy of P. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies. Pediatr Dent;30(7 Suppl):40. 2008.

43. Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet;369(9555):51- 59. 2007.

44. Featherstone JDB. The science and practice of caries prevention. J Am Dent Assoc;131(7):887-899. 2000.

45. Tham R, Bowatte G, Dharmage SC, Tan DJ, Lau MXZ, Dai X, et al. Breastfeeding and the risk of dental caries: a systematic review and meta‐analysis. Acta Paediatr;104(S467):62-84. 2015.

46. Mobley C, Marshall TA, Milgrom P, Coldwell SE. The contribution of dietary factors to dental caries and disparities in caries. Acad. Pediatr;9(6):410- 414. 2009.

47. Kotlow LA. The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: prevention, diagnosis, and treatment. J Hum Lact.;26(3):304-308. 2010.

48. Khoo AKK, Dabbas N, Sudhakaran N, Ade-Ajayi N, Patel S. Nipple pain at presentation predicts success of tongue-tie division for breastfeeding problems. Eur J Pediatr Surg.;19(06):370-373. 2009.

49. Bhattad MS, Baliga MS, Kriplani R. Clinical guidelines and management of ankyloglossia with 1-year followup: report of 3 cases. Case Rep Dent;2013. 50. Ripa LW. Nursing caries: a comprehensive review. Pediatr Dent.;10(4):268- 82. 1988.