Tongue-tie: ankyloglossia
Ankyloglossia is a congenital oral anomaly characterised by an unusually short lingum frenulum on the underside of the tongue. It is also called tongue tie. The condition can cause difficulties with breastfeeding, and speech and other problems in children and adults, including inability to lick the lips, play a wind instrument, or even with kissing.
There is a wide range of opinions regarding its significance, from having no significance to being the cause of significant problems [1]. Bandolier reviews the latest literature in the certain knowledge that someone will disagree with any conclusion.
Bandolier searched PubMed for any studies with ankyloglossia in title or abstract in the last 10 years. Those with abstracts that suggested them to be relevant for diagnosis, incidence or prevalence, or treatment, were retrieved and read.
Prevalence
Table 1 shows the incidence or prevalence results in breastfeeding infants or older children. In three US studies prevalence was 218 of 6,527 infants, an overall incidence of 3.3%. The range of 1.7% to 4.8% may have reflected different diagnostic criteria, and perhaps slightly different populations of infants (all newborn, or just those breastfeeding). There were 141 male and 72 female infants, a male:female ratio of 2:1.
Table 1: Studies on ankyloglossia prevalence and incidence in newborns and older children
| Reference | Location | Population | Definition | Incidence or prevalence |
| Breastfeeding | ||||
| Masaitis. J Hum Lact 1996 12: 229-232 | Oregon, USA | Breastfeeding newborns | Maternal questionnaire, and clinical diagnosis | 41 in 2,450 over 18 months Incidence 1.7% 36 frenotomies 20 male, 16 female |
| Messner. Arch Otolaryngol Head Neck Surg 2000 126: 36-39 | California, USA | Healthy neonates | Routine oral cavity examination, and clinical diagnosis | 50 in 1,041over 12 months Incidence 4.8% 36 male, 14 female 0 frenotomies |
| Ballard. Pediatrics 2002 110 (5): e63 | Cincinnati, USA | Term breastfeeding infants | Examination by same investigator, Hazelbaker assessment method | 127 in 3,036 infants over 42 months Incidence 4.2% 85 male, 42 female 123 frenotomies |
| Older children | ||||
| Pola. J Dent Child 2002 69: 59-62 | Oviedo, Spain | Six and 14 year old children | Examination by same investigator, measuring lingual mobility and dysglossia | 23 of 962 six year olds with short frenum Prevalence 2.4% 14 male, 9 female 32 of 732 14 year olds with short frenum Prevalence 4.4% 21 male, 11 female 55 frenectomies |
| Vörös-Balg. Oral Diseases 2003 9: 84-87. | Budapest, Hungary | Healthy children aged 1-14 treated in Pedodontic department over 18 months | Oral examination in a dental surgery | 9 of 1,017 Incidence of 0.9% 2 male, 7 female |
Two studies in Spain and Hungary examined ankyloglossia in older children. The prevalence in Spain was 2.4% in six years olds, and 4.4% in 14 year olds, while the incidence in a special clinic in Hungary was 0.9%. Again these were different populations and they used different assessment criteria. There were 37 male and 27 female children with ankyloglossia, a male:female ratio of 1.4:1.
Over all the studies, the male:female ratio was 1.8. Figure 1 shows the individual studies (two age ranges in one study in children), and demonstrates greater variability in the ratio with smaller samples.
Figure 1: Male:female ratio in ankyloglossia by size of study (dark symbols neonates)
Breastfeeding
To successfully nurse, an infant must latch on to the mother's areola with gum ridge, buccal pads and tongue. Movement of the jaw and tongue then squeeze milk from the ductules in the nipple, and tongue movements promote swallowing. Restriction of tongue movement because of a short lingum frenulum can affect latching on, and make feeding difficult for the infant and painful for the mother.
Untreated ankyloglossia can lead to more breastfeeding problems. In 36 mothers of affected infants, nipple pain lasting longer than six weeks, or difficulty with the baby latching on to the breast occurred in 9 (25%), compared with one of 36 (3%) in a control group of mothers with unaffected infants [2].
Surgical attention to the frenulum might make things better. In a small case series of 36 mother-infant pairs after frenectomy, most reported normal range of motion of tongue with complete or partial resolution of feeding problems by one week, and all by three months [3]. Breast feeding was continuing in 19 of 36 women at three months, and only two mothers discontinued because of ongoing breast feeding problems.
A larger and more detailed case series came to similar conclusions [4]. Here mean nipple pain was very significantly less after than before the operation (Figure 2). Ankyloglossia accounted for 35 of 273 (13%) mothers with breastfeeding problems seen at the outpatient lactation centre. Of these 31 were feeding more comfortably after the procedure. Three discontinued, and one was advised to bottle feed by a paediatrician.
Figure 2: Nipple pain on a 10-point scale before and after frenectomy in one study
Older children and adults
Two small but recent uncontrolled studies say something about surgery for ankyloglossia in children and adults.
In 30 children with ankyloglossia aged 1-12 years, surgery improved tongue protrusion and elevation [5]. In 15 children who had preoperative speech problems, improved articulation was found in nine after operation.
In 15 adolescents and adults with ankyloglossia aged 14 to 68 years [6], tongue protrusion and elevation were markedly less than in 20 controls (Figure 3). Surgery improved tongue protrusion and elevation by an average of 9 and 13 mm respectively.
Figure 3: Tongue movement in adolescents and adults with ankyloglossia and controls
Comment
That is essentially all the information found. No controlled trials in infants, not much about problems with older children or adults. Obviously paediatricians and ENT surgeons will see more severe cases, and general practitioners and midwives will refer some of the cases they see. Some cases may resolve spontaneously, or affected persons learn to compensate, but others may benefit from treatment.
But in the main this appears to be one of those areas where there is much opinion but little evidence. A much more thorough review [7] concludes that controversy is fuelled by lack of good information about intervention.
It is surprising that there is not more good information. Ankyloglossia is not rare, affecting one to four babies in every 100. There is a congenital component, but we know little about other possible associations, except possibly with cocaine use in pregnancy. Clearly there is a need for more research, which need be neither expensive nor complicated. Less opinion, please, and more evidence. A great topic for postgraduate qualifications and the tongue-tied.
References:
- AH Messner, ML Lalakea. Ankloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology 2000 54: 123-131.
- AH Messner et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000 126: 36-39.
- NS Masaitis, JW Kaempf. Developing a frenectomy policy at one medical centre: a case study approach. Journal of Human lactation 1996 12: 229-232.
- JL Ballard et al. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002 110:e63 (www.pediatrics.org/cgi/content/full/110/5/e63)
- AH Messner, ML Lalakea. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg 2002 127: 539-545.
- ML Lalakea, AH Messner. Ankyloglossia: the adolescent and adult perspective. Otolaryngol Head Neck Surg 2003 128: 746-752.
- ML Lalakea, AH Messner. Ankyloglossia: does it matter? Pediatric Clinics of North America 2003 50: 381-397.