Definition
Ankyloglossia, partial : The presence of a sublingual frenulum that changes the appearance or function of the infant’s tongue because of its decreased length, lack of elasticity, or attachment too distal beneath the tongue or too close to or onto the gingival ridge. In this document we will refer to partial ankyloglossia as simply “ankyloglossia.” “True” or “complete ankyloglossia,” extensive fusion of the tongue to the floor of the mouth, is extremely rare and is not within the scope of this discussion.
Background
At birth, the infant’s tongue is normally able to extend over and past the mandibular gum pad. Significant ankyloglossia prevents an infant from anteriorly extending and elevating the tongue, and many breastfeeding experts believe that these limitations alter the normal peristaltic motion of the tongue during feeding, resulting in the potential for nipple trauma and problems with effective milk transfer and infant weight gain.
Ankyloglossia, commonly known as tongue-tie, occurs in approximately 3.2% to 4.8% of consecutive term infants at birth and in 12.8% of infants with breastfeeding problems. The condition has been associated with an increased incidence of breastfeeding difficulties: 25% in affected versus 3% in unaffected infants.
Various methods have been suggested to diagnose and evaluate the severity of ankyloglossia and to determine the criteria for intervention. Short- and long-term consequences of ankyloglossia may include feeding and speech difficulties, as well as orthodontic and mandibular abnormalities and psychological problems.
In the 1990s a number of case reports and observational studies were published that documented an association between ankyloglossia and breastfeeding problems. There is considerable controversy regarding the significance of ankyloglossia and its management, both within and among medical specialty groups. Both the diagnosis of ankyloglossia and the use of frenotomy, an incision or “snipping” of the frenulum, to treat ankyloglossia vary widely. The frenotomy procedure, carefully performed, has recently been shown to decrease maternal nipple pain to improve infant latch and to improve milk transfer (personal communication, J. Ballard, July 27, 2004). There is a growing tendency among breastfeeding medicine specialists to favor releasing the tongue of the infant to facilitate breastfeeding and to protect the breastfeeding experience. To date, no randomized trials exist to demonstrate frenotomy for ankyloglossia is effective in treating infant or maternal breastfeeding problems.
Assessment of Ankyloglossia
All newborn infants, whether healthy or ill, should have a thorough examination of the oral cavity that assesses function as well as anatomy. This examination should include palpation of the hard and soft palate, gingivae, and sublingual areas in addition to the movements of the tongue, and the length, elasticity, and points of insertion of the sublingual frenulum.
When breastfeeding difficulties are encountered and a short or tight sublingual frenulum is noted, the appearance and function of the tongue may be semiquantified using a scoring system such as the Hazelbaker ( Table J-12 ). The Hazelbaker scale has been tested for interrater reliability (personal communication, J. Ballard, July 27, 2004) and validated in a sample of term neonates. Hazelbaker scores consistent with significant ankyloglossia have been shown to be highly correlated with difficulty with latching the infant onto the breast and maternal complaints of sore nipples. Alternatively, ankyloglossia may be qualified as mild, moderate, or severe by the appearance of the tongue and of the frenulum.
| Appearance Items | Function Items |
|---|---|
| Appearance of tongue when lifted | Lateralization |
| 2: Round or square | 2: Complete |
| 1: Slight cleft in tip apparent | 1: Body of tongue but not tongue tip |
| 0: Heart- or V-shaped | 0: None |
| Elasticity of frenulum | Lift of tongue |
| 2: Very elastic | 2: Tip to mid-mouth |
| 1: Moderately elastic | 1: Only edges to mid-mouth |
| 0: Little or no elasticity | 0: Tip stays at lower alveolar ridge or rises mid-mouth only with jaw closure |
| Length of lingual frenulum when tongue lifted | Extension of tongue |
| 2: > 1 cm | 2: Tip over lower lip |
| 1: 1 cm | 1: Tip over lower gum only |
| 0: < 1 cm | 0: Neither of the above, or anterior or mid-tongue humps |
| Attachment of lingual frenulum to tongue | Spread of anterior tongue |
| 2: Posterior to tip | 2: Complete |
| 1: At tip | 1: Moderate or partial |
| 0: Notched tip | 0: Little or none |
| Attachment of lingual frenulum to inferior | Cupping alveolar ridge |
| 2: Entire edge, firm cup | 2: Attached to floor of mouth or well below ridge |
| 1: Side edges only, moderate cup | 1: Attached just below ridge |
| 0: Poor or no cup | 0: Attached at ridge |
| Peristalsis | |
| 2: Complete, anterior to posterior | |
| 1: Partial, originating posterior to tip | |
| 0: None or reverse motion | |
| Snapback | |
| 2: None | |
| 1: Periodic | |
| 0: Frequent or with each suck |
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