Your Voice

March 1, 2008

Readers' letters on an article about ankyloglossia, or tongue-tie.

Tongue-tied

In regards to frenotomy being seldom discussed in pediatric training programs, I beg to differ. In programs where breastfeeding medicine is incorporated into the curriculum, such as the Academy of Breastfeeding Medicine, ankyloglossia is a routine problem that is addressed and managed.

In regards to local anesthesia, I tend to use it regularly. It not only prevents possible pain in the infant, but also provides the mother some comfort while her baby is undergoing the procedure. When doing the procedure, many of us do not use the hemostat. Things can get a bit tight in such a small space to work in, and good tongue elevation, proper assistance with restraints and a trusty sharp pair of blunt-tipped scissors usually suffices. In terms of age, I have done frenotomies up to 6 months of age without incident.

Finally, it also helps to have an otolaryngologist colleague readily willing to help when you have a baby with a true ankyloglossia that requires prompt surgical intervention.

Again, thank you for your article, which brought to attention a common problem that can hinder breastfeeding, but is easily managed.

Amy E. Evans, MDFresno, Calif.

Dear Editors,
I was very pleased that you published the fine article on ankyloglossia. Its importance has been all but forgotten in the US and in Europe since the 1960s, when formula became the norm for babies rather than breastfeeding. Its rebirth was due to increased knowledge of infant nutrition, revealing the benefits of breast milk. This has occurred slowly over the past 10 years. Had you asked med students what is a "tongue-tie," their response would probably be that they never heard of it.

The first written record and the recommendation of tongue-tie release shortly after birth was found in Japan, in a text dating back to 1025 BC.

I would like to make an addition to this excellent article. We have been studying the tongue and its function in nursing as it applies to the tongue-tie problem, using ultrasound before and after clipping. Our special interest has been the posterior tongue-tie or #4 subtype (in England "0%," in Japan "D").

In 2000 we "rediscovered" the posterior tongue-tie-behind the posterior mucosa of the mouth, often looking like a curtain screen, and formally recorded as a "short tongue." We had several infants in a row who had all of the classical symptoms of tongue-tie. They displayed poor elevation, poor side-to-side motion, usually poor extension, and caused nipple pain and trauma in the mothers. The babies showed easy fatigue, pulling off the breast, chewing the nipple, poor milk transfer, and occasionally a transiently good latch. The babies needed to go to the breast repeatedly and nurse almost continuously. The initial newborn latch, before milk engorgement of the breast, is often pretty good. After the milk comes in, the latch becomes progressively poorer, acting like a type-1 to type-3 tongue-tie.

To visualize this frenulum, it is almost essential to use the tongue elevator to push back the mucosa, so that the frenulum pushes through the groove and appears tight and shiny. To clip, one must hyper-extend the tongue so that the frenulum is outlined against the posterior mucosa, and then clip the rigid frenulum and overlying mucosa that springs open. The mucosa incision bleeds quite briskly, but responds to direct pressure (4 min.) with a gauze-covered finger. Rubber bite blocks can be helpful in keeping the mouth open.

The baby is then put to the breast after being calmed and when bleeding has stopped (about 10 minutes). There is usually an immediate improvement in latch, gape, and milk transfer. This may then relapse because of soreness (acetaminophen about 10 mg/kg every four hours for one day, then every six hours for four doses, and then PRN for up to four days). Sustained good nursing takes from five days (under one month of age) to six or more days (over three months of age). There is a big improvement in gape. It takes much patience and perseverance to retrain the older infant. There is also a big improvement in swallowing, reflux, and overall mother and child emotional satisfaction.

Truly,Elizabeth Coryllos, MD, IBCLC, Emeritus Chief of Pediatric Surgery at Winthrop-University Hospital,Catherine W. Genna, BS, IBCLCGerald Ente, MD