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Three Part Question

In [babies with poor breastfeeding and a tongue tie], does [division of the tongue tie compared to breastfeeding advice alone] [improve feeding]?

Clinical Scenario

A specialist registrar in a district general hospital receives a call from a health visitor who has seen a 2-week-old baby who is struggling to breastfeed adequately and who has a marked tongue tie. The parents are extremely anxious and after searching the internet are now requesting a tongue division as they are certain that this is the cause of the problem. The health visitor can also recall many success stories after this procedure and is concerned that without it the mother will abandon breastfeeding altogether. She asks you to refer the baby to the ENT specialists with a view to division.

Search Strategy

Cochrane and BestBETS: no relevant results.

NICE guidelines: one interventional procedure guideline.

Medline OVID

Medline (1996–November Week 3 2008) searched via Ovid with Breastfeeding AND (Tongue tie OR Ankyloglossia). Results were limited to humans, English language and all infants (birth to 23 months).

Search Outcome

Number of hits: twenty one, of which six were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hogan et al, 2005,	1866; 88 with tongue tie and feeding problems. 57 randomised: 28 had a division, 29 received intensive feeding support.	Randomised Controlled Trial (level 1b)	Subjective feeding improvement gleaned from a non-structured interview	27/28 (96%) of the division group improved, all within 48 h; 1/29 (3%) of the feeding support group improved. Those who did not improve had a division and 27/28 (77%) improved, all immediately.	Bias introduced as all non-division group were told that they could have a division if they did not improve. Follow-up was not independent.
Griffiths et al. 2004.	519 were followed after a division. 215 were followed up for <3 months.	Prospective uncontrolled cohort study (level 2b)	Structured interview of feeding and length of breastfeeding at 1 day and 3 months after division	174/215 (80%) had improved feeding. 124/215 (57%) had improved feeding immediately.	All had had intensive breastfeeding support prior to division. No growth data included. Diagnosis, division and follow-up all carried out by lactation consultants.
Amir et al, 2005	46 babies had tongue tie and breastfeeding problems. 35 had tongue tie severity scores that were high enough to recommend a division.	Uncontrolled case series (level 4)	Structured telephone interview at least 3 months after the division	Breastfeeding improved in 29/35 (83%) after the division.	Only those with the most severe degree of tongue tie were offered a division and followed up. 18 (51%) reported better attachment to the breast, 20 (57%) had improved sucking and 9 (26%) reported less pain.
Ballard et al, 2002	3036; 123 with tongue tie. 35 had poor feeding and impaired lingual function and underwent division.	Uncontrolled case series (level 4)	Unstructured interview 3 days after the procedure and at routine outpatient appointment	35/35 (100%) reported improved latch at 3 days. At routine outpatient follow-up (unspecified timing), 31/35 (89%) mothers said they were breastfeeding more comfortably and were “delighted” with the outcome. 3/35 (8.5%) stopped breastfeeding.	Growth data alluded to as 5/6 (83%) of those with preceding failure to thrive breastfed and achieved a normal rate of growth within 3–5 days after the procedure. Little information about growth data. There was no consistency throughout case series.
Masaitis and Kaempf, 1996	2450 babies studied. 36 of these had breastfeeding problems and a tongue tie and their parents agreed to a division.	Case report (level 4)	Continuation of breastfeeding, growth	36/36 (100%) had normal feeding after division. 34/36 (96%) had appropriate growth at 3 months,	No data provided about growth preceding the procedure.
Marmet et al, 1990	13 with tongue tie and breastfeeding problems; 7 had a division.	Case report (level 4)	Interview, non-structured	5/7 (71%) had improved latch. 1/7 (14%) showed no improvement.	Subjective measurement of success but it did correlate with those who had catch-up weight gain after the procedure.
Fleiss et al, 1990	3 babies with tongue tie and breastfeeding problems. 2 had a division.	Case report (level 4)	Interview, non-structured	1/2 (50%) had improved sucking. 1 (50%) developed a lisp as a child.	Small numbers and informal follow-up

Comment(s)

The effect of tongue tie on breastfeeding has been the subject of much controversy for many years and doctors have traditionally been the most sceptical about its effect(Messner).

In one study 90% of paediatricians and 70% of the ENT specialists surveyed felt that tongue tie rarely caused feeding difficulties compared to only 1% of lactation consultants. Geddes et al used ultrasound to study the efficacy of milk removal and suck before and after tongue tie division in 24 babies. They found that milk intake, milk transfer rate and the degree of latch improved in all babies after the procedure, apparently secondary to a lessening in compression of the nipple by the tongue after the division (Geddes). Despite this, there has been only one randomised control trial (RCT) comparing the effect of division with breastfeeding support alone. In this UK trial, each arm contained less than 30 babies and both groups were managed by lactation consultants, with the non-division patients being informed at the onset that they could have the procedure if they did not have a favourable outcome. There were therefore problems with bias, and subsequently impressive results were published: there was a 96% improvement in feeding in the division group compared to a 3% improvement in those only having feeding support (Hogan). In addition to the RCT, Griffiths’ prospective cohort study supported the use of division as a treatment for poor breastfeeding for those with a tongue tie. This and other case series and case reports which all suggest that division does have a role in resolving feeding difficulties (Amir, Ballard, Masaitis, Marmet, Fleiss) are in the most part gleaned from non-structured interviews with mothers, in many cases by lactation consultants who are often very much in favour of the procedure.

The effect division has on weight gain is a more objective marker of feeding success and is something that has been studied very little. One must remember that breastfeeding is multifactorial and a psychological effect cannot be ignored. Furthermore, little has been done to unpick exactly what the cause of breastfeeding problems is when the diagnosis of tongue tie has been made. The whole issue is complicated when considering that many studies have attempted to measure the degree of tongue tie, a notoriously difficult endeavour, and that once graded, the degree of impairment appears not to correlate with breastfeeding problems (Ricke). With all this considered, one cannot ignore the plethora of documented experience that supports this procedure, so much so that NICE have produced an interventional procedure guideline that acknowledges that the little evidence there is does seem to suggest that this procedure can improve breastfeeding while having no major safety concerns. As a result it suggests that the evidence is enough to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance. If mothers overwhelmingly tell us that it works, then why should we argue?

Clinical Bottom Line

Observation studies and randomised controlled trials with high risk of bias report the majority of mothers believe that breastfeeding benefits from a tongue tie division. (Grade B) Unless evidence of significant harm emerges, it seems reasonable to facilitate frenulotomy if appropriate structures are in place. (Grade B)

References

1. Messner A, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol 2000;54:123–31.
2. Geddes D, Langton DB, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122:188–94.
3. Hogan M, Westcott C, Griffiths M. Randomised control trial of division of tongue tie in infants with feeding problems. J Paediatr Child Health 2005;41:246–50.
4. Griffiths D. Do tongue ties effect breastfeeding? J Hum Lact 2004;20:409–14.
5. Amir L, James JP, Beatty J. Review of tongue tie release at a tertiary maternity hospital. J Paediatr Child Health 2005;41:243–45.
6. Ballard J, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002;110:1–6.
7. Masaitis N, Kaempf J. Developing a frenulotomy protocol at one medical center: a case study approach. J Hum Lact 1996;12:229–32.
8. Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary to correct breastfeeding problems. J Hum Lact 1990;6:117–21.
9. Fleiss PM, Burger M, Ramkumar H, et al. Ankyloglossia: a cause of breastfeeding problems? J Hum Lact 1990;6:128–9.
10. Ricke L, Baker NJ, Madlon-Kay DJ, et al. Newborn tongue-tie: prevalence and effect on breastfeeding. J Am Board Fam Pract 2005;18:1–7.
11. National Institute for Health and Clinical Excellence. Interventional procedure guidance 149. Division of ankyloglossia (tongue tie) for breastfeeding. London: NICE, 2005.