Is tongue tie really the problem? Incidence of ankyloglossia in an infant population presented with suboptimal feeding: a cross-sectional survey

Introduction There is little consensus worldwide on the impact of ankyloglossia on breastfeeding difficulties, and the impact of frenulotomy on improving breastfeeding in these cases. While frenulotomy is encouraged in some countries, including the United States, it is not recommended in Canada or Japan, and has even been abandoned in the Netherlands.1 Worldwide prevalence estimates vary greatly, partly due to a lack of definitive diagnostic criteria.1 The current UK guidelines from the National Institute for Health and Clinical Excellence (NICE) state that there is little evidence for frenulotomy in improving the public health goal of higher long-term breastfeeding rates, and that conservative measures including massaging and exercising the frenulum should be implemented.2 There is growing evidence for the role of musculoskeletal dysfunctions contributing to suboptimal breastfeeding, and infants with suboptimal breastfeeding are increasingly presented to the chiropractor.3-6 It was noted in a previous study that the incidence of ankyloglossia (tongue tie) in a population presented for chiropractic care with suboptimal breastfeeding appeared to be disproportionately high at 58%,7 compared to worldwide estimates of 3-16%.8-11 In cases of suboptimal breastfeeding, musculoskeletal issues are also common,7 and it is anatomically plausible that ankyloglossia and musculoskeletal problems may coexist or even be directly associated. It would seem perfectly reasonable to chiropractors, and indeed allied health care professionals, that an adult with tight hamstrings could have changes in posture and biomechanics of their low back. Similarly, a tight lingual frenulum has the potential to alter the biomechanics of the tongue, jaw and neck, and cause the infant to use suboptimal motor patterns in an attempt to suck. Further, asymmetries of the head, jaw and neck are common in infants, and have been associated with birth trauma, birth intervention and prolonged second stage of labour.12 This is reflected in the population of infants in this clinic presented with feeding difficulties, where a higher than expected rate of birth intervention was demonstrated.7 The importance of mobility of the tongue has been demonstrated in an ultrasound study, which described wedging of the anterior tongue between the nipple-areola and the lower lip, and undulation of the posterior tongue.13 This requires the infant to As the number of infants presenting to chiropractors with the problem of suboptimal breastfeeding is increasing, further questions about this population are raised. The incidence of ankyloglossia (tongue tie) diagnosis appears to be high in this population. However, there is little literature or clarity on the role of the ankyloglossia in the often complex clinical presentation of feeding difficulties, particularly on sustaining breastfeeding in the medium to long term. This study was designed to describe a population of infants presented to a chiropractic teaching clinic with the problem of suboptimal breastfeeding, and assess this population for diagnosis and management of ankyloglossia. This will be used as a starting point for further research into these common problems of ankyloglossia and suboptimal breastfeeding. Inclusion criteria were infants presenting to this clinic with the complaint of feeding difficulties, as reported by the mother. Data were collected using maternal questionnaires and a total of 131 infants were included over a period of five months. Ankyloglossia had been diagnosed prior to presentation to the chiropractor in 39% of infants, and of these, 77% had undergone frenulotomy (tongue tie cut) once or more. Given the high incidence of ankyloglossia diagnosis and frenulotomy in these infants with persistent feeding difficulties, both the diagnosis and management of this problem must be reflected upon and questioned. This study highlights a clinical need for a) clearer diagnostic criteria for ankyloglossia and, b) further research with a focus on sustained breastfeeding following frenulotomy and other treatments.