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Congenital tongue-tie and its impact on breastfeeding

  • Private practice
For the second time in U.S.
history, a national breastfeed-
ing campaign has been
The goal of the National
Breastfeeding Awareness
Campaign is to encourage
mothers to commit to exclu-
sive breastfeeding for the first
6 months of their child’s life in
order to reduce morbidity and
Contemporary science has
demonstrated unequivocally
an increased disease burden
in children who were not
breastfed, with maximal bene-
fit occurring in those who were
exclusively breastfed for the
first 6 months of life. Epidemi-
ological data, however, dem-
onstrate that exclusive breast-
feeding rates have remained
very low, despite the rise in
overall breastfeeding
By Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC
Catherine Watson Genna, BS, IBCLC
Alexander C. Salloum, MD, MA
By Lori Feldman-Winter, MD, FAAP
Many of today’s practicing physi-
cians were taught that treatment
of tongue-tie, (ankyloglossia) is
an outdated concept a relic of
times past. Among breastfeeding
specialists tongue-tie has
emerged as a recognized cause
of breastfeeding difficulties - and
a very easily corrected one.7,8,10,12,
14, 19
During the last several decades
of predominant bottle-feeding,
tongue-tie was relegated to the
status of a “non-problem” be-
cause of the lack of significant
impact upon bottle feeding be-
haviors. The goal of this article is
to alert pediatricians to the po-
tential link between tongue-tie
and breastfeeding problems in
order to expedite intervention in
symptomatic cases.
Background Information
Tongue-tie (ankyloglossia, tight
frenulum) is a condition in which
the bottom of the tongue is teth-
ered to the floor of the mouth
by a membrane (frenulum) so
that the tongue’s range of mo-
tion is unduly restricted. This
may result in various oral devel-
opment, feeding, speech, swal-
lowing, and associated problems.
Genetic factors are suspected, as
tongue-tie is frequently familial.
Tongue-ties can be divided into
four types, according to how
close to the tip of the tongue
the leading edge of the frenulum
is attached:
Type 1 is the attachment of the
frenulum to the tip of the
tongue, usually in front of the
alveolar ridge in the lower lip
Type 2 is two to four mm be-
hind the tongue tip and attaches
on or just behind the alveolar
Type 3 tongue-tie is the attach-
ment to the mid-tongue and the
[continued on p 2]
Summer 2004
Congenital Tongue-Tie and Its
Impact on Breastfeeding
Pediatricians Needed to Make
National Breastfeeding
Awareness Campaign Successful
The California Perinatal Quality
Care Collaborative
Chapter Breastfeeding
Coordinator Reports from
California, Florida and Indiana
Join the Section on
Breastfeeding: Best
for Baby and Mother
Section on Breastfeeding
(combination of breastfeed-
ing plus formula feeding).
Thus, while almost 70% of
American mothers initiated
breastfeeding in 2001, less
than half initiated exclusive
breastfeeding, and only
17.42% were exclusively
breastfeeding at 6 months.1
[continued on p 7]
Breastfeeding: Best for Baby and Mother Page 2
middle of the floor of the mouth and is usually
tighter and less elastic.
Type 4 is essentially against the base of the tongue,
and is thick, shiny and very inelastic.
Types 1 and 2, considered “classical” tongue-tie,
are the most common and obvious tongue-ties, and
probably account for 75% of incidence. Types 3 and
4 are less common, and since they are more difficult
to visualize are the most likely to go untreated.
Type 4 is most likely to cause difficulty with bolus handling and swallowing, resulting in more
significant symptoms for mother and infant (see section on Diagnostic Assessment).
Oral-motor Movements That Differ Between Bottle and Breastfeeding
An infant can obtain milk from a bottle without the wide gape and consistent suction needed for
a good breast latch. If the tongue-tied infant cannot maintain the tongue over the lower gum
during sucking, the “phasic bite reflex” (chewing) is triggered.24 This chewing motion is sufficient
to transfer milk from the bottle, but is clearly problematic at breast. Bottle feeding allows milk
to drip into the mouth without effort, thus requiring less tongue muscle effort (such as tongue
grooving, cupping and depression) than needed for breastfeeding (Hartman, P, oral communica-
tion, 2003). Breastfeeding requires well-defined peristalsis from the front to the back of the
tongue as well as tonguepalate synchronization. Some tongue-tied infants cannot even manage
a bottle.
Diagnostic Assessment
Physical examination and observation of breastfeeding should be conducted, with particular
attention to the following items:
Assessment of range of motion of the tongue should include the degree of extension of the
tongue beyond the lower dental ridge and lip,13 elevation to palate with mouth wide
open,10,13 and transverse movement from one corner of the lips to the other without
twisting the tongue. Elevation seems to be the most important tongue movement for
breastfeeding and should be weighted most heavily in the assessment.8,20,25
Thorough evaluation of adequacy of latch and effectiveness of milk transfer are important.
The amount and rate of milk transfer from the breast can be determined by test-weighing
[continued on p 3]
The American Academy of Pediatrics (AAP)
offers the Breastfeeding: Best for Baby and Mother
newsletter as a member benefit of the AAP
Section on Breastfeeding. Information about the
AAP Breastfeeding Promotion in Physicians’
Office Practices (BPPOP-Phase II) program also
is included. The newsletter is intended as a fo-
rum for sharing information about breastfeeding
and AAP breastfeeding initiatives to facilitate
networking among AAP members. The AAP
provides this newsletter through its Department
of Community Pediatrics Division of Community
Health Services.
Comments and questions are welcome and can
be directed to:
American Academy of Pediatrics
Division of Community Health Services
141 Northwest Point Blvd
Elk Grove Village, IL 60007-1098
Phone: 800/433-9016, ext 7821
Fax: 847/434-8000
Web site:
AAP Staff
Betty Crase, IBCLC, RLC, Manager
Cyndy Rouse, Division Assistant
Thomas F. Tonniges, MD, Director, Department
of Community Pediatrics
Newsletter Editor
Nancy Powers, MD
Chairperson, Communications Committee
AAP Section on Breastfeeding
AAP Chapter Breastfeeding Coordinator, Kansas
Electronic mailing lists are available for AAP Chap-
ter Breastfeeding Coordinators, members of the
BPPOP-Phase II program, and members of the AAP
Section on Breastfeeding. Contact program staff for
information regarding participation.
The recommendations listed in this newsletter and
in the mentioned publications do no indicate an
exclusive course of treatment or serve as a stan-
dard of medical care. Variations, taking into account
individual circumstances, may be appropriate. This
newsletter and the materials mentioned within this
newsletter discuss titles published by organizations
other than the American Academy of Pediatrics.
Statements and opinions expressed in these publica-
tions are those of the authors and not necessarily
those of the American Academy of Pediatrics.
Any part of this newsletter may be reproduced for
noncommercial educational purposes.
© 2004 American Academy of Pediatrics
Classic heart shaped tongue caused by restricted central tongue tip elevation. This presentation is actually
sometimes less symptomatic than the tighter, shorter frenula that present as flattened (simple) or bunched
tongue .
Classic Simple
Types 3 and 4 may require a digital exam
© 2004 Catherine W Genna © 2004 Catherine W Genna
Breastfeeding: Best for Baby and Mother Page 3
the infant with an appropriate digital
scale and standardized protocol. (See
Box B.)
Evaluate the efficiency of bolus handling
(ability to hold milk on the grooved
tongue for a controlled swallow that is
well coordinated with breathing).1,2,8
Cineradiography and close observation
have been the primary tools. Signs of
imperfect coordination between swal
lowing and breathing include increasing
nasal congestion over the course of a
feed, gulping sounds, decreasing respire
tion rate during sucking, sucking in un
usually short bursts (fewer than 10-15
sucks per burst) and even short bouts of
apnea.24 If the infant nurses, transfers
milk, and breathes well over a three to
five minute period, this is good clinical
evidence of normal suck-swallow-
breathing coordination.
Observe the degree of fatigue and irrita
bility shown by the infant (especially
important in posterior tongue tie, which
is less apparent to the examiner), during
and after feeding, often expressed as jaw
and tongue tremor, fussiness and arching
away during feeding or needing to feed
again and again after short periods of
Document the degree of nipple pain and
nipple skin erosion of the mother.
Examine for any other contributing or
confounding issues including occult clefts
of the palate, facial deformity, muscular
or neurological deficit, thrush, etc.
Tongue-tie is seen relatively frequently in
association with other birth defects.2,6,14
The Surgical Treatment of Tongue-tie
Frenotomy is a simple, safe and effective sur-
gical procedure. It improves comfort, effec-
tiveness and ease of feeding for the mother
and infant, thereby increasing the exclusivity
and duration of breastfeeding for affected
dyads. (Benefits/outcomes other than for
improved breastfeeding are beyond the scope
of this article).
A simple “snip” with a blunt ended scissors is
usually all that is needed and bleeding is mini-
mal. It is less traumatic than ear piercing, and
much less invasive and painful than circumci-
sion. The author usually prefers to use topical
benzocaine on a small cotton swab to each
side of the frenulum and has used this in in-
fants and young children from 0-5 years with
good results and without side effects. Immedi-
ately after the frenotomy is done, the infant is
placed back on the breast, and the latch ad-
justed. There is usually immediate improve-
ment in milk transfer and maternal com-
Fortunately, complications are minimal.
Rarely, the release does not help breastfeed-
ing but does help with speech later on. It is
not harmful to the baby. Occasionally there
might be enough bleeding to stain half of a
2 x 2 gauze pad instead of the more usual few
Usually there seems to be no pain and breast-
feeding in the immediate post operative pe-
riod is sufficient analgesia for the nursling.
[continued on p 4]
Rollunder tongue-tie
Bunched tongue-tie
Box A
Presentation of
The presentation of symptomatic tongue-
tie may vary widely, including symptoms
and signs in both infant and mother.
Maternal presentation is commonly char-
acterized by:
nipple pain and/or erosions
painful breasts
low milk supply
plugged ducts
frustration, disappointment, and
discouragement with breastfeeding
untimely weaning
Infant symptoms and signs include:
poor latch and suck
clicking sound while nursing (poor
ineffective milk transfer
inadequate weight gain or weight loss
irritability or colic
fussiness and frequent arching away
from the breast
fatigue within one to two minutes of
beginning to nurse
difficulty establishing suction to
maintain a deep grasp on the breast
gradual sliding off the breast
“chewing” of the nipple
falling asleep at the breast having
taken less than an optimal feed, as
proven by “test weight” on a digital
scale (experience of authors)
However, the author suggests infant ace-
tominophen drops 10mg/kg q4h for 24
hours as needed. A drop of topical benzo-
caine on the clean small finger, may be used
if the frenotomy site seems sore during the
first 24 hours. It can be placed under the
tongue where the snip was performed.
Fortunately, complications are minimal.
Only rarely is a general anesthetic needed,
when a frenuloplasty (transverse cutting
and vertical repair) is needed rather than a
simple anterior to posterior snip
Medical management of tongue-tie
surgical intervention may not be an option
because of religious, cultural, or personal
reasons or because the parents are unable
to find a medical professional willing to
provide surgical treatment. In these cases
the lactation consultant usually plays a criti-
cal role. Multiple latch modifications may
be employed to find one that is adequate.
Mothers may need to express milk to help
maintain an adequate milk supply and opti-
mal infant growth. As the child grows and
the mother perseveres, successful breast-
feeding may be possible, though some de-
gree of discomfort may continue. Contin-
ued breastfeeding in this situation typically
requires much time, patience, emotional
and professional support, and a dedicated
Other Oral Frenula
In addition to the lingual frenulum, there
are several other oral frenula (Genna,
Weissinger): a buccal frenulum connects
cheek to gum; a labial frenulum connects
the upper or lower lip to the gum, espe-
cially the superior labial frenulum which
runs from the center of the upper lip to
the gum line. These may interfere with lip
A baby who cannot flange his /her upper lip
because of a tight upper labial frenulum
may need to alter his/her nursing position
or have it surgically released in order to
permit effective nursing. A mother with a
short nipple and inelastic breast tissue may
have trouble even achieving latch-on with
such a baby. It may be that a short or tight
lower labial frenulum can cause similar prob-
lems by preventing the lower lip from flang-
Tongue-tie is a significant clinical entity,
which, when symptomatic, should be treated
as early as possible to minimize this breast-
feeding problem. Surgical treatment is safe
and effective. Complications are rare and
general anesthesia is not required.
About the Author
Dr Coryllos is a pediatric surgeon, and is
emeritus director of pediatric surgery at
Winthrop University Medical Center, a
teaching hospital in New York. She has per-
formed over 500 frenotomies since 1953,
and has found the results to be satisfactory
in all cases, and excellent in most, with few
complications. [continued on p 5]
1. Ardran G, Kemp F, Lind J. A Cinera-
diographic study of breastfeeding. Br J
of Radiol. 1958;31(363):156-162
2. Ardran G, Kemp F. Some important
factors in the assessment of oropharyn-
geal function. Dev Med Child Neurol.
3. Ballard, JL et al. Ankyloglossia: as-
sessment, incidence, and dffect of fre-
nuloplasty on the breastfeeding dyad.
Pediatrics. 2002;110(5):e63-e68
4. Bosma J, Hepburn L, Josell S, et al.
Ultrasound demonstration of tongue
motions during suckle feeding. Dev
Med Child Neurol. 1990;32:223-229
5. Bullock F, Woolridge M, Baum, J.
Development of coordination of suck-
ing, swallowing and breathing: ultra-
sound study of term and preterm in-
fants. Dev Med Child Neurol.
1990;32:669-678 [Continued on p 6]
Breastfeeding: Best for Baby and Mother Page 4
Untreated tongue-tie in an 11 year old child.
Mis-shapen palate and dental ridge
in the same child
Test-weighing is defined as “weighing the
infant before and after breastfeeding to
determine intake.”
Test-weighing requires an appropriate
digital scale with the following features
1. Digital read-out
2. Integration function that allows for
movement of the infant
3. Accurate to 2 grams
Test-Weighing Procedure:
1. Before breastfeeding, place baby on the
scale and weigh him. No need to undress
the baby. This is the "before" weight.
2. Mother breastfeeds the infant. DO
3. Reweigh the infant, WITH THE EXACT
etc). This is the "after" weight.
4. Subtract the first (before) weight from
the second (after) weight. The difference
in grams is considered the "intake" in
5. Some scales automatically store the
values and compute the difference for
you. Refer to manufacturers instructions.
Breastfeeding: Best for Baby and Mother Page 5
Schema of frenotomy procedure in infants
(0-12 mos) and in carefully selected cases, >12 mos., and up to 3-4 years.16
I. Tongue-tie grooved director (Pilling and Co.- Philadelphia). (Can use fingers in some infants.)
II. Stevens Tenotomy (blunt-ends) scissors or small blunt ended Metzenbaums
III. Topical Anesthesia to each side of Frenulum on cotton swab
a. oil of clove, or
b. dental flavored benzocaine gel In the case of an older child, greater than 10-12 months,
use either a or b plus inject to frenulum with 1cc syringe and #25-26 needle ¼- ½ cc 1%
xylocaine with 1/10,000 epinephrine.
IV. Head lamp or surgical focused floor lamp. If needed may use #7 magnifying opti-visor.
V. ImmobilizationSwaddle in receiving blanket, baby papoose immobilizer (baby may need to
be held and comforted for 2-3 minutes after local anesthesia is applied and then repositioned before clipping.) A person is
needed (often parent) to hold head. Then the physician (or a helper) presses down gently on the chin. Physician places
groove director under the tongue straddling the frenulum, holds frenulum in place with visualization of tongue base and
frenulum, and the frenulum is then snipped along the underside of the tongue to its base. The area is checked to insure
complete release.
VI. Post frenotomy
a. Small amount of bleeding control with pressure from a 2x2 gauze pad under the tongue. There is occasionally a
visible small vein down the anterior edge of the frenulum. Ligation may be considered though usually pressure is enough.
b. Mother holds and comforts, and almost immediately puts the infant to the breast.
c. Latch, milk transfer, swallowing, and especially mother’s comfort are immediately evaluated.
d. Child is then re-evaluated for wider mouth opening and improved tongue protrusion, elevation and a deeper latch.
There will be improved maternal comfort, often immediately.
e. Follow-up: recheck at 1 week, 2 months, and as needed, which can be entrusted to an International Board Certified
Lactation Consultant. Mother is given an emergency phone number and is instructed to call anytime for anything and as
often as she requires.
f. Nursing on demand.
g. Weight checks.
h. In the infant, it may be necessary to engage in tongue stroking, from the base of the tongue to the tip, in the days
immediately after tongue-tie release in order to help extension of the tongue, particularly if the infant is more than five
days of age. (Authors’ experience.) A pacifier “tug of war” may also help. This may be required for seven to fourteen
days for optimal results. The assistance of a lactation consultant will be most helpful. In the older infant or child, tongue
exercises are more frequently required in order to help the patient learn the use of a mobilized tongue. Lolly pops and
ice cream cones work very well, especially for encouraging tongue protrusion.
VII. Cautions
a. Orifices of submandibular and lingual salivary glands open under the tongue on the floor of the mouth. Therefore the
snip must be closer to the base of the tongue than the floor of the mouth.
b. The earlier frenotomy is performed, the faster the infant will adapt to the increased tongue mobility and assume normal
oral motor function. If frenotomy is delayed, mothers should be counseled to expect several days to weeks before
breastfeeding is optimal. Because the late correction of tongue-tie takes time to become fully effective, (the child has to
learn how to use a tongue with normal mobility), the mother should be in contact with a lactation consultant or her
pediatrician for consistent professional assistance and emotional support.
Grooved director and blunt
Metzenbaum scissors.
© 2004 Catherine W Genna
Breastfeeding: Best for Baby and Mother Page 6
References: (Continued)
6. Emmanouil-Nikoloussi E, Kerameos-Foroglou C. Congenital syndromes connected with tongue malformations.
Bull Assoc Anat (Nancy). 1992;76:67-72
7. Fletcher SG, Meldrum JR. Lingual function and relative length of the lingual frenulum. J Speech Hearing Res 2.
8. Genna CW. Breastfeeding and tongue-tie. Leaven. 2002;38(2):27-29
9. Glass RP, Wolf LS. Incoordination of sucking, swallowing and breathing as an etiology for breastfeeding difficulty.
J Hum Lact. 1992;10(3):185-189
10. Hazelbaker AK. Assessment Tool for Lingual Frenulum Function. Columbus, OH: Privately printed;1992.
11. Hingley G. Ankyloglossia clipping and breastfeeding. J Hum Lact. 1990;6:103
12. Jain E. Video: Tongue-tie: Impact on Breastfeeding [videotape]. Calgary, Alberta, Canada: Lakeview Breastfeeding Clinic;
13. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999;30(4): 259-262
14. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am. 2003;50:381-397
15. Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and how. Otolaryngol Head Neck Surg. 2002;3:93-97
16. Marmet C, Shell E, Marmet R: Neonatal frenotomy may be necessary to correct breastfeeding problems. J Hum Lact.
17. Messner AH, Lalakea ML, Aby J, MacMahon J, Bair E. Ankyloglossia: incidence and associated feeding difficulties. Arch
Otolayngol Head Neck Surg. 2000;126:36-39
18. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54:123-131
19. Mukai S, et al. Ankyloglossia with deviation of the epiglottis and larynx. Ann Otol Rhinol Laryngol Suppl 1991;153,3-20
20. Palmer B. The Influence of breastfeeding on the development of the oral cavity: a commentary. J Hum Lact.
21. Ross MW. Back to the breast: retraining infant suckling patterns. Lactation Consultant Series; Wayne, NJ; Avery
Publishing Group;1987
22. Salloum, AC, MD, MA. Student IV paper for “Medicine in Contemporary Society.” Stonybrook Medical School, SUNY; 2003
23. Wiessinger D, Miller M. Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. J Hum Lact
24. Wolf LS, Glass RP. Feeding and Swallowing Disorders in Infancy: Assessment and Management. Tucson, AZ; Academic
Press, Inc; 1992
25. Woolridge M. The anatomy of infant sucking. Midwifery. 1986;2:164-171
Breastfeeding: Best for Baby and Mother Page 7
Breastfeeding promotion efforts have
been successful in getting women to
breastfeed, but the payoffs of better
health remain less than optimal without
the commitment to exclusive breastfeed-
ing for 6 months.2
The U.S. Department of Health and Hu-
man Services through the Office on
Women’s Health (OWH) worked with the
Advertising Council to create public ser-
vice announcements for television and
radio on the importance of exclusive
breastfeeding for the first 6 months of life.
In addition, print advertisements were
created for newspapers, magazines and
Specific requirements were established
for the selection of information used in the
advertising campaign: well-designed stud-
ies published after 1990, studies from
developed countries, breastfeeding dura-
tion of at least six months and sample
sizes of 100 children or more. The studies
looked at the effects of breastfeeding on
the incidence of diarrhea, hospitalization
for respiratory illness, obesity/overweight
and otitis media. For a reference list, see
page 8.
Public health experts are hopeful the cam-
paign will go far to shift the American
norm from formula feeding with and with-
out breastfeeding to breastfeeding without
the need for supplementing with formula.
A campaign dealing with any aspect of
child health and welfare requires the co-
operative support of pediatricians to make
it a success. This campaign is no differ-
ent. The U.S. public health system is
counting on pediatricians to provide the
necessary support for women who re-
spond to the campaign and choose to
breastfeed, as well as women who have
questions, problems or want the cam-
paign’s message validated.
Members of the AAP Section on Breastfeed-
ing Leadership Team worked with the OWH
to provide scientific expertise for the cam-
paign. In addition, several pediatricians are
involved in 18 community demonstration
projects (CDP) funded by the OWH to en-
hance the campaign’s impact. The following
cities have a CDP:
Atlanta, Georgia
Birmingham, Alabama
Boston, Massachusetts
Camden, New Jersey
Chicago, Illinois
Kansas City, Missouri
Knoxville, Tennessee
Los Angeles, California
New Orleans, Louisiana
Philadelphia, Pennsylvania
Portland, Oregon
Providence, Rhode Island
Pueblo, Colorado
San Juan, Puerto Rico
Rosebud, South Dakota
San Francisco, California
St. Paul, Minnesota, and
Washington, D.C.
To find a CDP near you, call 1-800-994-
WOMAN (9662).
There are a number of steps pediatricians
can take to get involved. The first is to be
prepared to validate the campaign. Moth-
ers should feel the messages they hear or
read are shared by all of the professionals
who care for them and their babies. Pe-
diatricians also can support the campaign
Affirming to mothers that the
AAP supports breastfeeding as
the optimal nutrition for infants.
Explaining why a campaign is
needed in the United States at
this time. For instance, tell moth-
ers that that despite high initia-
tion rates of breastfeeding, low
duration rates persist. Also, ex-
plain the importance of exclusive
Encouraging all mothers, with
rare exceptions, to breastfeed
exclusively for about six months,
which means delaying other
foods or fluids, and to continue
breastfeeding thereafter for as
long as mother and child desire
Coordinating community re-
sources to support mothers,
such as the CDPs, or referring
them to the OWH-funded free
Breastfeeding Helpline (1- 800-
994-WOMAN) or Web site
(, which has
extensive information and help
for breastfeeding mothers.
Working collaboratively with
members of your health care
team to assess and manage
breastfeeding support.
Scheduling the first ambulatory
visit by a qualified observer for
all breastfed newborns at 3 to 5
days of life.
Enhancing your knowledge
about breastfeeding and skills for
assessment of breastfeeding by
attending continuing medical
[continued on p 8]
education (CME) courses dedicated to breastfeeding topics, joining the AAP Section on Breastfeeding and
hosting CME in your community.
Giving Grand Rounds on breastfeeding promotion and management at your community hospital.
The Academy has always promoted breastfeeding as the best way to nourish and nurture infants. Pediatricians were an integral
part of the first U.S. public health campaign at the turn of the century to promote breastfeeding, but at the same time they were
campaigning to purify cow’s milk. There is no need to launch a public health campaign to improve infant formula.
For those who cannot breastfeed, infant formula is an acceptable solution. But the solution to improved health status for the major-
ity can be achieved by promoting and supporting exclusive breastfeeding for the first 6 months of life and continued breastfeeding
for at least 12 months and thereafter for as long as mutually desired.
It is time to embrace exclusive breastfeeding as ideal behavior and find ways to eliminate unnecessary use of infant formula. The
National Breastfeeding Awareness Campaign may create the catalyst for change, and pediatricians are an essential link to the
campaign’s success.
References for Diarrhea:
1. Scariati P, Grummer-Strawn L, Beck Fein S. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the
United States. Pediatrics. 1997;99(6):e5-e9
2. Raisler J, Alexander C, O’Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health.
3. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first 6 months of life. J Pediatr.
4. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C. Protective effect of breast feeding against infection. BMJ. 1990;
References for Otitis Media:
5. Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM. Relation of infant feeding practices, cigarette smoke
exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr.
6. Scariati P, Grummer-Strawn L, Beck Fein S. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the
United States. Pediatrics. 1997;99(6):e5-e9
7. Raisler J, Alexander C, O’Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health.
8. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first 6 months of life. J Pediatr.
9. Duffy LC, Faden H, Wasielewski R, Wolf J, Krystofik D, Tonawanda/Williamsville Pediatrics. Exclusive breastfeeding protects
against bacterial colonization and day care exposure to otitis media. Pediatrics. 1997;100(4):e7
Page 8 Breastfeeding: Best for Baby and Mother
10. Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects
against otitis media. Pediatrics. 1993;91(5):867-872
References for Hospitalization for Respiratory Illness
11. Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr.
12. Howie PW, Forsyth JS, Ogston SA, Clark A, du V Florey C. Protective effect of breast feeding against infection. BMJ. 1990;
13. Nafstad P, Jaakkola JJ, Hagen JA, Botten G, Kongrud J. Breastfeeding, Maternal Smoking, and Lower Respiratory
Tract Infections. Eur Respir J. 1996;9:2623-2629
14. Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, Kendall GE, Burton PR. Association Between Breast
Feeding and Asthma in 6-Year-Old Children: Findings of a Prospective Birth Cohort Study. BMJ. 1999;319:815-819
15. Oddy WH, Sly PD, de Klerk NH, Landau LI, Kendall GE, Holt PG, Stanley FJ. Breast feeding and respiratory morbidity in
infancy: a birth cohort study. Archives of Disease in Childhood. 2003;88:224-228
16. Cushing AH, Samet JM, Lambert WE, Skipper BJ, Hunt WC, Young SA, McLaren LC. Breastfeeding reduces risk of
respiratory illness in infants. Am J Epidemiol 1998;147:863870
References for Obesity
17. Gillman MW, Rifas-Shiman SL, Camargo CA, Berkey CS, Frazier AL, Rockett HR, Field AE, Colditz GA. Risk of overweight
among adolescents who were breastfed as infants. JAMA. 2001;285:2461 2467
18. Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the
Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2):e81-86
19. Hediger ML, Overpeck MD, Kuczmarski RI, Ruan WJ. Association between infant breastfeeding and overweight in young
children. JAMA. 2001;285:2453 2460
20. Toschke AM, Vignerova J, Lhotska L, Osancova K, Koletzko B, von Kries R. Overweight and obesity in 6- to 14-year old
Czech children in 1991: protective effect of breast-feeding. J Pediatr. 2002;141:764 769
21. Von Kries R, Koletzko B, Sauerwald T, von Mutius E. Does breast-feeding protect against childhood obesity? Adv Exp Med
Biol. 2000;478:29-39
22. Strbak V, Skultetyova M, Hromadova M, Randuskova A, Macho L. Late effects of breast-feeding and early weaning:
seven-year prospective study in children. Endocr Regul. 1991;25(1-2):53-57
Dr. Feldman-Winter chairs the AAP Section on Breastfeeding Education Committee.
(Note: This article is being published as a commentary in the August 2004 issue of AAP News. The online edition
( will contain links to the abstracts of the citations in the commentary.)
Page 9 Breastfeeding: Best for Baby and Mother
Page 10 Breastfeeding: Best for Baby and Mother
The California Perinatal Quality Care Collaborative (CPQCC)
By Nancy E Wight MD, IBCLC, FABM, FAAP
The concept of collaboration among institutions for the purpose of improving overall quality of care is a key component of successful and
efficient change in health care. Dialogue between clinical units, as well as visits by a multidisciplinary team from one unit to another, can
provide an exchange of ideas and solutions to clinical problems. Where evidence is inconclusive, sharing ideas and approaches to practice can
offer incentives to seek answers to important questions through collaborative clinical research.1
Building on the existing VON (Vermont-Oxford Network) framework, the California Association of Neonatologists (CAN), in association
with multiple public and private partners (Kaiser Permanente Health Care Plan, the David and Lucille Packard Foundation, Pacific Business
Group on Health, CA Dept. Health and Human Services, CA Perinatal Section AAP, CA ACOG) developed the California Perinatal Quality
Care Collaborative (CPQCC) to foster benchmark performance by all of the NICUs in California. The three arms if the CPQCC are the
Data Center, The Perinatal Quality Improvement Panel (PQIP) and the research unit. 1
PQIP regional opinion leaders identify NICU care practices that have the potential for improvement, using as criteria the availability of indica-
tor data, demonstrated variability in current practice, and research evidence of the validity and impact on outcome of the recommended prac-
tices. Practice recommendations in a selected area of care are presented in a stand-alone quality improvement “toolkit” and a multidiscipli-
nary quality improvement workshop designed to “jump-start” unit teams. Participants are sent exercises before the workshop that are de-
signed to assess current practice and create “cognitive dissonance” as a force for change.
Quality improvement (QI) initiatives have targeted antenatal steroid use, surfactant use, consistent mechanical ventilation, abandonment of
postnatal steroid use, and prevention of nosocomial infection. In 2004, the QI initiatives are nutrition support of the VLBW infant (specifically
supporting breastfeeding) and prevention of early-onset sepsis.
I had the privilege of working on “Nutritional Support of the Very Low Birth Weight Infant: Part I, which encompasses 19 best practice rec-
ommendations in 3 sections, with an extensive reference list and multiple, practical appendices. 2 The entire toolkit was designed to help the
NICU care team assess current nutritional practices and outcomes, and to promote and support breastmilk for VLBW infants as part of opti-
mal nutritional management. Part 2 (2005) will include best practices in parenteral and enteral nutrition, plus additional attention to contin-
ued support for breastfeeding in the NICU and post-discharge. The Toolkit, Part 1 is currently available as a free download (~150 pages).2
1. Wirtschafter DD, Powers RJ. Organizing regional perinatal quality improvement: global considerations and local implementation.
NeoReviews. 2004; 5(2):e50-59
2. CPQCC/PQIP: nutritional support of the very low birth weight infant: part 1,
Florida Chapter Activities
By Joan Meek, MD, FAAP, IBCLC
Arnold “Bud” Tanis, MD, and Joan Meek, MD, FAAP, IBCLC, continue to serve as the Florida Chapter Breastfeeding Coordinators. They
work closely with all of the Chapter Breastfeeding Coordinators and with the AAP Section on Breastfeeding, within the AAP Department of
Community Pediatrics, to support breastfeeding. [continued on p 11]
The 9th annual International Academy of Breastfeeding Medicine meeting, “Hot Topics in Breastfeeding: Celebrating the Year of the Family,”
will be held in Orlando, Florida, October 21-25, 2004. Several chapter members will be participating in that meeting, including Dr. Rob Law-
rence from the University of Florida. Information about the meeting can be found at Application has been made for AAP
co-sponsorship of the meeting.
Goals for the future include continued education of pediatric practitioners and ancillary health care personnel across the state and
development of a multidisciplinary statewide breastfeeding coalition.
Breastfeeding: Best for Baby and Mother Page 11
Florida [continued]
Indiana Chapter Activities
By Kinga A Szucs, MD, FAAP
The Indiana Breastfeeding Task Force is currently working on the Indiana State Breastfeeding Plan following a training conference by Best
Start Social Marketing last year, which enabled a state-wide breastfeeding needs assessment and helped evaluate rates by county and barriers
to breastfeeding. The Task Force includes representatives from the Indiana WIC Program, Indiana State Department of Health Maternal and
Child Health Services, Indiana Perinatal Network, Healthy Mothers, Healthy Babies, Healthy Start, LLLI, as well as a breastfeeding mother
representative and myself from the AAP.
With the launch of the National Breastfeeding Campaign, we are organizing a subcommittee, within the Task Force, to deal with involving the
media as much as possible. There will also be various health fairs coming up at our Community Health Centers, along with the Indiana Black
Expo Summer Celebration Black and Minority Health Fair which will give us a chance to reach more people in the community.
For World Breastfeeding Week in August 2004, events included an Indianapolis Area Family Walk For Breastfeeding and the Midwest Breast
Fest in South Bend with the goal of trying to break the Guinness Book of World Records with the largest number of breastfeeding mothers
and babies in one place at one time.
Previous activities have included the Indiana Perinatal Network putting together the Breastfeeding Promotion Consensus Statement, followed
by the Governor of Indiana issuing a Breastfeeding Proclamation, in 2002, supporting breastfeeding for World Breastfeeding Week. In Decem-
ber 2002, Methodist Hospital in Indianapolis became the first in the state with the Baby Friendly Hospital (BFHI) designation, and continues to
be the largest BFHI in the US. This has been followed by another hospital having an active Certificate of Intent and many others working to-
wards policies and procedures that foster the BFHI principles. In July 2003, a law was enacted to remove legal barriers to breastfeeding in
public: ”A woman may breastfeed her child anywhere the woman has a right to be.” Also in 2003, the Indiana Breastfeeding Resource Hand-
book updated 4th edition was published and sent to physicians.
Our future efforts will include legislative issues, such as providing health insurance coverage for breast pump rental, lactation consultant ser-
vices, and possibly for donor human milk and a tax rebate for employers providing breastfeeding support to their employees. A few model
employee lactation programs have been identified that can be publicized and replicated in other workplace, hospital and clinic settings.
Benefits of section membership include
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... An improvement in breastfeeding, speech articulation, and dentofacial development is observed in symptomatic cases following treatment [14]. [12,13]. ...
... Meanwhile, 90% of pediatricians and 70% of otolaryngologists believe that ankyloglossia never, or rarely, causes a feeding problem [18]. Medical organizations such as the American Academy of Pediatrics [12] and the National Institute for Health and Care Excellence [19] now acknowledge that tongue-tie, or ankyloglossia, is a significant clinical entity that should be treated as early as possible to minimize breastfeeding problems. Given that breastfeeding helps both infants and mothers, the clinician needs to address any condition that may impair breastfeeding [20]. ...
... ). anquiloglossia mais utilizados atualmente11,36 Coryllos et al., 2004) tem como base a observação de uma única característica anatômica relacionada a aparência do frênulo, ou seja, a altura da sua inserção na superfície ventral da língua. Para ele, como a associação entre estrutura e limitação funcional ainda é incerta, o diagnóstico de anquiloglossia permanece subjetivo.A respeito da etiologia, a presença do frênulo lingual é justificada pela ausência de apoptose, que é um mecanismo de morte celular geneticamente programado e fundamental para remodelação dos tecidos, durante o desenvolvimento embrionário. ...
... ). anquiloglossia mais utilizados atualmente11,36 Coryllos et al., 2004) tem como base a observação de uma única característica anatômica relacionada a aparência do frênulo, ou seja, a altura da sua inserção na superfície ventral da língua. Para ele, como a associação entre estrutura e limitação funcional ainda é incerta, o diagnóstico de anquiloglossia permanece subjetivo.A respeito da etiologia, a presença do frênulo lingual é justificada pela ausência de apoptose, que é um mecanismo de morte celular geneticamente programado e fundamental para remodelação dos tecidos, durante o desenvolvimento embrionário. ...
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Este trabalho buscou mapear o panorama global da anquiloglossia em recém-nascidos por meio da análise bibliométrica de produções científicas até janeiro de 2023. Para obtenção dos estudos, foi realizada uma busca avançada com os termos “Newborn”, “Ankyloglossia” e seus sinônimos nas plataformas Pubmed, Embase, Cochrane, Biblioteca Virtual de Saúde, Web of Science e Scopus. Os resultados foram importados para o gerenciador de referência Zotero. Após a remoção das duplicatas e aplicação dos critérios de elegibilidade, 431 estudos foram incluídos na análise e importados para o software VOSviwer versão 16.18. As palavras-chave mais citadas na pesquisa foram “Cirurgia” (198) e “Aleitamento” (151), que também apresentaram forte ligação entre si. Dentre os 49 países pesquisados, os Estados Unidos, o Reino Unido e a Austrália foram os que mais publicaram sobre o assunto, com 107, 44 e 28, respectivamente. O estudo mais relevante no portfólio estudado foi escrito por Ballard e colaboradores sob o título “Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad”. A revista “Pediatrics” obteve o maior número de citações (608) e ano de 2019 registrou a maior quantidade de artigos sobre a anquiloglossia em recém-nascidos (44). Os achados deste estudo demonstram que a temática ligada aos freios orais tem despertado um interesse crescente na comunidade científica e evidenciam a preocupação em desvendar o impacto real da anquiloglossia na amamentação do bebê, assim como a necessidade de buscar um consenso no diagnóstico em relação à indicação cirúrgica.
... One of the most widely used scoring systems is the Coryllos system published in 2004 in an American Academy of Pediatrics newsletter (10). The author does not explain how she developed her scoring system, how many infants she examined, or how the scoring system was validated and there are no published studies describing intra or inter-rater reliability (10). ...
... One of the most widely used scoring systems is the Coryllos system published in 2004 in an American Academy of Pediatrics newsletter (10). The author does not explain how she developed her scoring system, how many infants she examined, or how the scoring system was validated and there are no published studies describing intra or inter-rater reliability (10). ...
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The most common symptom attributed to ankyloglossia is difficulty breast feeding due to poor latch, inefficient milk extraction and/or maternal nipple pain. During the past two decades, despite a declining birth rate, there has been a dramatic increase in the number of infants diagnosed with and treated for ankyloglossia in the United States, Canada and Australia. Despite a dramatic increase in the diagnosis and treatment of ankyloglossia in these countries, there remains no universally agreed upon definition of ankyloglossia and none of the published scoring systems have been rigorously validated. However ankyloglossia is defined, the majority of infants with ankyloglossia are asymptomatic. Perhaps, infants with ankyloglossia have a greater incidence of difficulty breast feeding. Lingual frenulotomy may decrease maternal pain and at least transiently improve the quality of breast feeding in some infants however no published studies take into account the fact that sucking and feeding are soothing to infants and the observed improvements immediately following frenulotomy may be a response to the pain associated with the procedure rather than a result of the procedure itself. While there are almost certainly some infants in whom tongue-tie interferes with breast-feeding, there is currently no good evidence lingual frenulotomy leads to longer duration of breast-feeding. Frenulotomy appears to be a generally safe procedure however there are reports of serious complications. Finally, there are no studies of long-term outcomes following frenulotomy during infancy and given traditional thinking that the lingual frenulum is a cord of connective tissue tethering the tongue to the floor of the mouth may be incorrect and the frenulum contains motor and sensory branches of the lingual nerve, the procedure may be less benign than previously thought.
... We developed a novel method for monitoring non-nutritive sucking in infants using a custom-built pressure-meter coupled to a pacifier. We tested this approach on newborn infants with and without ankyloglossia, or tongue-tie, a congenital anomaly known to impact breastfeeding (17,18) . We found that subjects with ankyloglossia performed longer suction bursts, while most other suction parameters were similar to controls. ...
Full-text available
Purpose Compare infant suction in babies with and without ankyloglossia using a microprocessor-controlled pressure sensor coupled to a pacifier. Methods Fifty-five infants from 0 to 2 months of age underwent clinical examination for ankyloglossia, after which they were offered a silicone pacifier connected to the pressure acquisition device and suction activity was recorded. Thus, we extracted the frequency of sucks within a burst, the average suck duration, the burst duration, the number of sucks per burst, the maximum amplitude of sucks per burst and the inter-burst interval. Results The key difference in newborns with ankyloglossia in relation to control was that they perform longer bursts of suction activity. Conclusion The longer burst durations are likely a compensatory strategy and may underlie the pain reported by mothers during breastfeeding. We therefore propose a method for objectively quantifying some parameters of infant suction capacity and demonstrate its use in assisting the evaluation of ankyloglossia. Ankyloglossia; Sucking Behavior; Newborn; Breast Feeding; Lingual Frenum
... Los pediatras, neonatólogos y formadores en lactancia materna por la Iniciativa para la Humanización de la Asistencia al Nacimiento y la Lactancia (IHAN) valoraban la anquiloglosia mediante inspección y palpación según la escala de clasificación de Catherine Watson Genna y Elizabeth V Coryllos, que diferencia 4 grados en función de la anatomía del frenillo (9). Así mismo, evaluaban las tomas al pecho mediante la Bristol Breastfeeding Assessment Tool (BBAT) (10). ...
Full-text available
Aunque falta evidencia de alta calidad, se sugiere realizar la frenotomía si se reportan dificultades en la lactancia materna asociadas a la anquiloglosia. Para evaluar si la frenotomía es segura y aporta beneficios a corto y largo plazo, se diseñó un estudio observacional, descriptivo y retrospectivo con 206 lactantes de 34 o más semanas de gestación a los que se había realizado la frenotomía por presentar anquiloglosia y dificultades en la lactancia materna. El grado de anquiloglosia se valoró según la clasificación de C Genna y E Coryllos; y las tomas al pecho se evaluaron mediante la Bristol Breastfeeding Assessment Tool (BBAT). Si persistían las dificultades tras modificar la posición, se procedía a practicar la frenotomía. Se utilizó el programa IBM SPSS Statistics 25 para realizar un análisis descriptivo; un estudio de frecuencias; la prueba de Chi Cuadrado (X2); una prueba T-student para datos emparejados; y una regresión lineal. La calidad de la toma mejoró tras la frenotomía (4,875 vs 7,580; p=0.000); y, a largo plazo, el 76.9% seguía con lactancia materna exclusiva durante 4 meses o más, que se asoció con menor dolor al amamantar (p=0.001) y tomas al pecho más cortas y espaciadas (p=0.027). La tasa de complicaciones fue muy baja. La frenotomía practicada en lactantes con dificultades en la LM es un procedimiento seguro que conlleva una mejora significativa de la calidad de la toma al pecho, reduce el dolor al amamantar y la duración de las tomas, lo que contribuye a prolongar la lactancia materna exclusiva.
... The classification of Kotlow (1999) 8 is based on anatomical parameters, in which is measured the length of free tongue, classifying the ankyloglossia as mild (12-16 mm), moderate (8-11 mm), severe (3-7 mm) and complete (<3 mm). Another classification was proposed by Coryllos et al. (2004) 9 , in which anatomical characteristics are also analyzed, but are correspondent to the frenulum aspect, shape and place where the tongue is anchored. It can be classified into up four types of ankyloglossia. ...
Full-text available
To evaluate breastfeeding in babies up to six months of age before and after frenotomy surgery in a reference hospital in a city from Santa Catarina state. Methods: An observational quality improvement study, carried out with babies up to six months of age undergoing frenotomy and their mothers in a reference hospital in southern Santa Catarina state. A questionnaire was applied to the mothers in two moments (before and after the surgery), with information regarding breastfeeding, sociodemographic, anthropometric and behavioral characteristics of them and of the babies. Descriptive analyzes were performed and the association between breastfeeding and the independent variables was assessed through Pearson’s chi-square and Fisher’s exact tests, using a 5% significance level. Results: A total of 74 children were studied, with 48 of them returning after surgery. 83.8% were breastfed before surgery and 64.9% after surgery. Before surgery, 58.1% of children effectively took the breast at once. After surgery, this prevalence was 83.3% (p=0.015). Before surgery, 75.9% of the mothers reported not feeling pain, while, after surgery, almost all of them (95.8%) reported this (p=0.004). Most mothers reported improvement in grip (83.3%), increase in the duration of breastfeeding (69.0%), improvement of baby’s breathing (75.0%), and an increase in the frequency of breastfeeding (51.7%). Conclusions: There was a decrease in the prevalence of breastfeeding after frenotomy. However, there was an improvement in the babies ‘grip and breathing and a reduction in the mothers’ pain when breastfeeding. It is emphasized the need to implement multidisciplinary actions in both primary and hospital care to assist mothers in order to prolong the duration of exclusive breastfeeding.
Full-text available
This historical article discusses changes in opinions about tongue-tie (ankyloglossia) over two millennia. The sudden surge in interest, since 1990, in the impact of tongue-tie on tongue functions during breastfeeding and during speech development has renewed the historical controversies in contemporary terms and circumstances. A feature has been, and continues to be, the persistence of differences of opinion between and within the various medical professions and laypeople about the significance of tongue-tie in infancy, the indications for its division, and who should perform this procedure and under what conditions. We also consider presumed reasons for frequently extreme divergences of opinions in the historical span, and the difficulty of expecting clinical recommendations to be supported by evidence at the accepted level.
Background: Symptoms related to infant ankyloglossia/tongue-tie may deter mothers from breastfeeding, yet frenotomy is controversial. Methods: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar from 1961-2023. Controlled trials and cohort studies with validated measures of surgical efficacy for breastfeeding outcomes were eligible. Meta-analyses synthesized data with inverse-variance weighting to determine standardized mean differences (SMD) between pre-/postoperative scores. Results: Twenty-one of 1568 screened studies were included. Breastfeeding self-efficacy improved significantly post-frenotomy: medium effect after 5-10 days (SMD 0.60 [95% CI: 0.48, 0.71; P < 0.001]), large effect after 1 month (SMD 0.91 [CI: 0.79, 1.04; P < 0.001]). Nipple pain decreased significantly post-frenotomy: large effect after 5-15 days (SMD -1.10 [CI: -1.49, -0.70; P < 0.001]) and 1 month (SMD -1.23 [CI: -1.79, -0.67; P = 0.002]). Frenotomy had a medium effect on infant gastroesophageal reflux severity at 1-week follow-up (SMD -0.63 [CI: -0.95, -0.31; P = 0.008]), with continued improvement at 1 month (SMD -0.41 [CI: -0.78, -0.05; P = 0.04]). From LATCH scores, breastfeeding quality improved after 5-7 days by a large SMD of 1.28 (CI: 0.56, 2.00; P = 0.01). Conclusions: Providers should offer frenotomy to improve outcomes in dyads with ankyloglossia-associated breastfeeding difficulties. Protocol registration: PROSPERO identifier CRD42022303838 . Impact: This systematic review and meta-analysis showed that breastfeeding self-efficacy, maternal pain, infant latch, and infant gastroesophageal reflux significantly improve after frenotomy in mother-infant dyads with breastfeeding difficulties and ankyloglossia. Providers should offer frenotomy to improve breastfeeding outcomes in symptomatic mother-infant dyads who face challenges associated with ankyloglossia.
Objective: The purpose of this study was to evaluate the spectrum of pediatric quality-of-life sequelae associated with ankyloglossia that may affect children who do not undergo tongue-tie release (frenotomy) during infancy. Data sources: This study contains data from PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar (1961-January 2023). Review method: The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews reporting guidelines. Experimental and observational studies were eligible if they reported baseline outcomes associated with ankyloglossia in children above a year of age. Two reviewers independently screened studies, extracted data, and assessed quality. Low-quality studies were excluded. Conclusions: Twenty-six of 1,568 screened studies (> 1,228 patients) were included. Six studies were high quality and 20 were medium quality. Studies identified various symptoms that may be partially attributable to ankyloglossia after infancy, including speech/articulation difficulties, eating difficulties, dysphagia, sleep-disordered breathing symptoms, dental malocclusion, and social embarrassment such as oral hygiene issues. Multiple comparative studies found associations between ankyloglossia and risk factors for obstructive sleep apnea; a randomized controlled trial found that frenotomy may attenuate apnea severity. Ankyloglossia may also promote dental crowding. Implications for practice: Ankyloglossia may be associated with myriad effects on children's quality of life that extend beyond breastfeeding, but current data regarding the impact are inconclusive. This review provides a map of symptoms that providers may want to evaluate as we continue to debate the decision to proceed with frenotomy or nonsurgical therapies in children with ankyloglossia. A continuing need exists for controlled efficacy research on frenotomy for symptoms in older children and on possible longitudinal benefits of early frenotomy for maxillofacial development. Supplemental material:
Full-text available
This paper aims to present a simple account of the mechanisms by which a baby removes milk from the breast, gleaned from past and current literature, to counter the tendency for inaccurate descriptions of the mechanics of infant sucking to be reproduced. The process is described by which milk is expressed from the lactiferous sinuses within the nipple and breast, by compression of the nipple against the palate by rhythmical pulsations of the surface of the tongue. Active in the process of milk transfer are the roles played by negative suction pressure by the infant, and positive ductal pressure due to action of the mother's milk ejection reflex, which interact in making milk available for removal. The reflexes which the newborn possesses to aid feeding are described and suggestions offered as how best to utilise these reflexes in order to fix a baby successfully on the breast. The intention is that armed with an appropriate understanding of the underlying processes by which milk is transferred from mother to baby a midwife is best equipped to advise a mother regarding the correct technique for achieving trouble-free breast-feeding.
Full-text available
Objectives After completing this article, readers should be able to: 1. List the primary steps in organizational development of a regional perinatal quality improvement program. 2. Describe opinion-making, practice-enabling, and audit and feedback strategies.
The challenge of frenotomy and frenuloplasty lies not in their technical difficulty, but rather, in appropriate case selection. The possible consequences of ankyloglossia include feeding and speech difficulties, as well as a number of other sequelae related to restricted tongue mobility. However, it is difficult to predict which patients will be affected either slightly, greatly, or not at all by their condition. Opinion varies regarding appropriate indications for surgical correction of ankyloglossia and the ideal timing for intervention. This article details the potential symptoms associated with tongue-tie, patient evaluation and indications for surgical repair, the technique of frenotomy and frenuloplasty, and expected surgical outcomes, based on currently available data.
Theimportance ofbreast-feeding to infant health intheUnited States isstill debated. Manystudies support a protective effect, particularly against gastrointestinal andlower respiratory tract illnesses andgen- eral morbidity.' However, infant feeding research hashadmethodological problems including confounding, selection bias, and imprecise definitions ofbreast-feeding and outcomes.2 These design problems haveled some researchers andhealth careproviders toquestion whether breast-feeding confers significant health benefits tobabies inindus- trialized nations.35 Forexample, a recent national surveyofphysicians foundthat many didnotbelieve that breast-feeding was themostbeneficial formofinfant feeding or that itdecreased theincidence ofotitis media 6
Malformations of the tongue, are structural defects, present at birth and happening during embryogenesis. Developmental anomalies or defects may be major or minor, single or multiple, depending on their size, site and effect. The aim of this study was to present and to describe congenital syndromes which are associated with tongue malformations and to classify these malformations in groups, according to the tongue's clinical manifestations. The most common malformations of the tongue combined with syndromes associated with them, are fully discussed in this review article. Malformations of the tongue which are discussed in this review article, have been classified in the following categories: 1. Aglossia 2. Microglossia 3. Tongue hemiatrophy 4. Tongue hemihypertrophy 5. Macroglossia 6. Long tongue 7. Ankyloglossia 8. Cleft or bifid tongue 9. Syndromes that affect tongue and cannot be classified in a special condition Each category is discussed separately in this article.
The effect of breast feeding on some clinical and thyroid function parameters was studied in a prospective longitudinal study from birth up to 7 years of age. At the ages 1-7 years, the obesity rates observed in children breast-fed for less than 3 months were substantially higher than in children who had been breast-fed over longer intervals. Mean age when obesity was reported was similar in all groups (4-5 years). The rates of respiratory tract diseases were found to be highest in children which had been breast-fed for less than 2 weeks. Breast-feeding for more than 6 months had a protective effect against diseases of the gastrointestinal tract. The longitudinal follow-up revealed biphasic changes of thyroid hormones and TSH in sera with a nadir at 2-3 years, followed by an increase at the end of preschool age. Duration of breast-feeding did not affect profoundly these parameters at the ages 1-7 years. Surprisingly, during late preschool age (5-6 years) total serum cholesterol increased with the age at weaning. The atherogenic index in 6-year-old children was most favourable in the group breast-fed over more than 1 but less than 3 months. This was due to the highest levels of HDL-cholesterol in this group. We conclude that the age at weaning may be important for the later development of children.