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About 3% of infants are born with a tongue-tie which may lead to breastfeeding problems such as ineffective latch, painful attachment or poor weight gain. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) has been developed to give a quantitative assessment of the tongue-tie and recommendation about frenotomy (release of the frenulum). The aim of this study was to assess the inter-rater reliability of the HATLFF. Fifty-eight infants referred to the Breastfeeding Education and Support Services (BESS) at The Royal Women's Hospital for assessment of tongue-tie and 25 control infants were assessed by two clinicians independently. The Appearance items received kappas between about 0.4 to 0.6, which represents "moderate" reliability. The first three Function items (lateralization, lift and extension of tongue) had kappa values over 0.65 which indicates "substantial" agreement. The four Function items relating to infant sucking (spread, cupping, peristalsis and snapback) received low kappa values with insignificant p values. There was 96% agreement between the two assessors on the recommendation for frenotomy (kappa 0.92, excellent agreement). The study found that the Function Score can be more simply assessed using only the first three function items (ie not scoring the sucking items), with a cut-off of </=4 for recommendation of frenotomy. We found that the HATLFF has a high reliability in a study of infants with tongue-tie and control infants.
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BioMed Central
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International Breastfeeding Journal
Open Access
Research
Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum
Function
Lisa H Amir*
1,2
, Jennifer P James
2
and Susan M Donath
3
Address:
1
Key Centre for Women's Health in Society, University of Melbourne, Australia,
2
Breastfeeding Education and Support Services, The Royal
Women's Hospital, Melbourne, Australia and
3
Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Royal
Children's Hospital, Melbourne, Australia
Email: Lisa H Amir* - lamir@unimelb.edu.au; Jennifer P James - jenni.james@rwh.org.au; Susan M Donath - susan.donath@mcri.edu.au
* Corresponding author
Abstract
Background: About 3% of infants are born with a tongue-tie which may lead to breastfeeding
problems such as ineffective latch, painful attachment or poor weight gain. The Hazelbaker
Assessment Tool for Lingual Frenulum Function (HATLFF) has been developed to give a
quantitative assessment of the tongue-tie and recommendation about frenotomy (release of the
frenulum). The aim of this study was to assess the inter-rater reliability of the HATLFF.
Methods: Fifty-eight infants referred to the Breastfeeding Education and Support Services (BESS)
at The Royal Women's Hospital for assessment of tongue-tie and 25 control infants were assessed
by two clinicians independently.
Results: The Appearance items received kappas between about 0.4 to 0.6, which represents
"moderate" reliability. The first three Function items (lateralization, lift and extension of tongue)
had kappa values over 0.65 which indicates "substantial" agreement. The four Function items
relating to infant sucking (spread, cupping, peristalsis and snapback) received low kappa values with
insignificant p values. There was 96% agreement between the two assessors on the
recommendation for frenotomy (kappa 0.92, excellent agreement). The study found that the
Function Score can be more simply assessed using only the first three function items (ie not scoring
the sucking items), with a cut-off of 4 for recommendation of frenotomy.
Conclusion: We found that the HATLFF has a high reliability in a study of infants with tongue-tie
and control infants
Background
About 3% of infants are born with a tongue-tie or partial
ankyloglossia [1]. The Academy of Breastfeeding Medicine
Protocol defines partial ankyloglossia as "the presence of
a sublingual frenulum which changes the appearance
and/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" [[2] p1]. Complete ankyloglossia in which there is
extensive fusion of the tongue to the floor of the mouth is
extremely rare.
Since the early 1990s, a number of case studies and case
series of infants with tongue-tie experiencing feeding
problems, such as ineffective latch, painful attachment
and poor weight gain, have been published in the breast-
Published: 09 March 2006
International Breastfeeding Journal2006, 1:3 doi:10.1186/1746-4358-1-3
Received: 06 September 2005
Accepted: 09 March 2006
This article is available from: http://www.internationalbreastfeedingjournal.com/content/1/1/3
© 2006Amir et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
International Breastfeeding Journal 2006, 1:3 http://www.internationalbreastfeedingjournal.com/content/1/1/3
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feeding literature [3-6]. Many of the case studies/series
report an improved ability to breastfeed following a sim-
ple release of the frenulum (frenotomy) [7]. In infants
aged up to about three months, clinicians have found that
it is safe to release the frenulum with a small pair of sterile
scissors when the infant having difficulty breastfeeding is
found to have a tight frenulum comprised of a thin mem-
brane [7]. Our practice has been to release the frenulum in
infants if there is a significant tongue-tie and there is evi-
dence of difficulty breastfeeding such as slow rate of milk
transfer or ongoing nipple pain or trauma.
A range of clinicians perform this simple frenotomy: den-
tists, surgeons, paediatricians, obstetricians, general prac-
titioners and ear, nose and throat specialists [3,7]. In some
settings, infant feeding specialists are also performing fre-
notomies after appropriate training [8,9], however this
does raise "legal and ethical issues about the scope of lac-
tation consultant practice" which varies around the world
[10] p413].
Our review of 35 infants following tongue-tie release
found a high level of parental satisfaction and no compli-
cations [11]. Some of the parents reported that they appre-
ciated the careful examination of the infant's mouth
during the assessment procedure. For example one parent
stated "Very pleased with assessment" [11] p245].
Correct attachment to the breast involves the infant mov-
ing the tongue forward to grasp and draw the nipple and
surrounding breast tissue well into the mouth to form a
teat [12,13]. Some infants with tongue-tie are unable to
grasp the nipple/breast, while others attach poorly caus-
ing nipple pain or damage [2]. The aetiology of breast-
feeding difficulties in these infants has not been
elucidated, however, ultrasound studies may provide
some evidence in the future. A preliminary study of ten
infants using submental ultrasound assessment detected a
change in nipple position and tongue movement during a
feed following frenotomy [14].
An RCT in Southampton, UK, in 2002 identified infants
with a tongue-tie who were experiencing breastfeeding
problems [8]. Fifty-seven infants were randomly assigned
to have immediate frenotomy by the lactation consultant/
infant feeding specialist or to receive help with position-
ing and attachment by the lactation consultant and review
in 48 hours. They found that releasing the tongue-tie
improved feeding in 27 out of 28 infants, compared to 1
out of 29 who improved without release [8].
As there is no generally agreed definition of tongue-tie, a
quantitative instrument has been developed: the Hazel-
baker Assessment Tool for Lingual Frenulum Function
(HATLFF) [15]. Alison Hazelbaker stated "Because of my
Dot-plot of new Function ScoreFigure 1
Dot-plot of new Function Score.
1
2
3
4
5
6
New Function Score
tongue-tie
control
group
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Table 1: Hazelbaker Assessment Tool for Lingual Frenulum Function (1998 version)
Appearance Items
Appearance of tongue when lifted
2: Round OR square
1: Slight cleft in tip apparent
0: Heart-shaped
Elasticity of frenulum
2: Very elastic (excellent)
1: Moderately elastic
0: Little OR no elasticity
Length of lingual frenulum when tongue lifted
2: More than 1 cm OR embedded in tongue
1: 1 cm
0: Less than 1 cm
Attachment of lingual frenulum to tongue:
2: Posterior to tip
1: At tip
0: Notched tip
Attachment of lingual frenulum to inferior alveolar ridge
2: Attached to floor of mouth OR well below ridge
1: Attached just below ridge
0: Attached at ridge
Function Items
Lateralization
2: Complete
1: Body of tongue but not tongue tip
0: None
Lift of tongue
2: Tip to mid-mouth
1: Only edges to mid-mouth
0: Tip stays at alveolar ridge or rises to mid-mouth only with jaw closure
Extension of tongue:
2: Tip over lower lip
1: Tip over lower gum only
0: Neither of above, OR anterior or mid-tongue humps
Spread of anterior tongue
2: Complete
1: Moderate OR partial
0: Little OR none
Cupping
2: Entire edge, firm cup
1: Side edges only, moderate cup
0: Poor OR no cup
Peristalsis:
2: Complete, anterior to posterior (originates at the tip)
1: Partial: originating posterior to tip
0: None OR reverse peristalsis
Snapback
2: None
1: Periodic
0: Frequent OR with each suck
©
Alison K. Hazelbaker, MA, IBCLC July 1 1998
14 = Perfect score (regardless of Appearance Item score)
11 = Acceptable if Appearance Item score is 10
<11 = Function impaired. Frenotomy should be considered if management fails. Frenotomy necessary if Appearance Item score is <8.
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personal experiences with ankyloglossia and my frustra-
tion with the lack of a formal way to assess its presence in
breastfed infants, I wanted to develop an assessment
approach that would make it easier to determine the
extent of the impact that tongue-tie had on tongue mobil-
ity in the breastfed baby" [15] p47]. Five appearance
items, such as length of lingual frenulum (>1 cm, 1 cm, <1
cm) and seven function items, such as extension of the
tongue (tip over the lower lip, tip over lower gum only,
neither) are assessed (See Table 1). Ballard and colleagues
have explained how to score each item [1]. Hazelbaker
has demonstrated that the tool has content validity, how-
ever, it needs to be formally assessed for reliability [1],
and this was the aim of this study.
Method
The primary hypotheses were that:
1. Two assessors will give infants referred for tongue-tie
similar recommendations for release based on the Hazel-
baker Assessment Tool for Lingual Frenulum with an
inter-rater reliability of at least 0.75 (kappa).
2. Two assessors will give normal infants similar recom-
mendations based on the Hazelbaker Assessment Tool for
Lingual Frenulum with an inter-rater reliability of at least
0.6 (kappa).
Infants referred to the Breastfeeding Education and Sup-
port Service (BESS) at The Royal Women's Hospital for
assessment of tongue-tie were assessed by the BESS medi-
cal practitioner (LHA) and a second assessor, one of the
BESS lactation consultants (usually JPJ). A convenience
sample of healthy infants attending BESS was also
assessed by two assessors. Parents were informed about
the study, given a Plain Language Statement and signed
the Informed Consent form before participating.
Basic demographic information was collected, including
age of mother and baby, parity, mother's level of educa-
tion and private health insurance. Information about
breastfeeding and family history of tongue-tie was also
collected.
The infants were assessed by two assessors, who each com-
pleted the HATLFF independently prior to a feed.
Inter-rater reliability was measured using kappa for agree-
ment between the assessors on recommendation for
tongue-tie release. Kappa is a measurement of the propor-
tion of potential agreement beyond chance (actual agree-
ment beyond chance/potential agreement beyond
chance) [16]. Some experts have described the value of
kappa as 0 to 0.2 as "slight", 0.2 to 0.4 as "fair", 0.4 to 0.6
as "moderate", 0.6 to 0.8 as "substantial" and 0.8 to 1.0 as
"almost perfect" [16]. In most clinical examinations,
agreement between examiners is not perfect, and a kappa
of 0.4 is common [16]. Cronbach's alpha was used to
examine the correlation between the items. Cronbach's
alpha measures the inter-item correlations, ie how closely
the items fit together to describe something. It is recom-
mended that the value of alpha should be between 0.70
and 0.90 [17]. In the group of infants assessed for tongue-
tie, we expected approximately 75% of infants to be
scored as recommending frenulum release (from previous
study) [11]. Assuming a kappa of 0.75 with a precision of
0.2, the sample size would be 48 infants. Sample size cal-
culated using Stata 8.0 (sskdlg procedure). Therefore we
planned to recruit 50 infants with tongue-tie and 50 con-
trol infants.
The study was approved by The Royal Women's Hospital
Research and Ethics Committee (04/24, 7 Sept 2004) and
the University of Melbourne (HREC 040676, 17 Sept
2004).
Table 2: Reliability of each item
Item Kappa P value
Appearance items
Appearance of tongue when lifted 0.54 <0.01
Elasticity of frenulum 0.53 <0.01
Length of lingual frenulum when tongue lifted 0.51 <0.01
Attachment of lingual frenulum to tongue 0.39 <0.01
Attachment of lingual frenulum to inferior alveolar ridge 0.62 <0.01
Function items
Lateralization 0.71 <0.01
Lift of tongue 0.67 <0.01
Extension of tongue 0.65 <0.01
Spread of anterior tongue -0.02 0.74
Cupping 0.01 0.44
Peristalsis 0.05 0.07
Snapback 0.03 0.38
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Results
Infants were recruited from September 2004 to April
2005. Fifty-eight infants with tongue-tie were recruited,
age range 1 day to 84 days, mean 17 days, median 10 days,
56% were male (32/57, 1 missing). There were 25 control
infants age with an age range from 7–55 days, mean 26,
median 22 days.
Table 2 shows the reliability of each item in the Assess-
ment Tool. The Appearance items received kappas
between about 0.4 to 0.6, which represents "moderate"
reliability. The first three Function items (lateralization,
lift and extension of tongue) had kappa values over 0.65
which indicates "substantial" agreement. The four Func-
tion items relating to infant sucking (spread, cupping, per-
istalsis and snapback) received low kappa values with
insignificant p values.
There was 96% agreement between the two assessors on
the recommendation for frenotomy (see Table 3). The
kappa statistic was 0.92, which represents excellent agree-
ment or "almost perfect" [16].
The items in each part of the assessment tool were exam-
ined to see how well the items fitted together. For the
seven Function items Cronbach's alpha was 0.5074 (ie
low). When the four items relating to the infant's sucking
were removed (spread, cupping, peristalsis and snap-
back), the three items remaining in the new Function
Score received a higher reliability with a Cronbach's alpha
of 0.8655. The five items contributing to the Appearance
Score had a Cronbach's alpha of 0.7487. This is an accept-
able reliability and did not alter if individual items were
dropped.
The dot-plot (Figure) shows the distribution of new Func-
tion scores: from 0 to 6. Most of the infants referred with
tongue-tie scored 4 or less, while most of the control
infants scored 5 or 6. Therefore a cut-off of "less than or
equal to 4" indicating a recommendation for frenotomy
was chosen for the new Function score. This new cut-off
has a high sensitivity and specificity with an area under
the ROC curve of 0.9948.
There was no difference in any recommendation (ie
whether to release or not) between the old Function score
and the new Function score. Therefore, there was no
change in the kappa statistic with the new shorter Func-
tion score: 0.92 (excellent agreement).
Discussion and conclusions
This is the first inter-rater reliability study of the Hazel-
baker Assessment Tool for Lingual Frenulum Function.
(The recent study by Ricke and colleagues compared inter-
rater reliability only on the first nine infants assessed
[18]).
We found that the HATLFF has a high reliability in recom-
mendation for frenotomy in a study of infants with
tongue-tie and control infants. The two assessors had a
high degree of agreement in each of the Appearance items
and the first three Function items, however there was a
lack of agreement between the assessors on each of the
four Function items related to infant sucking. We found
that it appears that the Function Score can be more simply
assessed using only the first three function items (ie not
scoring the sucking items).
Further research in this area is needed [19]. Currently,
there are a number of other studies underway, for example
in Canada, clinicians are developing a simpler tool to
assess tongue-tie in breastfed infants [20].
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LHA designed, conducted and analysed the study and
drafted the manuscript. JPJ participated in the design and
conduct of the study. SMD assisted in study design and
analysis. All authors read and approved the final manu-
script.
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Table 3: Assessors' recommendations.
Recommendation – Assessor 2
Recommendation – Assessor 1 Release No need to release Total
Release 56056
No need to release 3 24 27
Total 59 24 83
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... 2,6 • Hazelbaker assessment: 11 It is a tedious assessment not exempt from inconveniences, such as little inter-observer agreement, attributable to its subjective items and the influence of the child's collaboration during examination (Annex). 14 • Amir assessment: 15 In 2006, Amir et al. reviewed the items in Hazelbaker assessment and observed that the 3 items for lingual function (tongue lateralization, lift, and extension) showed a greater diagnostic effectiveness and inter-observer agreement (Kappa index: 0.65). Based on this, the authors propose using a simplified version of the Hazelbaker assessment including only these items, with a cutoff point of 4 or less to perform a frenotomy. ...
... Based on this, the authors propose using a simplified version of the Hazelbaker assessment including only these items, with a cutoff point of 4 or less to perform a frenotomy. 15 According to current evidence, there is no justification for actively looking for short frenulum during infants' routine check-ups. Ankyloglossia should only be considered a Type I: The frenulum is thin and elastic, anchored from the tip of the tongue. ...
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Short frenulum, or ankyloglossia, may lead to breastfeeding problems, with an impact on infant development, nipple damage, and early abandonment of breastfeeding. There are currently no homogeneous diagnostic criteria, thus leading to both overdiagnosis and underdiagnosis and associated clinical consequences. The challenge to approach this condition lies in establishing whether it is a normal anatomical variation or a lingual frenulum without a functional impact and when breastfeeding difficulties which are typically attributed to it are actually caused by the frenulum. Approximately 50% of ankyloglossia cases do not result in breastfeeding problems or these can be resolved with support and advice. Surgery may be proposed for the rest of the cases. This article offers an update on the classification and treatment of ankyloglossia, which will help health care providers to provide an adequate management to these patients.
... The diagnosis of ankyloglossia is challenging due to lack of uniform diagnostic criteria. Published screening tools that are available to aid in the diagnosis of ankyloglossia include the following: Koltow's grading system (which is a classification not a screening tool), the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF), shortened form of the ATLFF, the Bristol Tongue Assessment Tool (BTAT), Lingual Frenulum Protocol (NTST), and Frenotomy Decision Tool for Breastfeeding Dyads [20][21][22][23][24][25]. However, none of these have been validated on large samples as predictive of a response to frenotomy. ...
... However, none of these have been validated on large samples as predictive of a response to frenotomy. Only some parts of the ATLFF, the BTAT, and the NTST have been shown to have good interrater reliability [22][23][24]. ...
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Background: In the past 10-15 years, there has been increased concern about ankyloglossia and its effect on infant breastfeeding. This has been associated with increased performance of frenotomy. Physicians and other healthcare professionals with expertise in breastfeeding have voiced concerns about complications related to the performance of infant frenotomy. Reviews of this topic have reported no significant complications after frenotomy. Other data on complications consist of case reports. Methods: An online survey was developed by physicians with expertise in breastfeeding and e-mailed to physician and dentist members of Academy of Breastfeeding Medicine (ABM) between 11 November and 31 December 2019. It requested information from the respondents who cared for the mother/infant breastfeeding couple about their experiences personally caring for infants with complications or misdiagnoses related to referral for frenotomy or the performance of a frenotomy. Data were analyzed using chi square, Cramer's V correlation, and binomial logistic regression. Results: Of 211 eligible respondents, 129 (61%) had cared for an infant with a complication or misdiagnosis. Two hundred and nine (209) infants were reported to have a complication and 237 had a misdiagnosis. The most common misdiagnoses reported were 101 of 237 infants (43%) with neuromuscular dysfunction and 65 of 237 (27%) with inadequate breastfeeding support. The most common complications reported were a repeat procedure considered/requested/performed 65 of 203 (32%) and oral aversion 57 of 203 (28%). Parental report of infant pain was associated with performance of a posterior frenotomy (Chi Square p < .003). Bleeding was associated with using scissors/scalpel vs laser/bovie/electrosurgery (Chi Square p = .001). Oral aversion was associated with performance of frenotomy by laser/bovie/electrosurgery vs scissors/scalpel (adjusted Odds Ratio of 4.05; 95% CI 2.07, 7.93). Conclusions: Complications and misdiagnoses are occurring after infant frenotomy. Physicians and dentists should work closely with lactation professionals to provide skilled breastfeeding support and to evaluate for other confounding problems that might impact infant breastfeeding before referral for frenotomy. Randomized controlled trials of optimized lactation support vs. frenotomy and of scissors vs laser in performance of frenotomy are needed.
... izgled in funkcijo jezika ter JF. Edina pomanjkljivost tega inštrumenta je nizka zanesljivost (12). Hazelbakerjeva zaključuje, da je bolj pomembno prepoznati, kdaj je JF kratek, kot določiti, v kateri razred sodi. ...
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... The diagnosis of ankylglossia can be done by simple visual inspection and/or palpation of the frenulum to a more complex classification system such as Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) (Hazelbaker 1993) [7,14]. This is a highly recommended and reliable tool used in assessment of infants younger than 3 months of age [15]. It mainly looks at the function and the appearance of the frenulum. ...
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... Once the presence of ankyloglossia was confirmed, parents were informed of the current study and asked whether they would like to participate. Those who agreed underwent a further detailed examination by the surgeon to better characterize the degree of ankyloglossia according to the modified lingual frenulum function assessment form (Supplementary Appendix A). 20,21 This was done to ensure that the degree of ankyloglossia was assessed to be moderate to severe in a consistent manner (ie, mild cases of ankyloglossia were excluded). After clinical assessment, participants were assessed by a speech language pathologist using the Goldman-Fristoe Test of Articulation-2 (GFTA-2). ...
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Objective The relationship between ankyloglossia and speech is controversial. The objective of this study was to determine the effect of tongue-tie release on speech articulation and intelligibility. Methods A prospective cohort study was conducted. Pediatric patients (>2 years of age) being referred for speech concerns due to ankyloglossia were assessed by a pediatric otolaryngologist, and speech articulation was formally assessed by a speech language pathologist using the Goldman-Fristoe Test of Articulation 2 (GFTA-2). Patients then underwent a tongue-tie release procedure in clinic. After 1 month, speech articulation was reassessed with GFTA-2. Audio-recordings of sessions were evaluated by independent reviewers to assess speech intelligibility before and after tongue-tie release. Results Twenty-five participants were included (mean age 3.7 years; 20 boys). The most common speech errors identified were phonological substitutions (80%) and gliding errors (56%). Seven children (28%) had abnormal lingual-alveolar and interdental sounds. Most speech sound errors (87.9%) were age/developmentally appropriate. GFTA-2 standard scores before and after tongue-tie release were 85.61 (SD 9.75) and 87.54 (SD 10.21), respectively, (P=.5). Mean intelligibility scores before and after tongue-tie release were 3.15 (SD .22) and 3.21 (SD .31), respectively, (P=.43). Conclusion The majority of children being referred for speech concerns thought to be due to ankyloglossia had age-appropriate speech errors at presentation. Ankyloglossia was not associated with isolated tongue mobility related speech articulation errors in a consistent manner, and there was no benefit of tongue-tie release in improving speech articulation or intelligibility.
... The protocol included complete ear, nose, and throat (ENT) examination, including the Friedman tongue position scale [30], tongue-tie presence using the modified Hazelbaker scale [31], tongue measurements using the Iowa oral performance instrument I+ (IOPI) [32], and body mass index (BMI). ...
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Myofunctional therapy (MT) is used to treat sleep-disordered breathing. However, MT has low adherence—only ~10% in most studies. We describe our experiences with MT delivered through a mobile health app named Airway Gym®, which is used by patients who have rejected continuous positive airway pressure and other therapies. We compared ear, nose, and throat examination findings, Friedman stage, tongue-tie presence, tongue strength measured using the Iowa oral performance instrument (IOPI), and full polysomnography before and after the 3 months of therapy. Participants were taught how to perform the exercises using the app at the start. Telemedicine allowed physicians to record adherence to and accuracy of the exercise performance. Fifty-four patients were enrolled; 35 (64.8%) were adherent and performed exercises for 15 min/day on five days/week. We found significant changes (p < 0.05) in the apnoea–hypopnoea index (AHI; 32.97 ± 1.8 to 21.9 ± 14.5 events/h); IOPI score (44.4 ± 11.08 to 49.66 ± 10.2); and minimum O2 saturation (80.91% ± 6.1% to 85.09% ± 5.3%). IOPI scores correlated significantly with AHI after the therapy (Pearson r = 0.4; p = 0.01). The 19 patients who did not adhere to the protocol showed no changes. MT based on telemedicine had good adherence, and its effect on AHI correlated with IOPI and improvement in tongue-tie.
... 1 La Academia Americana de Medicina en Lactancia Materna define a la anquiloglosia como la condición física en la que existe un frenillo sublingual que cambia la apariencia o función de la lengua, debido a su longitud disminuida, falta de elasticidad o fijación demasiado distal en ese músculo, o demasiado cerca de la cresta gingival cuando es incompleta, y completa cuando se presenta un anclaje prácticamente total de la lengua al piso de la boca. 2 En la población general, los frenillos de la lengua tienen una prevalencia de 0.02 a 4.8%; esta variación se cree que es debido a una falta de uniformidad y estandarización de los métodos diagnósticos. La relación hombre-mujer es diferente, de acuerdo con el reporte consultado, los datos varían de 2.6:1.0 y de 1.5 :1.0. ...
... Gracias a la ambigüedad del protocolo, este ha tomado nombre dentro del campo de evaluación del frenillo lingual, por lo que es usado en varios estudios de casos, aunque presente detractores [18,24,25]. En el año 2013, CEFAC valido parcialmente el protocolo para la aplicación en neonatos [26,27], y luego lo valida completamente en 2015, por artículos que ha viabilizado su diagnóstico [11]. ...
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