With the increasingly persuasive evidence that breastfeeding provides infants and mothers with significant health benefits (Oddy et al, 1999; Kull et al, 2002; UNICEF, 2010), midwives and other health professionals should be doing everything possible to support women to initiate and continue breastfeeding. In some cases, ankyloglossia (or tongue-tie) is considered to inhibit breastfeeding, and current National Institute for Health and Care Excellence (NICE, 2005) guidelines support frenotomy—division of the tongue-tie—as an intervention to rectify this. However, the guidelines recognise that there is limited evidence to justify this; in addition, the guidelines are now dated, which makes the subject of this literature review highly topical. The literature available on frenotomy for tongue-tie is controversial (McBride, 2005; Edmunds et al, 2012) and lacks reliable, objective primary research studies (Hall and Renfrew, 2005).
There is no uniform definition, diagnostic criteria or classification system for ankyloglossia (Ricke et al, 2005; Mettias et al, 2013). It is described as a congenital anomaly whereby the baby is born with an abnormally short lingual frenulum (Glasson, 1998; NICE, 2005). Current NHS advice states that the condition affects 4–11% of babies and is more common in boys than girls (Ricke et al, 2005). The condition can bind the tongue to the floor of the mouth (Glasson, 1998) or restrict the movement of the tongue (NICE, 2005). As a consequence, the baby may not be able to draw the breast deeply into his or her mouth, which is a requirement of successful breastfeeding (Inch, 2009). Breastfeeding, and sometimes bottle-feeding, can become problematic. Problems may include inefficient milk intake and weight gain, poor latch and pain for the mother during breastfeeding (Griffiths, 2004; Hall and Renfrew, 2005; Edmunds et al, 2011). However, not all babies born with ankyloglossia experience feeding problems; estimates suggest that 25–60% of babies will present with difficulties (Association of Tongue-tie Practitioners, 2013; Mettias et al, 2013).
Frenotomy, or frenulotomy, is a procedure whereby the lingual frenulum is divided using sharp, blunt-ended scissors (Griffiths, 2004; NICE, 2005). During the procedure, the infant is usually swaddled, his or her head is stabilised, and rarely is any anaesthetic used (Griffiths, 2004; NICE, 2005). Many authors argue that the procedure is simple and associated with little or no bleeding (Hogan et al, 2005; NICE, 2005; Dollberg et al, 2006; Mettias et al, 2013; Emond et al, 2014).
Aim
The aim of this literature review is to improve breastfeeding outcomes by exploring whether frenotomy can result in more successful breastfeeding in newborn babies with ankyloglossia. The review critically appraises a number of research articles in order to shed light on this issue. It also examines whether the procedure can alleviate the mother's pain when breastfeeding and improve latch in breastfeeding babies. Additionally, this paper investigates the confounding factors and additional issues that may be associated with the procedure, and its effect on successful breastfeeding and duration of breastfeeding.
Methodology
Two databases were searched, EBSCOhost and Ovid Online, ensuring that the most relevant research articles could be located from a wide range of sources (Rees, 2011). The Population, Intervention, Comparison and Outcome (PICO) framework (Akobeng, 2005) was employed to define the search terms and related keywords for the question. Boolean logic was applied, enabling the search to be widened and focused appropriately (Aveyard, 2007). The critical appraisal tool CASP (Critical Appraisal Skills Programme) (2013) was then used to review the three randomised controlled trials (RCTs), and the British Medical Journal's (2015) appraisal tool was used to review the six questionnaire studies. Table 1 provides a summary of the research articles reviewed.
| Author, title | Year, location | Design | Methods, sample size, measures used | Key findings and recommendations for practice |
|---|---|---|---|---|
|
Emond A et al
|
2014 |
Randomised controlled trial | 107 infants randomised into immediate (n=55) or delayed (n=52) frenotomy. Researchers blinded as to intervention status. Difficulty in breastfeeding judged by LATCH score (Jensen et al, 1994). Primary outcome of breastfeeding at 5 days, secondary outcome of breastfeeding selfefficacy and pain scores. Final assessment at 8 weeks |
|
|
Dollberg S et al
|
2006 |
Randomised controlled trial | 25 mothers of healthy infants with tongue-tie, referred due to sore nipples. Randomised into: (1) frenotomy, breastfeeding, sham, breastfeeding (n=14) or 2) sham, breastfeeding, frenotomy, breastfeeding (n=11). Researchers and mothers blinded. Latch and pain score obtained from mother after each sham or frenotomy procedure |
|
|
Hogan M et al
|
2005 |
Randomised controlled trial | 57 infants with tongue-tie and breastfeeding problems randomised, both breastfeeding and bottle-feeding: 20 breastfed and eight bottle-fed infants put into immediate frenotomy group; 20 breastfed and nine bottle-fed infants put into 48 hours of intensive lactation consultant support. Mothers gauged any changes to the original feeding problems. Telephone follow-up carried out at 24 hours, 4 weeks and after 4 months; mother was only judge of breastfeeding changes |
|
|
Mettias B et al
|
2013 |
Questionnaire study | 63 infants who had tongue-tie division as outpatients. Guardians contacted by telephone to complete a survey prepared from National Institute for Health and Care Excellence guidelines; 67% of these had difficulties breastfeeding, 11% had poor growth, 22% had limited tongue movement and 28% of mothers had breast problems. No control group and study does not focus solely on breastfeeding |
|
|
Steehler MW et al
|
2012 |
Questionnaire study | 302 infants underwent assessment for tongue-tie; 91 mothers agreed to participate in follow-up survey. Of these, 82 infants underwent frenotomy and nine received no intervention |
|
|
Griffiths D
|
2004 |
Questionnaire study | 215 infants who had major problems breastfeeding despite professional support. Feeding was assessed by the mother 24 hours and then 3 months after frenotomy. No control group |
|
|
O'Callahan C et al
|
2013 |
Questionnaire study | 299 mothers of infants who underwent a frenotomy over a 5-year period completed a web-based survey about breastfeeding difficulties before and after the procedure |
|
|
Dollberg S et al
|
2014 |
Questionnaire study | 264 mother-infant dyads that underwent frenotomy for breastfeeding difficulties. Followed up at 2 weeks, 3 months and 6 months to answer questionnaire |
|
|
Ridgers I et al
|
2009 |
Questionnaire study | 220 infants underwent frenotomy for feeding difficulties. The mothers were contacted 4 weeks later to take part in a structured interview to assess changes in feeding and their overall experience |
|
Findings
A number of themes recur throughout the research literature; the themes are presented in Figure 1.
Mothers' experiences of breastfeeding
All of the research articles focused, to some degree, on the mothers' experiences of breastfeeding. The questionnaire studies were more likely to place weight on mothers' judgement of whether frenotomy had improved their breastfeeding. Emond et al's (2014) RCT incorporated a breastfeeding self-efficacy assessment. Interestingly, the authors found that the frenotomy procedure did improve the maternal breastfeeding self-efficacy assessment, but did not improve more objective breastfeeding scores. The authors included transcripts from interviews carried out with mothers. These tended to be related to the mother's experience of pain, and her frustration at painful breastfeeding.
Alongside Emond et al (2014), all other studies used the mother's experience of breastfeeding as an indicator as to whether frenotomy had been successful in improving breastfeeding, albeit using different methods. Dollberg et al (2014) pointed out that their study sample consisted of highly motivated mothers, which may have introduced some bias. The research articles critically appraised tend to address the mother's experience in relation to pain and breastfeeding efficiency, rather than focusing on her experience of, and feelings towards, the frenotomy itself and breastfeeding. However, Ridgers et al (2009) address the complex issue of bonding and its effect on feeding, acknowledging that, in some cases, tongue-tie may not be the only cause of feeding difficulties.
Duration of breastfeeding
The majority of the studies focused on whether frenotomy affected how long the participants continued to breastfeed their infants. Emond et al (2014) followed up their participants at 8 weeks and found that 80% of both the intervention and control groups were still breastfeeding. Griffiths (2004) found that 64% of participants breastfed for at least 3 months after frenotomy. O'Callahan et al (2013) found that their participants breastfed for a mean duration of 14 months, regardless of the classification of ankyloglossia diagnosis. Dollberg et al (2014) found that 56% of their participants were breastfeeding after 6 months. Hogan et al (2005) followed-up participants at 8 months, finding that the 60% continued to breastfeed until 4 months and that, by this point, 56 out of 57 infants randomised had undergone frenotomy.
This last observation helps identify a key problem affecting this type of research: that it is almost impossible to compare the duration of breastfeeding between groups that did and did not undergo frenotomy as part of the intervention. The majority of participants in control groups decided to opt for frenotomy eventually, and the two groups then become more similar. The study by Steehler et al (2012) was the only one to reveal a genuine difference between infants who did and did not undergo frenotomy. They found that 83% of their frenotomy group continued to breastfeed for an average of 7.09 months. In comparison, 67% of the babies who received no intervention continued to breastfeed for 6.28 months.
Latch
The majority of studies focused on the infant's ability to latch successfully onto the breast before and after frenotomy. Emond et al (2014) use a scoring system called LATCH (Jensen et al, 1994), designed to measure the effectiveness of breastfeeding, in which mothers score on:
Interestingly, Emond et al (2014) found no difference in LATCH scores between their two groups at 8 weeks. Dollberg et al (2006) found a statistically significant improvement in mothers' pain scores after frenotomy (P<0.001). Mettias et al (2013) found that following frenotomy, 98% of preoperative problems were resolved. These problems included poor growth and cracked and sore nipples, which could be attributed to poor latch.
Griffiths (2004) found that 88% of his participants' babies had difficulty latching onto the breast before frenotomy, and 80% of his sample had improved at 24 hours. O'Callahan et al (2013) found that, following frenotomy, infant latching significantly improved among their participants (P<0.001), as did nipple pain (P<0.001). In Dollberg et al's (2014) sample, 83% of the mothers reported nipple soreness, and 55% reported latching difficulties. Following frenotomy, 75% of mothers reported an improvement in breastfeeding difficulties. Furthermore, 50% of the mothers who had reported nipple wounds said that they had disappeared 4 days following frenotomy. This study did not include a control group.
Arguably, infant latching, nipple pain and soreness are difficult parameters to measure as they can be subjective. A ‘normal’ latch can vary in different infants. However, the majority of studies included in this review found that frenotomy could be found to improve latch and alleviate nipple pain.
Discussion
What happens to babies with ankyloglossia who do not undergo frenotomy?
The majority of research articles found that frenotomy can improve breastfeeding and have a positive effect on alleviating unwanted symptoms associated with breastfeeding. This argument is backed up in the wider literature (Edmunds et al, 2011). However, there is a distinct lack of representation from a control group in which infants did not undergo frenotomy—in the three RCTs, the majority of mothers in the control groups eventually decided to opt for frenotomy. In the remaining six questionnaire studies, only one study (Steehler et al, 2012) included a control group (nine mother–infant dyads) who opted for no frenotomy. The fact that most mothers included in the control groups decided to opt for frenotomy eventually indicates that they were likely to still be experiencing breastfeeding problems. Therefore, among the studies subject to critical appraisal, there was little opportunity to follow-up the long-term outcomes of mothers who decided for their infants not to undergo frenotomy, because most mothers ultimately did choose the procedure.
Mothers' culture, background and previous experiences of breastfeeding
Several studies have indicated that a woman's motivation to breastfeed and ideas about how long she would like to breastfeed for are directly related to other issues such as her culture, background and experiences of feeding previous children (Bonuck et al, 2005; Simmie, 2006; Bai et al, 2015). It is arguable that long-term outcomes of infants with ankyloglossia are likely to be related to these factors. Few of the studies in this review identify these issues. They do not address whether the mother had breastfed a previous child or whether she herself had been breastfed. In such research, it is problematic to regard the link between frenotomy and successful breastfeeding in isolation.
Risks or stress associated with frenotomy
The literature that focuses on frenotomy states that it is a simple procedure that rarely carries complications (Hogan et al, 2005; NICE, 2005; Dollberg et al, 2006; Mettias et al, 2013; Emond et al, 2014). Other authors also assert that the procedure is painless (Inch, 2009). However, few of the studies subjected to critical appraisal here consider the psychological impact, distress or trauma that frenotomy may cause the infant, or the stress that parents may experience. McBride (2005) touches on this issue, explaining that, although frenotomy is currently thought to be a safe and painless procedure for the infant that carries no need for anaesthetic, the same was believed about circumcision in infants a generation ago. He speculates whether the current approach to frenotomy without anaesthetic may be modified in the coming years. This suggests further research may be needed into whether anaesthetic should be used during the procedure—and, if so, what type.
Ridgers et al (2009) discuss the levels of distress experienced by the infants in their study, and touch on pain scores used to detect infant pain. They conclude that infants are unlikely to find the actual procedure painful or stressful, but they are irritated about having a finger inserted into their mouths.
It could also be argued that the frenotomy procedure could be traumatic to the infant's psychological development. In Freudian theory, a child works his or her way through a variety of psychosexual stages, the oral stage being the primary phase whereby the child explores and gains pleasure through the mouth (Freud, 1905). In developmental psychology, the infant's early experiences and any traumas experienced are classed as hugely important (Tyson and Tyson, 1990). Following this school of thought, despite being medically uncomplicated and carrying few clinical risks, the frenotomy procedure could pose significant disruptions to the child's normal early psychological development. More research is required to explore this possibility.
The value of breastfeeding support
It is important to consider whether it is the frenotomy procedure itself or breastfeeding support that causes improvements in unwanted breastfeeding symptoms. With effective breastfeeding support provided to the mother, many infants with ankyloglossia can successfully latch onto the breast, but often cannot replicate this latch when they return home (Edmunds et al, 2012). When mothers decide to consent for frenotomy, they are often provided with intensive support before and after the procedure. This can be beneficial, and may be likely to increase confidence in mothers who may have previously been feeling anxious with regard to breastfeeding.
In the RCTs assessed during this review, the control groups were provided with intensive support from lactation consultants or other breastfeeding specialists. However, among the questionnaire studies—where there is lack of a control group—it is difficult to know whether breastfeeding improved as a result of the frenotomy procedure or the extra time, support, and attention the women were likely to have experienced in conjunction with the procedure.
Implications for practice, education, management and research
Practice
The studies appraised, along with supporting literature, indicate that there is currently no uniform guidance regarding the diagnosis, grading and treatment of ankyloglossia (McBride, 2005; Ricke et al, 2005). The current NICE (2005) guidelines are dated and somewhat ambiguous. Edmunds et al (2011) reported a similar situation in the USA and Australia, noting the lack of published position statements by the large professional bodies. In the UK, Finigan (2009) experienced resistance to the development of a frenotomy service and discusses the controversy over the procedure. Perhaps it is this controversy that can cause anxiety in mothers and health professionals. Few would dispute that there are inconsistent approaches to assessment and management of ankyloglossia, where some midwives are more likely to check for tongue-tie than others. Following this, the advice then given to mothers may differ and cause confusion.
Several of the research articles appraised in this review make recommendations for infants to be assessed for tongue-tie by trained professionals, followed by timely referral to appropriate professionals (Griffiths, 2004; Hogan et al, 2005; Mettias et al, 2013; O'Callahan et al, 2013). This is a valuable recommendation for practice in midwifery and related fields. Building on this, midwives should be encouraged to be aware of the woman's social and cultural background and her previous experiences of breastfeeding, and how these factors may have an impact on her intentions regarding how to feed her infant (Nursing and Midwifery Council, 2009).
There is a question over whether improved breastfeeding is due to the frenotomy procedure itself, or to the extra breastfeeding support that women experience alongside the procedure, or indeed a combination of both. The implication for practice is that mother–infant dyads are likely to benefit from long-term access to breastfeeding support from midwives, breastfeeding specialists and lactation consultants, both in the hospital and the community, regardless of their decision regarding frenotomy. This could improve outcomes and prolong duration of breastfeeding through practical support, alleviating anxieties and increasing women's confidence. There is currently 24-hour access to breastfeeding support through La Leche League (2015) and other organisations such as the National Childbirth Trust (NCT, 2012) and the Breastfeeding Network (2014). It is important that women are regularly informed of how to access this type of support in the postnatal period and beyond.
Education and training for midwives
It is essential that midwives and midwifery students are provided with adequate training in how to look for ankyloglossia and subsequently support feeding in a way that reassures women and empowers them to continue to breastfeed, regardless of whether they decide to opt for frenotomy. It would be beneficial for this to be incorporated into training for student midwives and also during mandatory training for registered midwives. Clearly, the lack of a standardised definition and classification of ankyloglossia (McBride, 2005;Ricke et al, 2005) makes this difficult to achieve.
While assessment for tongue-tie should be an essential competency for health professionals involved in the care of women and babies (O'Callahan et al, 2013), it is important that these professionals are aware of the fact that ankyloglossia does not always cause breastfeeding problems (UNICEF, 2010; Mettias et al, 2013). This information should be emphasised to professionals and mothers to reduce needless anxiety, and also to prevent unnecessary frenotomy taking place. Education should include how to judge whether the ankyloglossia is causing unwanted breastfeeding symptoms.
Management
Local NHS Trusts would benefit from implementing a standard policy in relation to assessment for ankyloglossia and the subsequent options for management of the condition, should mothers and/or infants be symptomatic. This information should then be disseminated to the relevant health professionals to apply in their practice.
Research
The current literature on ankyloglossia and frenotomy is varied or, as McBride (2005: 242) has described it, ‘long on opinion but short on fact’. There were three RCTs included in this review, only one of which blinded mothers to the treatment group (Hogan et al, 2005; Dollberg et al, 2006; Emond et al, 2014). There is a need for more blinded RCTs that involve larger sample sizes. Also useful would be long-term follow-up of breastfeeding outcomes in mother–infant dyads that decide not to opt for frenotomy, investigating questions such as: how long did they breastfeed for, and did breastfeeding remain problematic or painful?
Future research on the effectiveness of frenotomy for ankyloglossia would benefit from addressing cultural and social issues as well as personal attitudes to breastfeeding, as these can be confounding factors and affect the validity of research. Furthermore, research focusing on the possible distress caused by frenotomy and the need for anaesthetic is needed.
Future research into effective and standardised ways to assess and classify ankyloglossia—and to grade the effect that it has on breastfeeding—could warrant knock-on implications for practice, education and management in the NHS.
Conclusion
The research under review demonstrates that frenotomy can be effective for reducing nipple pain and improving a baby's latch onto the breast, thus alleviating unwanted breastfeeding symptoms. However, the research fails to address issues such as the woman's motivation to breastfeed, her social and cultural background, and how these are related. It is, therefore, difficult to attribute improvements in breastfeeding to the frenotomy itself, or the extra support received with breastfeeding.
The majority of research focused on the mother's experience of breastfeeding before and after a frenotomy procedure, to ascertain whether the procedure had been successful. There is a lack of representation from a control group who do not undergo frenotomy. The scarcity of follow-up with any control groups means it is difficult to determine whether the procedure can lead to prolonged breastfeeding.
Few of the studies appraised address the psychological impact of frenotomy on the infant or the parents. Despite being medically deemed as uncomplicated and safe, it may be that the procedure has an impact on the child's early experience and development. More research is required in this area.
The current lack of uniform guidance regarding the diagnosis, grading and treatment of ankyloglossia is likely to contribute to inconsistencies in the way midwives and other health professionals address this issue. Those working with newborns and mothers should be educated and trained in how to assess for ankyloglossia, and make a judgement on whether it is causing breastfeeding problems (bearing in mind that the condition does not always cause problems) following locally agreed policies.