Tongue-tie and breastfeeding: Identifying problems in the diagnostic and treatment journey
Tongue-tie is a common condition that often adversely affects breastfeeding. There is research that suggests that frenulotomy can improve breastfeeding but there is also evidence of lack of professional knowledge on tongue-tie.
This was a qualitative interview study with GPs, midwives, health visitors and nine mothers to explore facilitators and barriers to receiving a diagnosis of and treatment for tongue-tie.
Mothers told a common story of having to push for support, experiencing diagnostic and treatment delays and suffering ongoing distress, which threatened their ability to establish breastfeeding. Mothers also described feeling vulnerable in the neonatal period, and witnessing a variation in professional knowledge about tongue-tie.
Variable professional knowledge, conflicting advice, and a delayed diagnosis can lead to a difficult patient pathway. Assessment for tongue-tie should be considered when approaching infants with feeding difficulties. Frenulotomy should also be considered and services made available where findings suggest the cause is structural and breastfeeding support has not helped.
Tongue-tie (ankyloglossia) is a common condition with a prevalence between 0.2 and 10.7% (Segal et al, 2007; Francis et al, 2015; Power and Murphy, 2015), and is defined as an embryological remnant of tissue between the under-surface of the tongue and the floor of the mouth that can restrict tongue movement. This is an important condition for primary care because it can cause breastfeeding difficulty for the mother and infant, including nipple pain, difficult attachment and increased bottle feeding rates (Segal et al, 2007; Suter and Bornstein, 2009; Edmunds et al, 2011). Mothers have described an ‘anticipatory dread’ towards breastfeeding an infant with tongue-tie (Edmunds et al, 2013). Tongue-tie can be obvious, such as with a restricting frenulum or heart-shaped tongue, but some infants may only be diagnosed after assessment of breastfeeding difficulties, positioning, attachment, tongue appearance and function, by practitioners with the appropriate expertise (Figure 1) (Hill and Johnson, 2007). Other causes of difficult feeding such colic, reflux, poor attachment, positioning, and inverted nipples would need to be considered (Amir, 2014). Assessment for tongue-tie is not part of routine UK neonatal examination and is usually identified by GPs, midwives or health visitors in the context of emerging breastfeeding problems. Tongue-tie, if it is symptomatic, can be treated with a frenulotomy, which involves snipping the tongue with sharp, round scissors. Bleeding is stopped by allowing the baby to feed, which compresses the wound (Edmunds et al, 2011). In 2005, UK guidelines from the National Institute of Health and Clinical Excellence (NICE) (2005) concluded that limited evidence suggested that when tongue-tie is thought to be a problem, division is both safe and able to improve breastfeeding where conservative measures such as frenulum massage and breastfeeding support have failed, although there is no published research to recommend frenulum massage.
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