CTRI

Ankyloglossia or tongue tie is the presence of an unusually short, thick or tight lingual frenulum tethering the tongue tip to the floor of the mouth. (1) This may restrict normal tongue movements leading to difficulties in breastfeeding in the early neonatal period. Breastfeeding difficulties reported with tongue-tie include poor latch, poor milk transfer, maternal nipple pain, milk supply issues and poor infant weight gain. The prevalence of tongue tie varies from 10-46% as per various studies. Frenotomy is a commonly suggested intervention in cases with tongue tie. The impact of frenotomy on reduction in nipple pain and increasing the ease of breastfeeding is known. Impact of frenotomy on improvement in breastfeeding is debatable.(2)

Coryllos and colleagues described anterior (types 1 and 2) and posterior tongue-ties (types 3 and 4).(3) Haham et al. examined the incidence of these types but did not find a difference in breastfeeding problems based on type. (4) Ghaheri et al. found an improvement in breastfeeding after laser frenotomy for anterior and posterior tongue-ties. (5) However, Douglas questions the widespread diagnosis of posterior tongue-ties and discusses the role of other factors in impaired tongue function (e.g., infant musculoskeletal tensions and breastfeeding positioning). (6) Oâ€™Callahan et al. retrospectively examined anterior and posterior tongue-ties; they found many infants with posterior ankyloglossia had persistent breastfeeding difficulties after initial anterior frenotomy. The breastfeeding issues improved only after the posterior frenotomy was performed. (7)

In our facility, we see several babies with tongue tie having feeding difficulties, poor latch and mothers complaining of breast and nipple pain. Very often these infants present with poor weight gain or excessive weight loss after birth. Some of them undergo a frenotomy in order to facilitate proper latching at the breast and breastfeeding. The aim of this study was to study the breastfeeding outcomes of infants with tongue tie and determine if frenotomy improves breastfeeding outcomes and decreases maternal nipple pain.

Keywords: ankyloglossia, breastfeeding difficulties, breast pain, LATCH assessment tool, tongue-tie

4. Study breastfeeding outcomes in babies with tongue tie with respect to exclusive breastfeeding at discharge/ 1 month/ 3 months and 6 months.

All stable term and late preterm infants identified to have tongue tie on assessment.

Preterms < 34 weeks, Neurologically abnormal neonates, Neonates with labial frenulum or other orofacial malformations

Methods: All mother infant dyads delivering/ admitted to the hospital will be provided lactation counselling by trained lactation counsellors. Dyads with feeding difficulties/failure to thrive/maternal nipple pain will be identified and assessed. All these neonates will be screened for tongue tie with the use of TABBY (Tongue tie and breastfed babies) tongue assessment tool, which is a visual tool for assessment of tongue tie. This screening will be done by trained lactation counsellors and confirmed by a certified lactation consultant.

A score of 8 indicates normal tongue function. 6-7 borderline and 5 or less suggests impaired tongue function.

Infants with borderline or impaired tongue function will be assessed for any neurologic problems by a neonatologist. An oromotor evaluation will be done by a neonatal therapist to look for oromotor dysfunction due to other causes. Feeding issues due to oromotor dysfunction due to causes other than tongue tie will be addressed by providing appropriate oromotor stimulation.

Once tongue tie is ascertained to be a significant problem for feeding difficulties by the clinical team, baby will be enrolled in the trial after obtaining a written informed consent from the parents.

The clinical profile of mother and baby will be noted. Feeding problems like poor latch, nipple pain, nipple injuries, low milk output, poor weight gain/excessive weight loss, low urine output etc will be assessed and recorded. Nipple abnormalities and evidence of nipple trauma will be assessed and recorded.LATCH score (max 10 points) will be assessed and recorded.

Nipple pain will be assessed on Likert scale of 1-10, 1 being no pain and 10 being maximum pain.

Coryllos ankyloglossia grading scale will be used to identify anterior and posterior variants of tongue tie.

Mothers will receive breastfeeding support by counselling and practical help for positioning and achieving a deep latch, prone feeding etc. Frenotomy Decision tool for breastfeeding dyads (Carole Dobrich) will be used to decide eligibility for frenotomy by a certified lactation consultant. A score of >= 2 indicates need for frenotomy.

Once decision for frenotomy is taken, a written informed consent will be obtained from the parents. The timing of frenotomy will be recorded (day of life). Frenotomy will be conducted by a trained surgeon.

The LATCH score will be assessed before frenotomy, immediately after frenotomy and 2 days post frenotomy. Maternal nipple pain will be assessed by a visual/ analogue Likert scale pre and post frenotomy. Bleeding post frenotomy will be noted.

A neonatal therapist will objectively assess improvement in oromotor function 2 days post frenotomy (using Neonatal Oromotor Assessment Scale- NOMAS).

Babies will be followed up 7 days and 14 days post frenotomy, and LATCH score and pain score reassessed. Adequacy of exclusive breastfeeding will be assessed by weight gain at 1 month post frenotomy, 3 months and 6 months of age on exclusive breastfeeding. Need for supplementary feeding will be recorded, volume of supplementary feeds and reason for providing supplementary feeds will be noted.