When neonatologist Elsie Mainali, M.D., Ph.D., noticed that many babies were diagnosed with ankyloglossia — tongue-tie — in her unit and were referred to otolaryngologists for surgical tongue-release procedures, she wanted to ensure the interventions were necessary. After conducting a systematic review of research on the topic and talking to several Pediatrix® Medical Group colleagues, Dr. Mainali found a tool that can help clinicians better assess the severity of the condition.
We recently sat down with Dr. Mainali, a member of the regional response team with Pediatrix Medical Group of Maryland, to learn more about ankyloglossia, how it’s diagnosed and how to correct it.
What is ankyloglossia?
The frenulum is a thin membrane in the mouth that connects the tongue to the floor of the mouth. Some babies are born with a frenulum that’s too thick or that extends to the tip of the tongue, called ankyloglossia. If the frenulum is very tight, the tongue pulls into a heart shape when the baby cries. It’s quite noticeable during a physical exam after birth.
If the frenulum restricts the tongue’s range of motion, it may cause breastfeeding issues or nipple pain. Sometimes the condition corrects itself naturally, but in many cases, a frenotomy is necessary. This is when the frenulum is cut to release the tightness. Without treatment, the condition can cause malnourishment or future speech issues.
Why is this topic controversial?
In my opinion, ankyloglossia is overdiagnosed, which causes unnecessary stress for parents and can increase health care costs. When a baby is diagnosed with the condition, some lactation consultants recommend that the frenulum be cut right away since it can help make breastfeeding easier for the baby and less painful for the mother. Other clinicians prefer watchful waiting to see if the frenulum loosens on its own or if the condition impacts feeding. As physicians, we have the opportunity to educate lactation consultants, nurses and residents on how to evaluate the condition better and determine when surgical intervention is necessary and, more importantly, when it isn’t. Further, when the frenulum needs to be cut, a neonatologist can perform the simple procedure without referring the child to a specialist for an outpatient procedure.
What criteria can be used to diagnose ankyloglossia and determine if surgery is necessary?
Alison Hazelbaker, Ph.D., IBCLC, an international board-certified lactation consultant and ankyloglossia patient, developed the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) to quantitatively assess tongue-tie and determine if frenotomy is necessary. The assessment includes five appearance criteria, including the length of the lingual frenulum and its elasticity, and seven functional criteria, including the extension of the tongue and lateralization. Each criterion is scored between 0 and 2, with a lower score indicating the most severe form of the condition.
How is the condition treated?
If a baby scores poorly on the Hazelbaker assessment, surgical intervention may be necessary.
A frenotomy is a simple surgical procedure that a neonatologist can do without anesthesia. I learned the procedure from Martin Nwanko, M.D., a neonatologist with Pediatrix Medical Group of Michigan. During a frenotomy, you quickly snip the frenulum with sterile scissors. The cut is made in a single motion in less than a second. The only risk associated with the procedure is excessive bleeding, so it’s not indicated in infants with a family history of bleeding disorders. The procedure is usually painless and blood-free. However, surgery is still surgery, no matter how simple it is. There may be a drop or two of blood in some cases, but the baby can often breastfeed immediately after the procedure.
A frenuloplasty (also called a frenectomy) may be indicated if the frenulum is too thick for a frenotomy. This is a more extensive procedure that requires a specialist and may need general anesthesia.
Is a frenotomy always necessary? How can doctors make a determination?
The most important issue in determining if surgery is necessary is if the condition impacts how the baby’s tongue functions. Can the baby cry? Can the baby breastfeed and get a good seal around the nipple? If these answers are yes, surgery is likely not necessary.
How did you roll out the Hazelbaker Assessment Tool at your facility?
I wanted to make sure we had total buy-in on any changes in procedure, so I shared peer-reviewed, evidence-based research with all stakeholders in my NICU, including the physicians, lactation consultants and nurses. There was a consensus to start using the Hazelbaker Assessment Tool to describe and grade the condition for the infants in our care.
What has been the impact of using the tool at your facility?
In the six months that we’ve been using the Hazelbaker tool, I’ve seen a tremendous decline in babies diagnosed with ankyloglossia. As a result, I have not needed to perform frenotomies as often.
What’s your advice for a parent whose child has been diagnosed with ankyloglossia?
Most parents expect to deliver a perfect baby, so when they learn that their baby may have an issue, it causes a lot of stress during an already stressful time. Sometimes new moms will search the internet for information about the condition and may not fully understand what they read. Gathering knowledge is important for a new parent, but the internet should not be a substitute for talking to the baby’s physician about that child’s specific condition. In some cases, no intervention is necessary, and in other cases, the neonatologist can correct the issue with a simple procedure that requires no anesthesia or stitches.
What advice do you have for your colleagues?
Research how many babies in your unit are being referred for frenulum-correction procedures, and if you think it seems too high, discuss the issue with your medical director and your team. There may be an opportunity to improve how ankyloglossia is assessed. It may make sense for your group to design a new clinical pathway to diagnose and treat the condition. And, if you’re interested in learning the procedure, ask a colleague to teach you.