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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the evaluation and management of neonatal ankyloglossia
and its complications in the breastfeeding dyad.

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine. Guidelines for the evaluation and
management of neonatal ankyloglossia and its complications in the
breastfeeding dyad. New Rochelle (NY): Academy of Breastfeeding
Medicine; 2004 Sep 3. 8 p. \[24 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Neonatal partial ankyloglossia (also called tongue-tie)

-   Infant health/nutrition

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Medical Genetics\
Nutrition\
Obstetrics and Gynecology\
Otolaryngology\
Pediatrics\
Speech-Language Pathology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Nurses\
Physician Assistants\
Physicians\
Speech-Language Pathologists

#### GUIDELINE OBJECTIVE(S)

To facilitate optimal breastfeeding through evaluation and management of
neonatal ankyloglossia and its complications

#### TARGET POPULATION

Infants with partial ankyloglossia

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Assessment of ankyloglossia through examination of infant\'s oral
    cavity, including palpation of hard and soft palate, gingivae,
    sublingual areas, and frenulum and function of infant\'s tongue
    (Hazelbaker score; mild, moderate, severe)

2.  Assessment of breastfeeding

    -   Interview mother for confidence/comfort (LATCH score)

    -   Examination of mother\'s nipples

    -   Assessment of degree of pain (pain scale)

    -   Observation of breastfeeding

    -   Determination of infant weight and rate of weight gain

    -   Determination of infant weight prior to and following
        breastfeeding

**Management/Treatment**

1.  Conservative management of tongue-tie (breastfeeding assistance,
    education, reassurance)

2.  Surgical management (\"tongue tie release\")

    -   Frenotomy or simple incision

    -   Z-plasty release

3.  Management of maternal and infant complications of ankyloglossia

    -   Problem-specific treatment of nipple damage, infection, or
        mastitis

    -   Nipple rest

    -   Milk expression

    -   Addressing of suppressed lactation and re-establishing milk
        supply

    -   Follow-up

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of ankyloglossia

-   Breastfeeding complications

-   Ankyloglossia-related morbidity

-   Adverse events associated with frenotomy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in
the past 20 years in the fields of medicine, psychiatry, psychology, and
basic biological science is undertaken for a particular topic. Once the
articles are gathered, the papers are evaluated for scientific accuracy
and significance.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I Evidence obtained from at least one properly randomized controlled
trial

II-1 Evidence obtained from well-designed controlled trials without
randomization

II-2 Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could
also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience,
descriptive studies and case reports; or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An expert panel is identified and appointed to develop a draft protocol
using evidence based methodology. An annotated bibliography (literature
review), including salient gaps in the literature, are submitted by the
expert panel to the Protocol Committee.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft protocol is peer reviewed by individuals outside of lead
author/expert panel, including specific review for international
applicability. Protocol Committee\'s sub-group of international experts
recommends appropriate international reviewers. Chair (co-chairs)
institutes and facilitates process. Reviews submitted to committee Chair
(co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine
(ABM) Board for review and approval. Comments for revision will be
accepted for three weeks following submission. Chair (co-chairs) and
protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s)
to make final suggestions and ascertain whether to maintain lead
authorship.

Final protocol is submitted to the Board of Directors of ABM for
approval.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Assessment of Ankyloglossia**

All newborn infants, whether healthy or ill, should have a thorough
examination of the oral cavity that assesses function as well as
anatomy. This examination should include palpation of the hard and soft
palate, gingivae and sublingual areas in addition to the movements of
the tongue, and the length, elasticity and points of insertion of the
sublingual frenulum.

When breastfeeding difficulties are encountered and a short or tight
sublingual frenulum is noted, the appearance and function of the tongue
may be semi-quantified using a scoring system such as the Hazelbaker
(see Table 1 in the original guideline document). The Hazelbaker scale
has been tested for interrater reliability and validated in a sample of
term neonates. Hazelbaker scores consistent with significant
ankyloglossia have been shown to be highly correlated with difficulty
with latching the infant onto the breast and maternal complaints of sore
nipples. Alternatively, ankyloglossia may be qualified as mild, moderate
or severe by the appearance of the tongue and of the frenulum.

**Assessment of the Breastfeeding Dyad**

Breastfeeding complications due to ankyloglossia can generally be placed
into broad categories of those due to maternal nipple trauma and/or
failure of the infant to breastfeed effectively. Specific complaints
include difficulty latching or sustaining a latch, infant becoming
frustrated or falling asleep at breast, prolonged feedings, a
dissatisfied baby, gumming or chewing at the breast, poor weight gain,
or failure to thrive. Maternal complaints include traumatized nipples,
severe unrelenting pain with feeding, inability to let down due to pain,
incomplete breast drainage, breast infections, and plugged ducts.

The physician should interview the mother to ascertain her degree of
confidence and comfort while breastfeeding. This can be done
semi-quantitatively by using a scoring system such as the LATCH Score or
a similar tool. The LATCH score has been shown to correlate with
breastfeeding duration but only due to sub-scores for breast comfort.

If the mother describes any nipple pain, the physician may wish to use a
pain scale in order to semiquantify her perception of the degree of her
pain. This serves to follow trends in the severity of pain, which may
help in determining the effectiveness of an intervention.

The infant should be weighed and the rate of weight gain since birth
should be assessed. The physician should observe the mother and infant
while breastfeeding, to assess the effectiveness of the feeding and
provide assistance as appropriate. Problems including an inadequate or
non-sustained latch and ineffective feedings should be noted. Test
weights may be useful in assessing milk transfer. The infant should be
weighed prior and after breastfeeding without a change in clothing or
diaper; the difference between the weights in grams indicates the amount
of breastmilk consumed in milliliters.

The mother\'s nipples should be examined carefully for creases, bruises,
blisters, cracks, or bleeding. Areolar edema and erythema should be
noted as possible signs of nipple infection. A family history of
bleeding diatheses should be elicited.

**Management of Ankyloglossia**

Conservative management of tongue-tie may be sufficient, requiring no
intervention beyond breastfeeding assistance, parental education, and
reassurance. For partial ankyloglossia, if a tongue-tie release is
deemed appropriate the procedure should be performed by a physician or
pedodontist experienced with the procedure, otherwise a referral should
be made to an ear, nose and throat specialist or oral surgeon. Release
of the tongue-tie appears to be a minor procedure, but may be
ineffective in solving the immediate clinical problem and may cause
complications such as infant pain and distress and postoperative
bleeding, infection, or injury to Wharton\'s duct. Complications,
however, are rare.

Frenotomy or simple incision or \"snipping\" of a tongue-tie is the most
common procedure performed for partial ankyloglossia (see \"The
Frenotomy Procedure\" in the original guideline document). It should be
recognized that postoperative scarring may further limit tongue
movement. Excision with lengthening of the ventral surface of the tongue
or a z-plasty release is a procedure with less postoperative scarring,
but carries the additional risks of general anesthesia.

**Management of Maternal and Infant Complications of Ankyloglossia**

If nipple damage or infection is present, a problem-specific treatment
program should be instituted. Mastitis and yeast infections should be
treated according to established guidelines.

Some mothers may need nipple rest for one to several days to allow
healing to occur before reinstituting feedings at the breast. These
mothers should be encouraged to express their breast milk in order to
maintain their milk supply, and to feed their milk to the baby by an
alternate method.

Suppressed lactation should be addressed and every attempt made to
re-establish the mother\'s milk supply. Infants who have been gaining
weight slowly or failing to thrive may need to receive supplements of
expressed breast milk or formula temporarily.

Follow-up for resolution of maternal and infant complications of
ankyloglossia should take place by the mother\'s and/or infant\'s
primary health care provider within 3 or 4 days of the frenotomy.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

The recommendations were based primarily on a comprehensive review of
the existing literature. In cases where the literature does not appear
conclusive, recommendations were based on the consensus opinion of the
group of experts.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate evaluation and management of neonatal ankyloglossia and its
complications

#### POTENTIAL HARMS

-   Release of the tongue-tie appears to be a minor procedure, but may
    be ineffective in solving the immediate clinical problem and may
    cause complications such as infant pain and distress and
    postoperative bleeding, infection or injury to Wharton\'s duct.
    Complications, however, are rare.

-   It should be recognized that postoperative scarring may further
    limit tongue movement. Excision with lengthening of the ventral
    surface of the tongue or a z-plasty release is a procedure with less
    postoperative scarring, but carries the additional risks of general
    anesthesia.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

A central goal of the Academy of Breastfeeding Medicine is the
development of clinical protocols for managing common medical problems
that may impact breastfeeding success. These protocols serve only as
guidelines for the care of breastfeeding mothers and infants and do not
delineate an exclusive course of treatment or serve as standards of
medical care. Variations in treatment may be appropriate according to
the needs of an individual patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Foreign Language Translations

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine. Guidelines for the evaluation and
management of neonatal ankyloglossia and its complications in the
breastfeeding dyad. New Rochelle (NY): Academy of Breastfeeding
Medicine; 2004 Sep 3. 8 p. \[24 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004

#### GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

#### SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of
Health and Human Services

#### GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: \*Jeanne Ballard, MD; Caroline Chantry MD, FABM,
*Co-Chairperson*; Cynthia R. Howard MD, MPH, FABM, *Co-Chairperson*

\**Lead author(s)*

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/protocol/ankyloglossiaFinal_11.pdf).

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Procedure for protocol development and approval. Academy of
    Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

Korean and German translations of the original guideline document are
available from the [Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/index.asp?menuID=139&firstlevelmenuID=139).

Additionally, the Hazelbaker Assessment Tool for Lingual Frenulum
Function is available in the original guideline document.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on November 2, 2007.
The information was verified by the guideline developer on November 12,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission
to be requested for use of multiple copies by e-mailing requests to
<abm@bfmed.org>. An official request form will be sent electronically to
person requesting multiple copy use.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 12/8/2008