Breastfeeding Improvement Following Tongue Tie Release: A Prospective Cohort Study
Bobak A. Ghaheri, MD; Melissa Cole, IBCLC; Sarah C. Fausel, BA; Maria Chuop, BS; Jess C. Mace, MPH, CCRP This article was published in The Laryngoscope, 00:000–000, 2016.
Numerous symptoms may arise that prevent mother-infant dyads from maintaining desired breastfeeding intervals. Investigations into treatments that positively influence breastfeeding outcomes allow for improved patient counseling for treatment decisions to optimize breastfeeding quality. This investigation aimed to determine the impact of surgical tongue-tie/lip-tie release on breastfeeding impairment.
Prospective, cohort study from June 2014 to April 2015 in a private practice setting.
Study participants consisted of breastfeeding mother–infant (0–12 weeks of age) dyads with untreated ankyloglossia and/or tethered maxillary labial frenula who completed preoperative, 1 week, and 1 month postoperative surveys consisting of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), visual analog scale (VAS) for nipple pain severity, and the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). Breastmilk intake was measured preoperatively and 1 week postoperatively.
A total of 237 dyads were enrolled after self-electing laser lingual frenotomy and/or maxillary labial frenectomy. Isolated posterior tongue-tie was identified in 78% of infants. Significant postoperative improvements were reported between mean preoperative scores compared to 1 week and 1 month scores of the BSES-SF (F(2) 5 212.3; P < .001), the I-GERQ-R (F(2) 5 85.3; P < .001), and VAS pain scale (F(2) 5 259.8; P < .001). Average breastmilk intake improved 155% from 3.0 (2.9) to 4.9 (4.5) mL/min (P < .001).
Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes. Improvements occur early (1 week postoperatively) and continue to improve through 1 month postoperatively. Improvements were demonstrated in both infants with classic anterior tongue-tie and less obvious posterior tongue-tie. This study identifies a previously under-recognized patient population that may benefit from surgical intervention if abnormal breastfeeding symptoms exist.
Breastfeeding, ankyloglossia, patient outcome assessment, outcome assessment (healthcare), visual analog scale, gastroesophageal reflux.
Level of Evidence
The rate of breastfeeding in the United States has been rising over the last 20 years with the increased emphasis on improved health outcomes in breastfed children and the recent impetus for hospitals to meet care standards established by the Baby Friendly Hospital Initiative. Previous research has demonstrated increased breastfeeding failure rate in mothers who intended to breastfeed in the hospital setting. The causes of breastfeeding cessation are multifactorial and include poor weight gain necessitating supplementation, poor latch, maternal nipple pain, and structural restrictions like ankyloglossia.
Ankyloglossia (either classic anterior tongue-tie or submucosal restriction) and a tethered superior labial frenum (upper lip-tie) cause altered latch and sucking mechanics. The suckling process is complex and multi-factorial, and dysfunction may cause diverse signs and symptoms in the breastfeeding dyad. Latch difficulties and suboptimal sucking mechanics may result in inefficient milk transfer, poor weight gain, low milk supply, nipple pain and trauma.
Recently, the Agency for Healthcare Research and Quality (AHRQ) evaluated the existing body of evidence regarding lingual frenotomy and maxillary labial frenectomy, concluding that the strength of outcomes-based evidence supporting those procedures was “generally low to insufficient.” The insufficient research quality is largely due to the lack of randomized controlled trials. Previous studies have examined the impact of lingual frenotomy on maternal pain, improvement in latch quality, and improvement of breastfeeding complaints. Some breastfeeding specialists have documented an improvement in maternal self-efficacy; this improvement in self-efficacy is an established predictor for continued breastfeeding. In children with reflux symptomatology, clinical improvement has been suggested following frenotomy. Due to the complex and multifactorial nature of infant reflux, and because of the lack of published studies trying to determine correlation between tongue-tie and reflux symptoms, further investigation is warranted.
To better elucidate treatment outcomes surrounding these procedures and to help address the AHRQ determination for higher level evidence, we designed a prospective cohort study aimed to test four hypotheses regarding tongue-tie/lip-tie release: 1) Surgical release will improve maternal breastfeeding self-efficacy. 2) Surgical release will improve maternal nipple pain. 3) The procedure will improve milk transfer rates following tongue-tie/lip-tie release. 4) The procedure will improve infant gastroesophageal reflux symptoms.
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