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Surgery for tongue tie shows some benefits; more research needed

May. 7, 2015, 10:32 AM

Surgically treating “tongue tie” in infants may be associated with improved breast-feeding and reduced nipple pain, as reported by mothers, but much more research is needed on best practices for treating the condition, according to a newly published systematic review.

The Vanderbilt Evidence-Based Practice Center (EPC), directed by Melissa McPheeters, Ph.D., MPH, in the Department of Health Policy, is one of 13 centers in the United States and Canada funded by the Agency for Healthcare Research and Quality (AHRQ) to review the evidence on important clinical questions.

The EPC performed a rigorous analysis of existing literature to assess the potential benefits and harms for surgical and non-surgical treatment for tongue tie, known as ankyloglossia, in infants, children and adolescents.

The report will be available to the public at the AHRQ website, and two papers derived from the research are being published in the journal Pediatrics.

Between 2 and 10 percent of infants are affected by tongue tie, a congenital condition characterized by an abnormally short, thickened or tight lingual frenulum — the tiny membrane that connects the tongue to the base of the mouth — that can restrict tongue mobility.

Problems associated with tongue tie can include breast-feeding issues in infants, and speech difficulties, self-esteem and other issues in older children.

But a lot of controversy exists around whether treating tongue tie, either surgically or with non-surgical interventions, is warranted or if it should be left alone.

Few studies had the answers or strong evidence to support a conclusive finding, the EPC report found.

“Much is being talked about in this area and there is a lot of controversy, yet no one is systematically studying this,” said David Francis, M.D., MS, assistant professor of Otolaryngology at Vanderbilt University Medical Center, and one of the report’s authors.

“This is a call to action for people to think of this as an opportunity to do research. One purpose of the literature review is to point out limitations in the evidence base and encourage people to fill those gaps.”

The surgical procedure to treat tongue tie is typically a frenotomy, which involves clipping or cutting the frenulum. Nonsurgical therapies include speech therapy and lactation intervention and observation to determine if intervention is warranted.

Francis said ankyloglossia has become a hot topic because some evidence suggests the limited tongue mobility caused by the condition can inhibit effective breast-feeding.

“With all the health benefits associated with breast-feeding, this issue has become more important. Proponents say we should clip the frenulum to make sure babies can feed better because of the benefits, and that’s where the controversy comes into play,” he said.

“We don’t know what the natural history of this condition is. We also don’t know what happens if we just leave it alone. There is not a lot of data for or against, hence why there is so much controversy or diversity of opinion. The available data do, however, suggest that mothers perceive an immediate improvement in breast-feeding after frenotomy. This is an important finding and one that cannot be understated as the mother is the ultimate arbiter of procedural success,” Francis said.

The Vanderbilt EPC team’s analysis included 58 unique studies, including six randomized, controlled trials, three cohort studies, 33 case series, 15 case reports and one unpublished thesis.

Most of the studies reviewed addressed therapeutic outcomes related to breast-feeding. Studies related to outcomes for speech accounted for the second most common effect explored.

“The conclusions from this analysis were that a small body of evidence suggests that frenotomy may be associated with improvements in breast-feeding as reported by mothers and potentially in nipple pain, but with short-term studies inconsistently conducted, the strength of evidence is generally low to insufficient at this time,” Francis said.

Comparative studies reported improvements in some measures of speech after surgical intervention, but assessment of outcomes was inconsistent and few studies addressed tongue mobility or self-esteem issues.

Research is lacking on nonsurgical interventions.

The EPC report noted that future studies could help provide additional data to confirm or change the measure of effectiveness for best practices for tongue tie.

Other authors on the report, from multiple disciplines, included the principal investigator, McPheeters; Siva Chinnadurai, M.D., MPH (Otolaryngology); Anna Morad, M.D. (Pediatrics/Newborn Nursery); Richard Epstein, Ph.D., MPH (Psychiatry); Sahar Kohanim, M.D. (Ophthalmology); and Nila Sathe, M.S. (Health Policy).

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