Literature Review of Breastfeeding and Tongue Ties
By Mary Miller, MA, IBCLC, RLC, MCH, CLC, CPD, CBC
TOTs basics
Tongue-tie is diagnosed when the thin tissue connecting the tongue to the bottom of the mouth is overly thickened, short, or attached too far towards the tip (anterior) of the tongue to allow for proper functional movement, including the ability to move the tongue in and out and/or up and down within the mouth (Hazelbaker, 2011). Tongue tie can cause difficulties with breastfeeding, inhibit speech, and even cause difficulties kissing and interfere with sexual relationships later in life (Messner & Lalakea, 2000, Fernando, 1998). Medical professionals are in disagreement about diagnostic criteria for ankyloglossia (Douglas, 2017b; Douglas, 2017c; Segal, Stephenson, Dawes, Feldman, 2007) and whether it impacts the breastfeeding dyad at all (Evans, 2008). This controversy within the field might result in missed diagnoses, presenting a uniquely devastating circumstance for the breastfeeding mother and infant.
A detailed case study involving ultrasound data to observe tongue movements, measured milk transfer, and vacuum suction in the mouths of a small sample of infants, there were a wide variety of vacuum levels as well as reported milk intake (Geddes, Kent, McClellan, Garbin, Chadwick & Hartmann, 2010). This study showed that nipple compression that occurred when a baby had a tongue tie was normalized post-frenotomy. Geddes et al (2010) theorized that in babies whose ankyloglossia does impact breastfeeding, “abnormal compression of the nipple may result in an ineffective suck by mechanically compressing the milk ducts in the nipple, obstructing the milk flow and thus reducing milk intake (p. 303).” This means that a baby may have a reduced ability to transfer milk at the breast regardless of whether any breastfeeding problems had been identified, and helping to explain why babies whose mothers have a rapid letdown (therefore making milk transfer quite easy for the restricted infant) may still gain weight appropriately while tied. The largest study done to date of infants thus far with tongue-tie showed that they had an easily “identifiable group of symptoms (poor latch, nipple trauma, and continuous feeding) that prevented them from breastfeeding” (Griffiths, 2004 p. 413).
A Note on Labial and Buccal Ties
Labial (lip) and buccal (cheek) ties are even more controversial than tongue ties and remain relatively unstudied in the literature. Perhaps more interestingly, the subject of lip ties has been a controversy for just as long as tongue ties; for at least several hundred years of recorded history, providers have been in disagreement about whether and how to incise the frenum (Romero-Maroto & Sáez-Gómez, 2012). These types of ties are considered (by those who believe they exist) to occur when the frenulum in these areas, if present, is overly short or taught and is impacting function in some way (Kotlow, 2010, 2011, 2013, 2017, 2018; Gaheri & Cole, 2017; Macaluso & Hockenbury, 2015). Indeed, Dr. Kotlow has also created a set of diagnostic criteria to identify and classify lip ties as well, indicating that the possibility of their impact on breastfeeding in combination with the increased risks of dental caries justify a division of these tissues if symptoms are present (2017).
However, there are also industry professionals who claim that lip and buccal ties are simply a figment of the imagination of those who don’t know how to competently support a dyad through the breastfeeding experience, as there is simply no empirical evidence to support their clinical significance (Hazelbaker, 2018, Douglas 2017a, 2017b). Such strong statements in opposition to the notion of buccal and upper lip ties are made to specifically state that these frena do not impact function in any way of the breastfeeding infant, as the infant has no need to flange his or her upper lip but needs only to avert it, with the seal of the mouth being made by the lower lip during breastfeeding (ACIOR, 2018, Douglas 2017a).
Available Diagnostic Assessment Tools for Ankyloglossia
There are a myriad of different diagnostic tools to assess for ankyloglossia in newborns. The HATLFF is the most researched tool described in the literature (Roberta Lopes de Castro, Irene Queiroz, José Roberto, Heitor Marques, Reinaldo Jordão& Giédre, 2016), usually in reference to breastfeeding infants. The next most commonly found tool within the literature was created by Dr. Larry Kotlow (2016) and is based on his decades of pediatric dental work and ankyloglossia research, which he published most recently in his book SOS 4 TOTS. His criteria tend to be utilized more by medical professionals such as dentists, otolaryngologists, orthodontists, and others. The research conducted by speech and language pathologists, chiropractors, and craniosacral therapists tend to use a less structured, historic method of assessing for tongue tie that’s more akin to “eyeballing” based on symptoms present and visual assessment of restriction.
Dr. Kotlow’s assessment contains a 4-point scale, with class 1 being the least severe (and posterior) and a class 4 being the most (anterior). Class 1 ties are considered submucosal (and are therefore difficult to see), where the frenulum is “located from the base of the tongue halfway to the salivary duct” and the class 4 ties “located at the tip of the tongue and extending halfway between the salivary duct and the tip of the tongue. The decision to perform a frenotomy is on function and appearance, but the classifications are in appearance only (Kotlow, 2016).
Hazelbaker’s assessment tool is focused on function over appearance (though both are assessed and scored) and is generally favored among professionals due to its evidence-based nature and high level of reliability. Amir et al. (2006) assessed the HATLFF for reliability and found that just the first three function items (lift of tongue, lateralization, and extension of tongue) were more vital to diagnosis than the four function items related to sucking (cupping, spread, snapback and peristalsis) (Amir, James & Donalth 2006).
Impacts of ankyloglossia
When a breastfeeding mother has a baby whose tongue is restricted, it can become extremely painful to nurse the infant. The baby can also have difficulty removing enough milk from the mother’s breast to sustain growth. This issue of poor milk transfer can result in a myriad of breastfeeding problems, including low milk supply, premature weaning, failure to thrive diagnoses, sleep deprivation, psychological impacts of depression and poor bonding between mother and child, gagging, choking or vomiting foods, speech development delays and more (Fernando, n.d.).
The frequency of ankyloglossia reported in our current medical literature encompasses a wide range; and anywhere from 0.02% to 10.7% of babies are reported to have it (Power & Murphy, 2015). Perhaps this range is so wide because of the lack of standardized diagnostic criteria for ankyloglossia. According to the literature, 50% of those considered to have ankyloglossia will not have any difficulty with breastfeeding (Power & Murphy, 2014, p. 490). It does not take much critical thought to question the validity of a statement such as this; indeed, some believe that ankyloglossia is not present unless there are restrictions that would impede breastfeeding (Hazelbaker, 1993) while others include additional challenges beyond breastfeeding within their diagnostic criteria (Kotlow, 2011). The literature is clear that there are many issues impacted by ankyloglossia, even if breastfeeding goes well for the dyad.
An important area of concern related to ankyloglossia is the greater health risks (and their treatment) associated with the inability to correctly utilize the tongue for all its various functions. Sleep apnea is a well-accepted risk of a short lingual frenulum due to the tongue’s obstruction of the airway. Of course, sleep apnea is now also being associated with the inflammation of tonsils and adenoids in these children (Huang, Quo, Berkowski & Guilleminault, 2015, Guilleminault, C., Huseni, S., & Lo, L., 2016), and perhaps the unnecessary removal of these organs from the body. These are not useless organs; in fact, tonsils and adenoids are important parts of the body’s immune system, acting as a first line of defense against bacteria and viruses entering the body’s sensitive mucous membranes (American Academy of Otolaryngology- Head and Neck Surgery, 2018).
Sleep apnea can even put our children at an increased risk for systemic hypertension and poor gut microbiota (Durgan, Ganesh, Cope, Ajami, Phillips, Petrosino, … Bryan,. 2016). This poor gut microbiota can impact a myriad of issues, from behavior, nutritional status and the stress response of the invividual involved. The bacteria can even influence the function of entire systems of organs within the bodies and can contribute to many diseases (Sekirov, Russell, Caetano, Antunes & Finlay, 2010).
Research is also showing that sleep disordered breathing is associated with a 40% increase for the child having a special educational need (Besson, 2015), including assistance for Attention Deficit Disorder symptoms (Blesch & Breese McCoy, 2016). In fact, up to 95% of those with obstructive sleep apnea experience attentional deficits (Youssef, Ege, Angly, Strauss & Marx 2011).
Reflux is another common affliction that is now thought to have a clinical link to ankyloglossia (Kotlow, 2011, Kotlow 2015). There are estimations that up to 25.9% of the US population experiences gastro-esophageal reflux disease (GERD) (El-Serag, Sweet, Winchester, & Dent, 2014). Dr. Kotlow (2018) and Dr. Scott Siegel (2017) have reported that ankyloglossia can cause aerophagia due to the excessive swallowing of air during nursing, and thus cause what appears to be acid reflux in babies. In his research, Dr. Kotlow asserts that infants presenting with reflux are frequently finding complete resolution of symptoms post-revision (2011, 2015, 2018). Even postural deficits are now being linked with severe ankyloglossia (Olivi, Signore, Olivi & Genovese, 2015.) This evidence warrants more research on the connections which may be found between ankyloglossia and severe spinal structural deficits such as spinal curvatures.
Controversy in Treatment
Cho, Kelsberg & Safranek (2010) reviewed a series of literature and found that a few drops of blood and crying for less than 15 seconds were the common “complications” found after a frenotomy was performed with scissors. No evidence of research into the rates of complication of laser frenotomies has been conducted, but anecdotally Dr. Larry Kotlow indicates that he’s never seen a single case of adverse outcomes related to proper frenotomy technique following his 20,000+ revisions performed (Kotlow, 2018). Cho, Kelsberg and Safranek indicate that some babies whose tongue ties are mild to moderate in nature can often exclusively breastfeed without intervention; however, any infant with a tongue tie who is experiencing breastfeeding challenges shows immediate improvement following a frenotomy (2010).
There is some debate on private social media among parents who believe that a laser frenotomy is always superior to a scissors frenotomy. This debate is present among professionals as well, with the leading world renowned experts disagreeing. Dr. Hazelbaker encourages scissors frenotomies to release just the restricted portion (not into a diamond shaped-wound) in situations warranted by her diagnostic criteria (Hazelbaker, 2018), and Dr. Kotlow touts the superiority of using the highest available technology (currently a CO2 laser) to perform complete bloodless frenotomies, achieving a diamond shaped wound as indication of the revision’s completeness (Kotlow, 2018). Research into this area of the literature was attempted for the purpose of writing this thesis over the period of roughly 18 months, and no useful empirical data was found comparing any particular method of revision for tongue ties, as the variables- diagnostic criteria and revision method- are too widely variable to be able to compare the tools used (Francis, Chinnadurai, Morad, Epstein, Kohanim, Krishnaswami, Sathe, McPheeters, 2015). This is one area of study in which the field would greatly benefit.
Physicians’ Opinions
A longitudinal study of 71 infants showed that over time, tongue ties do not change in any way (Martinelli., Marchesan, Berretin-Felix, 2014). This conclusion is in conflict to assertions in literature that untreated tongue ties will stretch or spontaneously resolve during the first year of life (Corrêa,Bonini, & Alves, 2008; Navarro & López, 2002).
It can be quite difficult for a mother to figure out who to turn to if she suspects there might be a tongue-tie. A widely referenced, unique study included 423 Otolaryngologists, 425 pediatricians, 400 speech pathologists and 350 International Board Certified Lactation Consultants (IBCLCs) showed just how controversial ankyloglossia truly is within the professional community (Messner & Lalakea, 2000). Findings revealed that almost 70% of IBCLCs, but a small minority of pediatricians and otolaryngologists believe that ankyloglossia is "frequently associated with breastfeeding problems," which may explain some of the United States’ deplorable breastfeeding success rates. This again shows how pediatricians seem to ignore the impact of tongue ties, just 21% of them versus 50% or more of otolaryngologists and speech pathologists believe that ties are only "sometimes associated with speech difficulties." Surgery is recommended "at least sometimes for feeding, speech, and social/mechanical issues" (such as speech impediments or difficulty licking lips/kissing) by percentages from 19-29% by pediatricians, as opposed to 53-69% of otolaryngologists (Messner & Lalakea, 2000 p.125-126).
Not included in the above referenced study is the obstetrics-gynecology (OB/GYN) providers, the final piece of the puzzle for mothers experiencing breastfeeding difficulty. Given the fact that most mothers have at least one or two follow up visits with the provider who attended their birth within the first six weeks postpartum, it would be in her best interest if she had a professional who had received some breastfeeding specific training during their education experience. So, Freed, Clark, Sorenson, Lohr, Cefalo and Curtis (1995b) set out to survey OB/GYNs and 3,275 of them responded. Surveys included questions regarding their training and education and quizzed them on what to do for certain common breastfeeding challenges. It was discovered that:
“Less than 50% of residents chose appropriate clinical management for a breast-fed jaundiced infant or a breast abscess. Practicing physicians performed slightly better, but still more than 20% chose incorrect advice for mothers with low milk supply... The greatest predictor of physician self-confidence was previous personal or spousal breast-feeding experience (Freed, Clark, Sorenson, Lohr, Cefalo, Curtis, 1995b p. 1609).”
The fact of the matter is that many care providers are inherently prevented from screening for ankyloglossia since they lack clear and concise industry guidelines from professional groups such as the American Academy of Pediatrics and the American College of Obstetrics and Gynecology- which offer confusing and conflicting information about ankyloglossia (AAP, 2015; AAP, ACOG, 2012). The American Academy of Family Physicians recommends frenotomy in cases of ankyloglossia, however does not provide guidance for screening tools or how a frenotomy should be performed (AAFP, 2010). One major resource that is not mentioned by any of these industry organizations is the Academy for Breastfeeding Medicine, which not only provides the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) diagnostic tool but also explains it and goes so far as to clearly explain the process of performing a frenotomy with scissors (Academy of Breastfeeding Medicine, 2004). Without a cohesive agreement on diagnostic criteria, it is unlikely that there will be any foreseeable future where babies can be universally screened and treated for ankyloglossia.
Maternal Perspective
Breastfeeding can be an integral component to the maternal experience for so many women. Maternal identity changes and evolves with the birth of each child. The concept of maternal identity is defined by Riordan and Wambach (2010) as “establishing intimate knowledge of the infant and feeling competent and confident in mothering activities, [and] feeling love for the infant (Riordan, Wambach 2010, p.740).” Maternal Role Attainment Theory indicates that the process of having a baby doesn’t simply turn one into a mother, but that a series of events over the first four months after the baby is born which contribute or detract from her self-confidence as a mother play a role in this process and can profoundly impact the bond between a mother and her child (Husmillo, 2013). This helps to explain why there is no faster way to ensure a mother feels incompetent as a mother than to tell her either that there is nothing wrong with her baby when she has painful, bleeding nipples, or that there is simply nothing that can be done to improve the situation (Riordan, Wambach 2010).
It seems that most common emotion women encounter when they are experiencing difficulty breastfeeding tongue-tied babies is an extreme level of frustration. Women interviewed in a phenomenological study done in Australia reported that they experienced health practitioners who seemed ignorant to the plight of nursing mothers with tongue-tied babies and who were not able to offer any useful insight or advice concerning their breastfeeding challenges (Edmunds, Fulbrook & Miles, 2014). They reported that everyone they spoke to about their difficulties feeding had different advice for them. Of those in this study whose babies received frenotomies, every single woman interviewed reported their breastfeeding experiences improved dramatically. The remaining three whose babies did not receive frenotomies reported some improvements but experienced ongoing difficulties. One of the strongest statements in this study included the common-sense fact that: “Breastfeeding difficulties should not be seen as a normal process, especially for women whose infants have tongue-tie” (Edmunds et al.,2014. p194).
Difficulties finding Treatment
The risks that come from not breastfeeding our children are more well-known now than at any point in history. Increased risks of pneumonia, diarrhea, obesity, diabetes, cancer, SIDS and other illnesses leading to death are associated with formula-feeding infants (Stuebe, 2009). For mothers, breast and ovarian cancers, diabetes, weight gain and metabolic syndrome are more prevalent among women who did not breastfeed their children (Stuebe, 2009). Long-term protections of breast milk have been discovered, including less inflammatory diseases, lower blood pressure and cholesterol in those breastfed as infants (Schack-Nielsen & Michaelsen, 2006).
This data leads one to question how so many birth providers, who are the mother’s primary caregiver during her immediate postpartum period and therefore are likely to be questioned regarding any difficulties she may be having with breastfeeding, are responding to these questions when they have received so little evidence-based training. A logical assumption would be that they are leading families based on anecdotal evidence from personal experience, which may or may not be helpful or applicable to her individual situation; however there seems to be no alternative offered to this since the education is simply not required of them in order to obtain their credentials. This survey of practicing OB/GYNs showed not only that the bulk of their breastfeeding instruction occurred in lectures or hospital rounds- neither of which have been shown to be active forms of learning, but also that common misconceptions were not changing from the first year of residency to the last, which indicates that little to no breastfeeding education was happening during this vital time.
Perhaps more concerning is that just 61% of all the residents agreed that breastfeeding is the optimal form of nutrition during the first several months of a baby’s life (Freed et.al, 1995b). Perhaps even worse is that only 57% of active OB/GYN Practitioners agreed that breastfeeding was the optimal source of nutrition for newborns. If that wasn’t startling enough given current breastfeeding recommendations, only very few residents (37-38%) and less than half (48%) of practitioners were aware that supplementing with formula during those first crucial weeks of life is one cause of breastfeeding failure (Freed et.al, 1995b). It is no wonder that our national breastfeeding success rates are abysmal in comparison with the number of women who start off breastfeeding at birth (CDC, 2014).
Social Impacts
Sleep apnea, systemic hypertension and poor gut microbiota can impact many social factors within the life of any person, let alone that of a young child. It is further complicated by poor gut microbiota impacting even our very responses to stress, thereby bringing with it the potential of worsening the emotional impact of all these issues upon the individual. Attention deficits can so clearly impact social function, as can chronic fatigue due to the disordered breathing and obvious subsequent impact on emotional control, which is clearly already a challenge for young children in the best of circumstances. Complicate that further with a dramatic increase in the need for special education services(Dollberg, Manor, Makai & Botzer, 2011, Messner & Lalakea, 2002), add in speech and language challenges (Ostapiuk, 2006; Walls, Pierce, Wang, Steehler, Steehler & Harley, 2014; Ito, Shimizu, Nakamura & Takatama, 2015) and there’s a child who is ripe for bullying within the current culture of schools within the U.S.A. at the time of this writing.
Breastfeeding and postpartum depression
A much under-discussed (but not under-researched) topic of interest is the relationship of breastfeeding success and postpartum mental health. The idea that breastfeeding success and confidence is associated with a lower risk of Postpartum Depression (PPD) is not considered to be controversial in nature. In fact, a successful breastfeeding relationship has been shown to have a clear cause and effect association with PPD (Sá Vieira, Torquato, Moraes Di, Maite, & Aparecida, 2016; Wedad Saad, Buthainah Ali, Bushra Ahmed, Abdullah & Nourah 2018), especially in women of low socioeconomic status (Catarine, Marilia, Leopoldina, Juliana, Jailma, Niedja & ... Pedro, 2017). Many parents of newborns understandably struggle to get enough sleep; however one can easily see how mothers of breastfeeding newborns who are struggling with breastfeeding might experience an increased level of sleep deprivation. Research does indicate that mothers with PPD (who are likely to also be experiencing difficulties with breastfeeding) who do not get enough sleep are at a greater risk for more severe depression (Stone, 2013). On the other side of this coin, studies also indicate that breastfeeding can, in fact, decrease active PPD symptoms and that breastfeeding mothers have an overall lower rate of PPD (Ashraf, Azadeh Zamani, & Reza Davasaz, 2012).
Breastfeeding Success, Postpartum Mood Disorders, and Child Maltreatment
Mothers with clinically significant depression (i.e. that it indisputably impairs their ability to function) and those with clinically significant post-traumatic stress disorder (perhaps due to a traumatic birth experience) were found to be at a higher risk of child maltreatment than control groups (Muzik, Morelen, Hruschak, Rosenblum, Bocknek, & Beeghly, 2017). Treatment for and prevention of these postpartum mood disorders may help mitigate their impact on the maternal experience and the children of these parents (Choi, & Sikkema, 2016).
Given this intrinsic link between breastfeeding success and postpartum mental health, it is pertinent to briefly discuss some of the ways that postpartum mental health can impact child maltreatment, and consequently that breastfeeding success can ultimate decrease the risk of child maltreatment due to postpartum mood disorders.
Structural Abnormalities Associated with Ankyloglossia
Indeed, there seems to be general agreement among those studying orofacial myofunctional disorders that ankyloglossia causes disorders in the growth and function of the face and oral cavity, by impairing their development. Evidence is clear that the more severe the ankyloglossia (according to Dr. Kotlow’s criteria), the more severely atypical the dental arches and overbite between upper and lower teeth (Srinivasan, Chitharanjan, 2013); specifically a narrow arch and high palate (Yoon, Zaghi, Ha, Law, Guilleminault, & Liu 2017). This impaired development can be a major contributing factor to the restriction of the upper airway (and therefore sleep disorders), postural alterations (due to the tongue, facial and bone structures of the head and torso’s interconnectedness) and it has been shown that delay in addressing the root cause of the disordered growth may eventually lead to the need for orthodontic treatment in the future and even the need for surgical realignment of the jaws down the road (Fabbie, 2015).
Integrative Healthcare
There is more research coming out in recent years in support of the addition of complementary therapies before or after treatment for ankyloglossia. The current evidence is in favor of integrating a variety of approaches, such as myofunctional therapy to reduce scar retraction (Ferrés-Amat, Pastor-Vera, Rodriguez-Alessi, Ferrés-Amat, Mareque-Bueno & Ferrés-Padró, 2017). This means that myofunctional treatment may help reduce the risk of scar tissue forming in place of the revised frenulum and creating a similar restriction, as the scar tissue can retract and pull the tongue downward, tethering it once more. Evidence is also supportive of chiropractic (Miller, Miller, Sulesund, Yevtushenko, 2009), craniosacral (Berg-Drazin, 2016) and osteopathic (Herzhaft-Le Roy, Xhignesse, Gaboury, 2016) therapies to support adequate suck function and breastfeeding behaviors in nursing babies.
Of course, the current state of healthcare availability due to health insurance issues within the United States greatly limits the availability of these services to families experiencing these kinds of issues. As insurance will not cover many of these treatments, they are essentially unavailable for those who cannot afford out-of-pocket treatments.
Conclusion
The currently available literature paints a bleak picture for the breastfeeding relationship between a mother and tongue-tied infant. Beyond the myriad health and behavioral issues related to ankyloglossia, it can be quite difficult for a mother to figure out who to turn to if she suspects one might be present. Research clearly shows that ankyloglossia has been uniquely devastating to the breastfeeding dyad throughout the last century of motherhood, and it continues to devastate the breastfeeding relationships of today as well as set a child up for health and social risks as they grow in light of its controversial nature among professionals. Unless lactation and pediatric medical professionals, whose responsibility it is to care for society at large as well as the breastfeeding dyad, can agree upon and universally screen for ankyloglossia, there are likely to be innumerably more failed breastfeeding relationships.
It is clear that while there is a great deal of controversy between medical professionals regarding breastfeeding with ankyloglossia (whether ankyloglossia is present, and whether it should be treated at all) is completely incongruous with the plethora of peer-reviewed data in existence today. With the knowledge that tongue-ties do not change over time (Martinelli, et.al, 2014), that complications from frenotomy are extremely mild- a few drops of blood and less than 15 seconds of crying, on average (Cho et al., 2010), that frenotomy helps an overwhelming majority of mothers breastfeed without incident (Edmunds, et.al 2013), and that it impacts so many facets of one’s overall health and physiology, it seems obvious that this low-risk and extremely effective procedure should be performed. The challenge for the mother, then, is to find a medical professional who has received adequate training on the subject matter to diagnose and treat the tongue tie. Though the data shows that while her International Board Certified Lactation Consultant (IBCLC) will likely find it, her IBCLC is legally unable to perform the procedure in most countries and has to refer to another provider – however, this provider, whether it is an Otolaryngologist, Pediatrician (Freed, et.al, 1995a) or OB/GYN is likely to have had very little training on breastfeeding in general, let alone something as specific as ankyloglossia (Freed, et.al, 1995b). Holistic practitioners can support the dyad through ankyloglossia treatment and habilitation, however there is no data indicating that complementary therapies alone can adequately treat ankyloglossia. While these therapies have been shown to improve breastfeeding and function in tandem with frenotomies, they are essentially unattainable for families who cannot afford to pay for each treatment out of pocket, as they are seldom covered by health insurance.
TOTs basics
Tongue-tie is diagnosed when the thin tissue connecting the tongue to the bottom of the mouth is overly thickened, short, or attached too far towards the tip (anterior) of the tongue to allow for proper functional movement, including the ability to move the tongue in and out and/or up and down within the mouth (Hazelbaker, 2011). Tongue tie can cause difficulties with breastfeeding, inhibit speech, and even cause difficulties kissing and interfere with sexual relationships later in life (Messner & Lalakea, 2000, Fernando, 1998). Medical professionals are in disagreement about diagnostic criteria for ankyloglossia (Douglas, 2017b; Douglas, 2017c; Segal, Stephenson, Dawes, Feldman, 2007) and whether it impacts the breastfeeding dyad at all (Evans, 2008). This controversy within the field might result in missed diagnoses, presenting a uniquely devastating circumstance for the breastfeeding mother and infant.
A detailed case study involving ultrasound data to observe tongue movements, measured milk transfer, and vacuum suction in the mouths of a small sample of infants, there were a wide variety of vacuum levels as well as reported milk intake (Geddes, Kent, McClellan, Garbin, Chadwick & Hartmann, 2010). This study showed that nipple compression that occurred when a baby had a tongue tie was normalized post-frenotomy. Geddes et al (2010) theorized that in babies whose ankyloglossia does impact breastfeeding, “abnormal compression of the nipple may result in an ineffective suck by mechanically compressing the milk ducts in the nipple, obstructing the milk flow and thus reducing milk intake (p. 303).” This means that a baby may have a reduced ability to transfer milk at the breast regardless of whether any breastfeeding problems had been identified, and helping to explain why babies whose mothers have a rapid letdown (therefore making milk transfer quite easy for the restricted infant) may still gain weight appropriately while tied. The largest study done to date of infants thus far with tongue-tie showed that they had an easily “identifiable group of symptoms (poor latch, nipple trauma, and continuous feeding) that prevented them from breastfeeding” (Griffiths, 2004 p. 413).
A Note on Labial and Buccal Ties
Labial (lip) and buccal (cheek) ties are even more controversial than tongue ties and remain relatively unstudied in the literature. Perhaps more interestingly, the subject of lip ties has been a controversy for just as long as tongue ties; for at least several hundred years of recorded history, providers have been in disagreement about whether and how to incise the frenum (Romero-Maroto & Sáez-Gómez, 2012). These types of ties are considered (by those who believe they exist) to occur when the frenulum in these areas, if present, is overly short or taught and is impacting function in some way (Kotlow, 2010, 2011, 2013, 2017, 2018; Gaheri & Cole, 2017; Macaluso & Hockenbury, 2015). Indeed, Dr. Kotlow has also created a set of diagnostic criteria to identify and classify lip ties as well, indicating that the possibility of their impact on breastfeeding in combination with the increased risks of dental caries justify a division of these tissues if symptoms are present (2017).
However, there are also industry professionals who claim that lip and buccal ties are simply a figment of the imagination of those who don’t know how to competently support a dyad through the breastfeeding experience, as there is simply no empirical evidence to support their clinical significance (Hazelbaker, 2018, Douglas 2017a, 2017b). Such strong statements in opposition to the notion of buccal and upper lip ties are made to specifically state that these frena do not impact function in any way of the breastfeeding infant, as the infant has no need to flange his or her upper lip but needs only to avert it, with the seal of the mouth being made by the lower lip during breastfeeding (ACIOR, 2018, Douglas 2017a).
Available Diagnostic Assessment Tools for Ankyloglossia
There are a myriad of different diagnostic tools to assess for ankyloglossia in newborns. The HATLFF is the most researched tool described in the literature (Roberta Lopes de Castro, Irene Queiroz, José Roberto, Heitor Marques, Reinaldo Jordão& Giédre, 2016), usually in reference to breastfeeding infants. The next most commonly found tool within the literature was created by Dr. Larry Kotlow (2016) and is based on his decades of pediatric dental work and ankyloglossia research, which he published most recently in his book SOS 4 TOTS. His criteria tend to be utilized more by medical professionals such as dentists, otolaryngologists, orthodontists, and others. The research conducted by speech and language pathologists, chiropractors, and craniosacral therapists tend to use a less structured, historic method of assessing for tongue tie that’s more akin to “eyeballing” based on symptoms present and visual assessment of restriction.
Dr. Kotlow’s assessment contains a 4-point scale, with class 1 being the least severe (and posterior) and a class 4 being the most (anterior). Class 1 ties are considered submucosal (and are therefore difficult to see), where the frenulum is “located from the base of the tongue halfway to the salivary duct” and the class 4 ties “located at the tip of the tongue and extending halfway between the salivary duct and the tip of the tongue. The decision to perform a frenotomy is on function and appearance, but the classifications are in appearance only (Kotlow, 2016).
Hazelbaker’s assessment tool is focused on function over appearance (though both are assessed and scored) and is generally favored among professionals due to its evidence-based nature and high level of reliability. Amir et al. (2006) assessed the HATLFF for reliability and found that just the first three function items (lift of tongue, lateralization, and extension of tongue) were more vital to diagnosis than the four function items related to sucking (cupping, spread, snapback and peristalsis) (Amir, James & Donalth 2006).
Impacts of ankyloglossia
When a breastfeeding mother has a baby whose tongue is restricted, it can become extremely painful to nurse the infant. The baby can also have difficulty removing enough milk from the mother’s breast to sustain growth. This issue of poor milk transfer can result in a myriad of breastfeeding problems, including low milk supply, premature weaning, failure to thrive diagnoses, sleep deprivation, psychological impacts of depression and poor bonding between mother and child, gagging, choking or vomiting foods, speech development delays and more (Fernando, n.d.).
The frequency of ankyloglossia reported in our current medical literature encompasses a wide range; and anywhere from 0.02% to 10.7% of babies are reported to have it (Power & Murphy, 2015). Perhaps this range is so wide because of the lack of standardized diagnostic criteria for ankyloglossia. According to the literature, 50% of those considered to have ankyloglossia will not have any difficulty with breastfeeding (Power & Murphy, 2014, p. 490). It does not take much critical thought to question the validity of a statement such as this; indeed, some believe that ankyloglossia is not present unless there are restrictions that would impede breastfeeding (Hazelbaker, 1993) while others include additional challenges beyond breastfeeding within their diagnostic criteria (Kotlow, 2011). The literature is clear that there are many issues impacted by ankyloglossia, even if breastfeeding goes well for the dyad.
An important area of concern related to ankyloglossia is the greater health risks (and their treatment) associated with the inability to correctly utilize the tongue for all its various functions. Sleep apnea is a well-accepted risk of a short lingual frenulum due to the tongue’s obstruction of the airway. Of course, sleep apnea is now also being associated with the inflammation of tonsils and adenoids in these children (Huang, Quo, Berkowski & Guilleminault, 2015, Guilleminault, C., Huseni, S., & Lo, L., 2016), and perhaps the unnecessary removal of these organs from the body. These are not useless organs; in fact, tonsils and adenoids are important parts of the body’s immune system, acting as a first line of defense against bacteria and viruses entering the body’s sensitive mucous membranes (American Academy of Otolaryngology- Head and Neck Surgery, 2018).
Sleep apnea can even put our children at an increased risk for systemic hypertension and poor gut microbiota (Durgan, Ganesh, Cope, Ajami, Phillips, Petrosino, … Bryan,. 2016). This poor gut microbiota can impact a myriad of issues, from behavior, nutritional status and the stress response of the invividual involved. The bacteria can even influence the function of entire systems of organs within the bodies and can contribute to many diseases (Sekirov, Russell, Caetano, Antunes & Finlay, 2010).
Research is also showing that sleep disordered breathing is associated with a 40% increase for the child having a special educational need (Besson, 2015), including assistance for Attention Deficit Disorder symptoms (Blesch & Breese McCoy, 2016). In fact, up to 95% of those with obstructive sleep apnea experience attentional deficits (Youssef, Ege, Angly, Strauss & Marx 2011).
Reflux is another common affliction that is now thought to have a clinical link to ankyloglossia (Kotlow, 2011, Kotlow 2015). There are estimations that up to 25.9% of the US population experiences gastro-esophageal reflux disease (GERD) (El-Serag, Sweet, Winchester, & Dent, 2014). Dr. Kotlow (2018) and Dr. Scott Siegel (2017) have reported that ankyloglossia can cause aerophagia due to the excessive swallowing of air during nursing, and thus cause what appears to be acid reflux in babies. In his research, Dr. Kotlow asserts that infants presenting with reflux are frequently finding complete resolution of symptoms post-revision (2011, 2015, 2018). Even postural deficits are now being linked with severe ankyloglossia (Olivi, Signore, Olivi & Genovese, 2015.) This evidence warrants more research on the connections which may be found between ankyloglossia and severe spinal structural deficits such as spinal curvatures.
Controversy in Treatment
Cho, Kelsberg & Safranek (2010) reviewed a series of literature and found that a few drops of blood and crying for less than 15 seconds were the common “complications” found after a frenotomy was performed with scissors. No evidence of research into the rates of complication of laser frenotomies has been conducted, but anecdotally Dr. Larry Kotlow indicates that he’s never seen a single case of adverse outcomes related to proper frenotomy technique following his 20,000+ revisions performed (Kotlow, 2018). Cho, Kelsberg and Safranek indicate that some babies whose tongue ties are mild to moderate in nature can often exclusively breastfeed without intervention; however, any infant with a tongue tie who is experiencing breastfeeding challenges shows immediate improvement following a frenotomy (2010).
There is some debate on private social media among parents who believe that a laser frenotomy is always superior to a scissors frenotomy. This debate is present among professionals as well, with the leading world renowned experts disagreeing. Dr. Hazelbaker encourages scissors frenotomies to release just the restricted portion (not into a diamond shaped-wound) in situations warranted by her diagnostic criteria (Hazelbaker, 2018), and Dr. Kotlow touts the superiority of using the highest available technology (currently a CO2 laser) to perform complete bloodless frenotomies, achieving a diamond shaped wound as indication of the revision’s completeness (Kotlow, 2018). Research into this area of the literature was attempted for the purpose of writing this thesis over the period of roughly 18 months, and no useful empirical data was found comparing any particular method of revision for tongue ties, as the variables- diagnostic criteria and revision method- are too widely variable to be able to compare the tools used (Francis, Chinnadurai, Morad, Epstein, Kohanim, Krishnaswami, Sathe, McPheeters, 2015). This is one area of study in which the field would greatly benefit.
Physicians’ Opinions
A longitudinal study of 71 infants showed that over time, tongue ties do not change in any way (Martinelli., Marchesan, Berretin-Felix, 2014). This conclusion is in conflict to assertions in literature that untreated tongue ties will stretch or spontaneously resolve during the first year of life (Corrêa,Bonini, & Alves, 2008; Navarro & López, 2002).
It can be quite difficult for a mother to figure out who to turn to if she suspects there might be a tongue-tie. A widely referenced, unique study included 423 Otolaryngologists, 425 pediatricians, 400 speech pathologists and 350 International Board Certified Lactation Consultants (IBCLCs) showed just how controversial ankyloglossia truly is within the professional community (Messner & Lalakea, 2000). Findings revealed that almost 70% of IBCLCs, but a small minority of pediatricians and otolaryngologists believe that ankyloglossia is "frequently associated with breastfeeding problems," which may explain some of the United States’ deplorable breastfeeding success rates. This again shows how pediatricians seem to ignore the impact of tongue ties, just 21% of them versus 50% or more of otolaryngologists and speech pathologists believe that ties are only "sometimes associated with speech difficulties." Surgery is recommended "at least sometimes for feeding, speech, and social/mechanical issues" (such as speech impediments or difficulty licking lips/kissing) by percentages from 19-29% by pediatricians, as opposed to 53-69% of otolaryngologists (Messner & Lalakea, 2000 p.125-126).
Not included in the above referenced study is the obstetrics-gynecology (OB/GYN) providers, the final piece of the puzzle for mothers experiencing breastfeeding difficulty. Given the fact that most mothers have at least one or two follow up visits with the provider who attended their birth within the first six weeks postpartum, it would be in her best interest if she had a professional who had received some breastfeeding specific training during their education experience. So, Freed, Clark, Sorenson, Lohr, Cefalo and Curtis (1995b) set out to survey OB/GYNs and 3,275 of them responded. Surveys included questions regarding their training and education and quizzed them on what to do for certain common breastfeeding challenges. It was discovered that:
“Less than 50% of residents chose appropriate clinical management for a breast-fed jaundiced infant or a breast abscess. Practicing physicians performed slightly better, but still more than 20% chose incorrect advice for mothers with low milk supply... The greatest predictor of physician self-confidence was previous personal or spousal breast-feeding experience (Freed, Clark, Sorenson, Lohr, Cefalo, Curtis, 1995b p. 1609).”
The fact of the matter is that many care providers are inherently prevented from screening for ankyloglossia since they lack clear and concise industry guidelines from professional groups such as the American Academy of Pediatrics and the American College of Obstetrics and Gynecology- which offer confusing and conflicting information about ankyloglossia (AAP, 2015; AAP, ACOG, 2012). The American Academy of Family Physicians recommends frenotomy in cases of ankyloglossia, however does not provide guidance for screening tools or how a frenotomy should be performed (AAFP, 2010). One major resource that is not mentioned by any of these industry organizations is the Academy for Breastfeeding Medicine, which not only provides the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) diagnostic tool but also explains it and goes so far as to clearly explain the process of performing a frenotomy with scissors (Academy of Breastfeeding Medicine, 2004). Without a cohesive agreement on diagnostic criteria, it is unlikely that there will be any foreseeable future where babies can be universally screened and treated for ankyloglossia.
Maternal Perspective
Breastfeeding can be an integral component to the maternal experience for so many women. Maternal identity changes and evolves with the birth of each child. The concept of maternal identity is defined by Riordan and Wambach (2010) as “establishing intimate knowledge of the infant and feeling competent and confident in mothering activities, [and] feeling love for the infant (Riordan, Wambach 2010, p.740).” Maternal Role Attainment Theory indicates that the process of having a baby doesn’t simply turn one into a mother, but that a series of events over the first four months after the baby is born which contribute or detract from her self-confidence as a mother play a role in this process and can profoundly impact the bond between a mother and her child (Husmillo, 2013). This helps to explain why there is no faster way to ensure a mother feels incompetent as a mother than to tell her either that there is nothing wrong with her baby when she has painful, bleeding nipples, or that there is simply nothing that can be done to improve the situation (Riordan, Wambach 2010).
It seems that most common emotion women encounter when they are experiencing difficulty breastfeeding tongue-tied babies is an extreme level of frustration. Women interviewed in a phenomenological study done in Australia reported that they experienced health practitioners who seemed ignorant to the plight of nursing mothers with tongue-tied babies and who were not able to offer any useful insight or advice concerning their breastfeeding challenges (Edmunds, Fulbrook & Miles, 2014). They reported that everyone they spoke to about their difficulties feeding had different advice for them. Of those in this study whose babies received frenotomies, every single woman interviewed reported their breastfeeding experiences improved dramatically. The remaining three whose babies did not receive frenotomies reported some improvements but experienced ongoing difficulties. One of the strongest statements in this study included the common-sense fact that: “Breastfeeding difficulties should not be seen as a normal process, especially for women whose infants have tongue-tie” (Edmunds et al.,2014. p194).
Difficulties finding Treatment
The risks that come from not breastfeeding our children are more well-known now than at any point in history. Increased risks of pneumonia, diarrhea, obesity, diabetes, cancer, SIDS and other illnesses leading to death are associated with formula-feeding infants (Stuebe, 2009). For mothers, breast and ovarian cancers, diabetes, weight gain and metabolic syndrome are more prevalent among women who did not breastfeed their children (Stuebe, 2009). Long-term protections of breast milk have been discovered, including less inflammatory diseases, lower blood pressure and cholesterol in those breastfed as infants (Schack-Nielsen & Michaelsen, 2006).
This data leads one to question how so many birth providers, who are the mother’s primary caregiver during her immediate postpartum period and therefore are likely to be questioned regarding any difficulties she may be having with breastfeeding, are responding to these questions when they have received so little evidence-based training. A logical assumption would be that they are leading families based on anecdotal evidence from personal experience, which may or may not be helpful or applicable to her individual situation; however there seems to be no alternative offered to this since the education is simply not required of them in order to obtain their credentials. This survey of practicing OB/GYNs showed not only that the bulk of their breastfeeding instruction occurred in lectures or hospital rounds- neither of which have been shown to be active forms of learning, but also that common misconceptions were not changing from the first year of residency to the last, which indicates that little to no breastfeeding education was happening during this vital time.
Perhaps more concerning is that just 61% of all the residents agreed that breastfeeding is the optimal form of nutrition during the first several months of a baby’s life (Freed et.al, 1995b). Perhaps even worse is that only 57% of active OB/GYN Practitioners agreed that breastfeeding was the optimal source of nutrition for newborns. If that wasn’t startling enough given current breastfeeding recommendations, only very few residents (37-38%) and less than half (48%) of practitioners were aware that supplementing with formula during those first crucial weeks of life is one cause of breastfeeding failure (Freed et.al, 1995b). It is no wonder that our national breastfeeding success rates are abysmal in comparison with the number of women who start off breastfeeding at birth (CDC, 2014).
Social Impacts
Sleep apnea, systemic hypertension and poor gut microbiota can impact many social factors within the life of any person, let alone that of a young child. It is further complicated by poor gut microbiota impacting even our very responses to stress, thereby bringing with it the potential of worsening the emotional impact of all these issues upon the individual. Attention deficits can so clearly impact social function, as can chronic fatigue due to the disordered breathing and obvious subsequent impact on emotional control, which is clearly already a challenge for young children in the best of circumstances. Complicate that further with a dramatic increase in the need for special education services(Dollberg, Manor, Makai & Botzer, 2011, Messner & Lalakea, 2002), add in speech and language challenges (Ostapiuk, 2006; Walls, Pierce, Wang, Steehler, Steehler & Harley, 2014; Ito, Shimizu, Nakamura & Takatama, 2015) and there’s a child who is ripe for bullying within the current culture of schools within the U.S.A. at the time of this writing.
Breastfeeding and postpartum depression
A much under-discussed (but not under-researched) topic of interest is the relationship of breastfeeding success and postpartum mental health. The idea that breastfeeding success and confidence is associated with a lower risk of Postpartum Depression (PPD) is not considered to be controversial in nature. In fact, a successful breastfeeding relationship has been shown to have a clear cause and effect association with PPD (Sá Vieira, Torquato, Moraes Di, Maite, & Aparecida, 2016; Wedad Saad, Buthainah Ali, Bushra Ahmed, Abdullah & Nourah 2018), especially in women of low socioeconomic status (Catarine, Marilia, Leopoldina, Juliana, Jailma, Niedja & ... Pedro, 2017). Many parents of newborns understandably struggle to get enough sleep; however one can easily see how mothers of breastfeeding newborns who are struggling with breastfeeding might experience an increased level of sleep deprivation. Research does indicate that mothers with PPD (who are likely to also be experiencing difficulties with breastfeeding) who do not get enough sleep are at a greater risk for more severe depression (Stone, 2013). On the other side of this coin, studies also indicate that breastfeeding can, in fact, decrease active PPD symptoms and that breastfeeding mothers have an overall lower rate of PPD (Ashraf, Azadeh Zamani, & Reza Davasaz, 2012).
Breastfeeding Success, Postpartum Mood Disorders, and Child Maltreatment
Mothers with clinically significant depression (i.e. that it indisputably impairs their ability to function) and those with clinically significant post-traumatic stress disorder (perhaps due to a traumatic birth experience) were found to be at a higher risk of child maltreatment than control groups (Muzik, Morelen, Hruschak, Rosenblum, Bocknek, & Beeghly, 2017). Treatment for and prevention of these postpartum mood disorders may help mitigate their impact on the maternal experience and the children of these parents (Choi, & Sikkema, 2016).
Given this intrinsic link between breastfeeding success and postpartum mental health, it is pertinent to briefly discuss some of the ways that postpartum mental health can impact child maltreatment, and consequently that breastfeeding success can ultimate decrease the risk of child maltreatment due to postpartum mood disorders.
Structural Abnormalities Associated with Ankyloglossia
Indeed, there seems to be general agreement among those studying orofacial myofunctional disorders that ankyloglossia causes disorders in the growth and function of the face and oral cavity, by impairing their development. Evidence is clear that the more severe the ankyloglossia (according to Dr. Kotlow’s criteria), the more severely atypical the dental arches and overbite between upper and lower teeth (Srinivasan, Chitharanjan, 2013); specifically a narrow arch and high palate (Yoon, Zaghi, Ha, Law, Guilleminault, & Liu 2017). This impaired development can be a major contributing factor to the restriction of the upper airway (and therefore sleep disorders), postural alterations (due to the tongue, facial and bone structures of the head and torso’s interconnectedness) and it has been shown that delay in addressing the root cause of the disordered growth may eventually lead to the need for orthodontic treatment in the future and even the need for surgical realignment of the jaws down the road (Fabbie, 2015).
Integrative Healthcare
There is more research coming out in recent years in support of the addition of complementary therapies before or after treatment for ankyloglossia. The current evidence is in favor of integrating a variety of approaches, such as myofunctional therapy to reduce scar retraction (Ferrés-Amat, Pastor-Vera, Rodriguez-Alessi, Ferrés-Amat, Mareque-Bueno & Ferrés-Padró, 2017). This means that myofunctional treatment may help reduce the risk of scar tissue forming in place of the revised frenulum and creating a similar restriction, as the scar tissue can retract and pull the tongue downward, tethering it once more. Evidence is also supportive of chiropractic (Miller, Miller, Sulesund, Yevtushenko, 2009), craniosacral (Berg-Drazin, 2016) and osteopathic (Herzhaft-Le Roy, Xhignesse, Gaboury, 2016) therapies to support adequate suck function and breastfeeding behaviors in nursing babies.
Of course, the current state of healthcare availability due to health insurance issues within the United States greatly limits the availability of these services to families experiencing these kinds of issues. As insurance will not cover many of these treatments, they are essentially unavailable for those who cannot afford out-of-pocket treatments.
Conclusion
The currently available literature paints a bleak picture for the breastfeeding relationship between a mother and tongue-tied infant. Beyond the myriad health and behavioral issues related to ankyloglossia, it can be quite difficult for a mother to figure out who to turn to if she suspects one might be present. Research clearly shows that ankyloglossia has been uniquely devastating to the breastfeeding dyad throughout the last century of motherhood, and it continues to devastate the breastfeeding relationships of today as well as set a child up for health and social risks as they grow in light of its controversial nature among professionals. Unless lactation and pediatric medical professionals, whose responsibility it is to care for society at large as well as the breastfeeding dyad, can agree upon and universally screen for ankyloglossia, there are likely to be innumerably more failed breastfeeding relationships.
It is clear that while there is a great deal of controversy between medical professionals regarding breastfeeding with ankyloglossia (whether ankyloglossia is present, and whether it should be treated at all) is completely incongruous with the plethora of peer-reviewed data in existence today. With the knowledge that tongue-ties do not change over time (Martinelli, et.al, 2014), that complications from frenotomy are extremely mild- a few drops of blood and less than 15 seconds of crying, on average (Cho et al., 2010), that frenotomy helps an overwhelming majority of mothers breastfeed without incident (Edmunds, et.al 2013), and that it impacts so many facets of one’s overall health and physiology, it seems obvious that this low-risk and extremely effective procedure should be performed. The challenge for the mother, then, is to find a medical professional who has received adequate training on the subject matter to diagnose and treat the tongue tie. Though the data shows that while her International Board Certified Lactation Consultant (IBCLC) will likely find it, her IBCLC is legally unable to perform the procedure in most countries and has to refer to another provider – however, this provider, whether it is an Otolaryngologist, Pediatrician (Freed, et.al, 1995a) or OB/GYN is likely to have had very little training on breastfeeding in general, let alone something as specific as ankyloglossia (Freed, et.al, 1995b). Holistic practitioners can support the dyad through ankyloglossia treatment and habilitation, however there is no data indicating that complementary therapies alone can adequately treat ankyloglossia. While these therapies have been shown to improve breastfeeding and function in tandem with frenotomies, they are essentially unattainable for families who cannot afford to pay for each treatment out of pocket, as they are seldom covered by health insurance.
References and Further Reading:
Academy of Breastfeeding Medicine (ABM) (2004) Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf
American Academy of Family Physicians (AAFP). (2010). Common Tongue Conditions in Primary Care. Retrieved from http://www.aafp.org/afp/2010/0301/p627.html
American Academy of Otolaryngology – Head and Neck Surgery. (2018). Tonsils and Adenoids. Retrieved from https://www.entnet.org//content/tonsils-and-adenoids
American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). (2012) Guidelines for Perinatal Care Seventh Edition. Retrieved from https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/medicaid/pdfs/ACOG-Guidelines-for-Perinatal-Care.pdf
American Academy of Pediatrics (AAP). (2015). Treatment of Ankyloglossia and Breastfeeding Outcomes: A Systematic Review. Retrieved from http://pediatrics.aappublications.org/content/early/2015/04/28/peds.2015-0658_
Australian Collaboration for Infant Oral Research (ACIOR). (Jan/Feb 2018). ACIOR Position Statement 1: Upper lip-tie, buccal ties and the role of frenotomy in infants. Australasian Dental Practice: the business magazine for dentists. pp. 144-146.
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Ito, Y.,Shimizu, T., Nakamura, T. &Takatama, C. (2015). Effectiveness of tongue-tie division for speech disorder in children. Pediatrics International. 57(2). pp. 222-226. doi: 10.1111/ped.12474.
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Journal of the American Orthodontic Society, 15(1), 18-21. V
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Kotlow, L. (2011). Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie and Ankyloglossia (Tongue-tie). Clinical Lactation. 2(4). 25-29. https://www.kiddsteeth.com/assets/pdfs/articles/aerophagia_2011.pdf
Kotlow, L. (2011). Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. European Archives of Paediatric Dentistry. 12(2). p 106.
Kotlow, L. (2016). SOS 4 TOTS. Troy, NY: The Troy Book Makers.
Kotlow, L.A. (2010). The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: prevention, diagnosis, and treatment. Journal of Human Lactation 26: 304.
Kotlow, L.A. (2013). Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. Published online 2 July 2013, DOI: 10.1177/0890334413491325.
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Messner, A. H., & Lalakea, M. L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54(2–3), 123–131. https://doi.org/10.1016/S0165-5876(00)00359-1
Messner, A.H & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology- Head and Neck Surgery. 127(6). 539-545. https://doi.org/10.1067/mhn.2002.129731
Miller, J.E., Miller, L., Sulesund, A.K., Yevtushenko, A. (2009). Contrubution of Chiropractic Therapy to Resolving Suboptimal Breastfeeding: A Case Series of 114 Infants. Journal of Manipulative & Physiological Therapeutics. 32(8). pp. 670-674.
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