Transcript Breastfeeding Conference

Impact on Breastfeeding
of Restrictive
Lingual Frenulum
Dr David Edwards StR Public Health
Public Health Suffolk
March 2012
• Concern raised over access to infant ‘tongue-tie’
lingual frenulum (LF) division to support
breastfeeding in Suffolk
• Investigation by Public Health:
– Ipswich Hospital - LF division policy and pathway
in place
– West Suffolk Hospital - did not provide LF
division to support breastfeeding
NICE Guidance (2005)
Division of ankyloglossia (tongue tie) for
breastfeeding (IPG149)
• Many ‘tongue-ties’ do not require treatment
• Conservative treatment includes breastfeeding
advice and counselling, exercising the tongue
• Surgical division of the lingual frenulum may enable
the mother to continue breastfeeding
• Safe – if by competent health professional
East of England Picture
• Over half of providers (n=8,
53%) with no
policy/guideline for LF
division
• Seven providers with
policies roughly in line with
NICE IPG149
• Wide policy variation on
assessment of LF and
pathway followed
Its About Tongue Mobility!
• Restricted tongue mobility can impair
breastfeeding – Mother/infant interaction
• Require clear identification, assessment of
tongue mobility impact on breastfeeding
• Intervention (LF division) when indicated
• Risk of policy stimulating unnecessary LF
division activity?
Regional policy
Policy for Division of the Lingual Frenulum
(tongue-tie division) of Infants (<3 months of
age) to Support Breastfeeding
• “..ensure consistency of approach in the East of
England in the provision lingual frenulum division
(tongue-tie division) where restricted tongue
mobility due to a tight lingual frenulum is impairing
the ability of the infant to breastfeed effectively”
Policy part 1: Assessment
• BEFORE referral for division – competent health
professional to assess tongue mobility
• Is infant positioning and attachment correct?
• Is tongue mobility impairing breastfeeding?
• If it does not impair breastfeeding then division is
not necessary
Policy part 2: Division
• Who and where to divide LF that is impairing ability to
breastfeed
• Lingual frenulum is divided using sterile scissors
• Safety
– Suitable clinical room which meets infection control
requirements
– Two staff, clinician conducting division and assistant
– Protocol in place for rapid response to uncontrolled
bleeding
Policy Implementation
• Training need for assessment of whether
tongue mobility is affecting breastfeeding
• Clear referral pathways across region for
referral of infants identified with clinical need
for LF division
• Support for breastfeeding mothers who do
not opt for division
Implementation of Policy:
What needs to be done in Suffolk?
• Training need for
identification and
assessment?
• Where should mother and
baby be referred to?
“Division of Restrictive Lingual Frenulum
– why, when and where?”
Mr Ashish Minocha
Consultant Paediatric & Neonatal Surgeon, Jenny Lind Children's Hospital, Norfolk and
Norwich University Hospital NHS Foundation Trust
Dr David Edwards
Specialist Registrar Public Health Suffolk County Council
Lingual Frenulum
• ‘Lingual frenulum' stretches from under the
tongue to the floor of the mouth
• Elastic and does not interfere with the
movements of the tongue
Embryological origin
• Vestigeal Structure
– frenulum is what is left of the tissues that should
have disappeared as the oral areas are formed
– not uncommon
– ‘webbing‘ can occur between upper or lower lips
and gums, cheeks and gums as well as in at the
base of the tongue
‘Tongue tie', ‘Ankyloglossia' or ‘short
frenum'
• Short Lingual Frenulum may lead to
restriction of tongue movement
The Academy of Breastfeeding Medicine
• defines partial ankyloglossia or “tongue-tie” as
"the presence of a sublingual frenulum which
changes the appearance and/or function of
the infant's tongue because of its decreased
length, lack of elasticity or attachment too
distal beneath the tongue or too close to or
onto the gingival ridge"
“Short, thick, tight or broad” Lingual
Frenulum
• Adverse effect on oromuscular function feeding and ? speech
• It may cause problems when it extends
from the margin of the tongue and across
the floor of the mouth to finish at the base
of the teeth
Incidence
•
•
•
•
Variable
?? Criteria
1941 Study - 4 per 1000 of the population.
16 percent of babies experiencing
difficulty with breastfeeding had a tongue
tie - University of Cincinnati, USA, 2002.
• 10 % of the babies - SGH, UK.
Variable appearance
Posterior Tongue tie – Does it exists
?
Kotlow’s Criteria
• With a finger, run it underneath the tongue
from side to side. The feeling of a tie can
be describe as a fence, speed bump or
ridge in the bottom of the mouth. A
normally developed mouth floor will feel
smooth. Any kind of a bump has the
potential to cause problems.
Genetic factors
• Strong familial tendency or just an awareness ??
• Tongue tie sometimes occurs together with other congenital
conditions which affect the structure of the mouth, such as
cleft lip or palate.
• It can also occur together with conditions such as severe
hearing loss or cerebral palsy.
• Boys are more often “tongue-tied” than girls !!
Diagnosis
• Traditional criteria
– Acute malnourishment
– Mis-articulation of tongue tip sounds such as
‘t', ‘d', and ‘n'
Signs & Symptoms in Babies
– Failure to latch on - slipping off the breast while feeding
– continuous feeding - frequent & inadequate
– Clicking sounds while feeding
– Continuous Dribbling & gagging
– Colic
– “Windy baby”
– Poor weight gain & physical growth
•
Maternal Signs & Symptoms
– Sore nipples
– Mis-shaped nipples
– Mastitis and/or blocked ducts
Children, Adolescents & Adults
– Appearance of the tongue
– Lack of lingual mobility
• speed and accuracy of tongue movements
– Eating difficulties - poor coordination of oral
musculature
– Severe Dental problems
– Unclear Speech ?
– Inability to enjoy simple pleasures !!
Assessment
– Breastfeeding, and any problems experienced
– Measurements of ‘free tongue', and height to which the
tongue can be lifted
– Appearance of the margin of the tongue, and whether
indentation is present
– Function and ability to protrude or to elevate the tongue
– Dental & Speech problems
Assessment & Classification
• Kotlow assessment (American Paediatric
Dentist) –length of free tongue >16 mm
acceptable
– Class I (12-16 mm) – mild
– Class II (8-11 mm) – moderate
– Class III (3-7 mm) - severe
– Class 4 (<3 mm) - complete
Assessment & Classification
• Hazelbaker Assessment tool
– Lactational Consultant
– Lingual Frenulum Anatomy & Function based assessment
• rely on assessors judgement of appearance and any sucking
problems
Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function
Lisa H Amir, Jennifer P James and Susan M Donath, Melbourne, Australia
International Breastfeeding Journal 2006, 1:3 doi:10.1186/1746-4358-1-3
Reliability of each item
Item
Kappa
P value
Appearance of tongue when lifted
0.54
<0.01
Elasticity of frenulum
0.53
<0.01
Length of lingual frenulum when tongue
lifted
0.51
<0.01
Attachment of lingual frenulum to tongue
0.39
<0.01
Attachment of lingual frenulum to inferior
alveolar ridge
0.62
<0.01
Lateralization
0.71
<0.01
Lift of tongue
0.67
<0.01
Extension of tongue
0.65
<0.01
Spread of anterior tongue
-0.02
0.74
Cupping
0.01
0.44
Peristalsis
0.05
0.07
Snapback
0.03
0.38
Appearance items
Function items
Assessment & Classification
• Appearance factors (Griffiths et al, Southampton)
–
–
–
–
diaphanous (transparent),
medium (non-transparent)
thick (chunky)
Visual assessment of the length
• Digital Calliper Quantitative evaluation (Marchesan et al ,
Brazil)
• Tongue tie Assessment Protocol (TAP) - scoring based on
appearance and function
Consequences of Tongue Tie
• Varied
• Depends on age of presentation
Maternal challenges
• The maternal experience of breastfeeding a tonguetied baby may include:
– Pain
– Nipple damage, bleeding, blanching or distortion of the
nipples
– Mastitis, nipple thrush or blocked ducts
– Severe pain with latch or losing latch
– Sleep deprivation caused by the baby being unsettled
– Depression or a sense of failure
Consequences in infants
• Early problems with breast feeding may lead to
– Termination of breastfeeding
– Failure to thrive
– Poor bonding between baby and mother
– Problems with introducing solids
Consequences in Children
–
–
–
–
–
–
–
–
Inability to chew age appropriate solid foods
Inability to enjoy lollies / licking ice-creams
Dribbling, Gagging, choking or vomiting foods
Persisting food fads
Difficulties with dental hygiene/ Dental problems
? speech problems
Behaviour problems
Lack of self confidence
Consequences in Adults
• Consequences of un-repaired tongue tie may
not reduce with time
• Social, domestic and work environment
difficulties
• Lack of self-esteem
• Dental health
Intervention
• Before 1940, tongue ties were routinely cut to help feeding
So what changed this practice ?
– reduction in the practice of breastfeeding
– “Not real medical problem” & “in the mind off over-zealous parents”
– fear of excessive/unnecessary surgery
Intervention ?
– Lactational Consultants & Breast Feeding Advisor
– Struggling and suffering mums
– And some of us starting to listen !
Tongue tie Division
Neonates & Infants (prior to eruption of teeth)
• Fax / email referrals accepted and
encouraged to avoid delay.
• Babies seen in next clinic – sometime on
the same day of referral (majority within a
few days to a week).
• Office Procedure
Tongue tie Division
Neonates & Infants
• Procedure
– One of the parent hold the baby
– Usually cry when examining which helps in
examination and division
– Complete division of tongue tie
– Some babies sleep through the procedure
– Most stops crying as soon as handed over to
mum and start feeding
Tongue tie Division
Neonates & Infants
• Tinge of blood – bleeding checked after 2
minutes and parents asked to wait another 20
minutes for a further review
• Encouraged to report progress in 2 weeks via
email / post or telephone
• No follow up appointment
Audit of service
% Boys
% Girls
0
100
0
11
9
55
45
98
43
18
70
30
88
100
51
37
58
42
202
200
99
133
69
66
34
2010
353
352
100
224
129
63
37
2011
386
375
97
2012
579
542
94
2013 till Sept
2013
570
525 (760)
92
Total
2261
2163
96
464 *
288 *
62
38
Year
Referral
Released
%
Boys
2005
2
2
100
2
2006
20
19
95
2007
61
60
2008
88
2009
Girls
Referrals & Releases
700
600
500
400
Referrals
300
Releases
200
100
0
1
2
3
4
5
Year
6
7
8
9
Response and Improvement
Year
Responses
Improvement
% Improvement
2005
2
2
100
2006
13
13
100
2007
35
35
100
2008
42
41
98
2009
73
68
93
2010
93
88
95
March 2011
15
15
100
Total
258
247
96
Total + 2011
273
262
96
All % rounded to the nearest whole number
Parental Satisfaction compared to Responses
Year
Responses
Parental satisfaction
% Satisfaction
2005
2
2
100
2006
13
13
100
2007
35
35
100
2008
42
41
98
2009
73
71
97
2010
93
89
96
March 2011
15
15
100
Total + 2011
273
262
97 %
All % rounded to the nearest whole number
Releases and Complications
Year
Releases
Complications
% Complications
2005
2
0
0
2006
19
0
0
Description
2007
60
2
3
1 Minor Bleeding,
1 Recurrence
2008
88
1
1
1 Ulcer
1 Minor
Ulcer
2009
200
3
2
2010
352
0
0
March
2011
79
0
0
Total
800
6
1
Bleeding,
3
Ulcer,
2
Bleeding,
1 ? Recurrence
All % rounded to the nearest whole number
2
Minor
Audit Conclusions
• Referral rate have increased due to
increasing awareness
• Total audit response rate 36%
• Frenulotomy rate
96%
• Improvement in feeding
96%
• Parental satisfaction
97%
• Complications (minor)
01%
Conclusion
• Early recognition & referral
• Breast feeding advisor / Lactational
consultant involvement helps in long term
support
• Safe & quick procedure
• Almost nil complication in “expert hands”
• No need to “wait & see” in presence of
feeding problems
Workshop
What can you do to improve
Breastfeeding in your
Clinical Commissioning
Group Area?