Relationship between Breastfeeding Difficulties, Ankyloglossia, and Frenotomy: A Literature Review

DISCUSSION

Breastfeeding is a natural and instinctive process in the evolution of humanity whose benefits for the mother–baby dyad have been evidenced with scientific progress,² in such a way that the intimate connection of this process to the child’s developmental development in terms of nutritional, physiological, immunological, cognitive, and emotional aspects is unanimously consolidated, in addition to providing numerous gains in the mother’s physical and mental health.^2,13 Therefore, if breastfeeding is considered to be the “gold standard” for the baby’s quality of life¹ and if research is able to highlight, clarify, and strengthen the issues involved in this process, it is expected that these will be frequent and coherent in the scientific community. However, this expected scenario diverged from that demonstrated by the present study in which only 16 articles published in the proposed analysis period could be included, following the chosen criteria and theme.

The importance of breastfeeding is well known, as well as the innumerable barriers inherent to this process^3–5,13 being ankyloglossia cited as one of the complicating factors.^8–12 For Campanha et al.¹³ in addition to being aware of the benefits of breastfeeding for the baby and its mother, every health professional who assists the mother–baby dyad must be aware of the prevention and management of the main problems that may occur during breastfeeding, aiming at prevention of early weaning; however, they are often unprepared,³⁸ as well as, great divergence in diagnoses and conduct.^8,37 This reality is of an alarming nature due to the lack of content in the literature since it is necessary to support any and all actions in consolidated scientific evidence and there is a scarcity of research that provides such foundations.

In addition to the reduced number of studies, also analyzing the availability of information in the literature, the lack of methodological standardization appears as a complicating factor. Among the selected researches, there is a great variation in all the parameters analyzed, as well as in the tools, scales, and methods. These variations even occurred in the diagnosis and classification of ankyloglossia. Such disparities hinder the construction of discussions and conclusions based, creating biases in the literature and clinical practice.

From the selection of all articles present in this review, the presence of two themes was found that subdivided them. And for methodological and didactic purposes, these were divided into two domains: association between alteration of the lingual frenulum and breastfeeding (1) and association between frenotomy and breastfeeding (2). It is important to note that such domains may correspond to the initial questions of professionals in the conduct and decision making when faced with cases of ankyloglossia in infants. Regardless of the methodological disparities already mentioned, the discussions developed took place in intradomain and interdomain manners.

In both domains, there was a diversity of instruments used to assess, diagnose, and classify ankyloglossia.

The multiprofessional clinical examination without the use of a standardized protocol was used to classify the presence or absence of ankyloglossia in the studies by Riskin et al.,⁴³ Emond et al.,⁴⁴ Martinelli et al.,⁴⁵ and Benoiton et al.⁴⁶ In the latter, ankyloglossia was also classified as: anterior, posterior, or mixed.

Four studies, Martinelli et al.,⁴⁵ Marcione et al.,⁵ Fujinaga et al.,²³ and Campanha et al.,¹³ adopted the “protocol of assessment of the frenulum of the tongue with scores for babies.”¹⁰

Wakhanrittee et al.⁴⁷ and Muldoon et al.³⁸ classified the lingual frenulum according to its severity: mild, moderate, and severe, whereas Walker et al.²⁴ aimed to describe the types of frenulum and thus classify them according to the distance between the tip of the tongue and the insertion of the lingual frenulum. Such classifications were made according to the place of insertion of the frenulum in the tongue, however, it is worth noting that its thickness was not taken into account.

The absence of a standardized classification and the common use of evaluation protocols makes the correlation between the frenulum type, the degree of severity of its anatomical alteration, and its respective functional impairment somewhat subjective and inconclusive in studies in recent years. There is a significant diversity of specialties in the health field active in this theme: nurses, pediatric doctors, otorhinolaryngologists, dentists, speech therapists, among others. Without standardization, research findings no longer control variables such as the evaluator’s vision, specialization, and experience, which makes the experimental quality questionable and consequently, its conclusions.

Emond et al.⁴⁴ emphasized with their findings that the need for better assessment tools since simple inspection of the lingual frenulum is not sufficient to determine which child should undergo the frenotomy procedure. These authors reinforced the importance of including observation and objective measures of breastfeeding effectiveness.

Riskin et al.⁴³ pointed out that infants with ankyloglossia, regardless of degree or subtype, had significantly more breastfeeding problems in the first month of life. Pransky et al.⁴ corroborate this reasoning, but with a nonmandatory relationship. For these, anterior and/or posterior ankyloglossia, in some cases, can contribute to difficulties in breastfeeding. The conditional presented by Pransky et al.⁴ is reinforced by the noncorrelation found between ankyloglossia, changes in suction, and breastfeeding difficulties in the studies by Haham et al.,⁷ Marcione et al.,⁵ and Fujinaga et al.²³ Despite not finding a relationship, Marcione et al.⁵ concluded that babies with altered lingual frenulum were more likely to change suction.

Dollberg et al.¹¹ pointed out that they did not find a significant correlation between the type of frenulum according to Coryllos and the reasons for performing the frenotomy. Contrasting these findings, Ghaheri et al.¹² presented significant data connecting the type of ankyloglossia and problems with breastfeeding. Such authors evidenced in their sample that 78% of infants with difficulties in breastfeeding had isolated posterior shortened lingual frenulum (class III or IV of ankyloglossia, according to Coryllos).

Campanha et al.¹³ showed a 36.07 times higher probability of newborns with ankyloglossia showing signs of difficulty in sucking. Statistical analysis of Campanha et al.¹³ revealed an association between ankyloglossia and complaints of difficulty in breastfeeding, in which 32% of mothers with complaints had newborns with ankyloglossia.

For Wakhanrittee et al.⁴⁷ and Muldoon et al.,³⁸ one of the factors associated with the failure of exclusive breastfeeding was the severity of the lingual frenulum, since the greater the severity of the lingual frenulum, the greater the limitation of the tongue and consequently the quality of the grip.

For Walker et al.,²⁴ the shortest distance between the tip of the tongue and the insertion of the frenulum was positively related to nipple pain and was a useful tool to identify ankyloglossia in newborns; however, they pointed out that the presence of a palpable cord was variable between examiners and should be interpreted with caution when assessing ankyloglossia in newborns.

With the exception of Ghaheri et al.,¹² Walker et al.,²⁴ and Campanha et al.,¹³ all other studies suggested the presence of a correlation between ankyloglossia and breastfeeding but could not prove the existence of this correlation through their findings. It is believed that this is mainly due to the large amount and the lack of control over variables such as the identification and classification of the degree of anatomical impairment and, therefore, the objective diagnosis of its functional impact.

The data found in the literature of the last years analyzed by the present study demonstrate the need for further evidence regarding the relationship between the type of lingual frenulum and difficulties in breastfeeding. They also showed that there is still a need for a tool to assess the anatomical and functional conditions of the lingual frenulum that is universally adopted in order to reduce as much as possible the evaluator’s bias in research, thus providing results that favor more assertive interventions based on findings with experimental quality.

The relief, according to the maternal perspective, of breastfeeding problems after frenotomy was pointed out by Riskin et al.,⁴³ Pransky et al.,⁴ Ghaheri et al.,⁴⁸ and Campanha et al.¹³ being the conduct of the frenotomy often influenced, in a decisive way, by the maternal complaint and not by an anatomophysiological diagnosis.

Management of breastfeeding is carried out by health professionals from different specialties around the world such as gynecologists, mastologists, obstetricians, pediatricians, nurses, speech therapists, physiotherapists, dentists, nutritionists, among others. The formation of these often becomes diversified, which intensifies the need to establish conducts based not only on complaints and subjective observational findings but are also dependent on the training and experience of the professional who assists the lactating-infant dyad.

In order to evidence the change from precondition and postcondition to any type of intervention, an evaluation using validated quantitative and qualitative methods is necessary, as long as they allow nonsubjective verification of the change between the evaluation moments and the magnitude of that change, whether with positive or negative effects. In the present review, it was also possible to verify the diversity of protocols and evaluation methods used to quantify the degree of impairment of the different difficulties experienced in the breastfeeding process.

The LATCH scale⁴² was used by Emond et al.,⁴⁴ Dollberg et al.,¹¹ Wakhanrittee et al.,⁴⁷ and Muldoon et al.,³⁸ being the most used standardized tool in recent years.

However, it was possible to observe the use of other methodological standards. Ghaheri et al.¹² and Ghaheri et al.⁴⁸ used the abbreviated version of this same scale. Fujinaga et al.²³ and Campanha et al.¹³ adopted the UNICEF breastfeeding observation protocol, while Martinelli et al.,⁴⁵ Marcione et al.,⁵ and Campanha et al.¹³ evaluated nonnutritive sucking and nutritive sucking according to part II of the “protocol for the evaluation of the frenulum of the tongue with scores for babies.”

Emond et al.⁴⁴ evaluated the degree of the lingual frenulum using the shortened version of the Hazelbaker assessment tool for the function of the lingual frenulum as previously described by Ricke et al.⁴⁹ and Amir et al.,⁵⁰ which showed the subjectivity of the evaluations and the need for experience to use them consistently; Emond et al.⁴⁴ used the Breastfeeding Self-Efficacy Scale.⁵¹

Haham et al.,⁷ Dollberg et al.,¹¹ Ghaheri et al.,¹² and Ghaheri et al.⁴⁸ used the classification of the frenulum according to Coryllos, while Pransky et al.⁴ classified as subtypes anterior (types I and II) or posterior (types III and IV).

The visual analog scale standard of pain⁵² was also used in some studies, as a protocol to assess breastfeeding difficulties.^11,12,48 Walker et al.²⁴ used a questionnaire on breastfeeding difficulties (Breastfeeding Assessment Tool).

However, the most used method to assess breastfeeding was still significantly based on the reports of lactating women, collected through structured questionnaires and/or interviews^7,43,46 and/or the classification of the infant in degrees of improvement^4,19 and such tools were not necessarily validated.

The tools that predominantly depend on the maternal vision create a great question about the subjectivity of the findings. It was noted the search of some authors for methods that eliminate this subjectivity, such as the LATCH scale and part II of the “protocol of evaluation of the frenulum of the tongue with scores for babies.” However, it is necessary to carry out more research carried out by different study groups focusing on results with greater foundation and in different samples.

Both Emond et al.⁴⁴ and Dollberg et al.¹¹ used the same assessment tool, the LATCH scale, and both did not find a predictor for successful breastfeeding after frenotomy. In contrast to such studies, Wakhanrittee et al.⁴⁷ and Muldoon et al.³⁸ also used the same LATCH scale and presented data that support the positive effect of frenotomy on breastfeeding variables in children with ankyloglossia.

Benoiton et al.,⁴⁶ Ghaheri et al.,¹² Billington et al.,¹⁹ and Ghaheri et al.⁴⁸ concluded that frenotomy is effective in babies with ankyloglossia and results in a significant improvement in breastfeeding. Ghaheri et al.¹² and Ghaheri et al.⁴⁸ characterized the improvement as being early (1 week after surgery) and that it continues until 1 month after surgery. Billington et al.¹⁹ presented findings of complete resolution of symptoms at 3 months in 80% of cases. These data can be justified with the results of Martinelli et al.⁴⁵ who objectively demonstrated the change in the suction pattern after frenotomy. There was an increase in the number of sucks and a decrease in the pause time between them, and this finding was a differential in the literature in recent years.

The findings in the scientific literature evidenced in the present bibliographic review allow the statement that conservative conduct should be the guide in the clinical routine. That is, an infant with diagnosed ankyloglossia but without functional impairment (weight gain and adequate suction pattern) and an infant without breast complications should not be submitted to early frenotomy. If, when diagnosed with ankyloglossia, the only impact on lactation is any breast complication in the lactating woman, one should choose to follow up on lactation management, and only if the frenotomy is not resolved should it be considered.

An infant with ankyloglossia but without functional impairment in lactation should be monitored and the frenotomy only performed when and, mainly, if there is a functional justification, such as at the moment of food insertion if there is any change in chewing and swallowing and/or at the time in which some phonetic distortion is diagnosed.