9/22/2015. Lisa Gagnon, CPNP, APRN SOHN Fall 2015 Program. Types I- IV. Anterior, posterior. All Tongues are not alike!

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1 Lisa Gagnon, CPNP, APRN SOHN Fall 2015 Program Madison North Haven Shelton Yale New Haven Children s Hospital 1. The learner will describe different types of ankyloglossia and identify criteria for diagnosis 2. The learner will identify specific feeding problems infants and children may present with related to tongue tie. 3. The learner will describe the procedure for lingual frenulectomy 4. The learner will identify two ways to support or provide education or resources for the parent/guardian of the child with feeding difficulties related to tongue tie. Ankyloglossia is defined as a structural abnormality of the lingual frenulum Controversy exists about the precise definition In general there is a restriction in protrusion or elevation of the tongue due to frenulum elongation or shortening Incidence and epidemiology vary based on criteria of diagnosis & recognition Types I- IV 94% Anterior, 6% Posterior (Hong 2010) 3.2% diagnosed inpatient, 12% outpatient. Anterior, posterior (Ballard, Auer, Khoury, Pediatrics 2002) 2 breast feeding studies- 5-10% of Babies who had BF difficulties had tongue tie. 16% in another study All Tongues are not alike! 1

2 Breast feeding difficulties Pain throughout the feed Changed shape of nipple-compression Short latch, need for shield Poor Weight gain/dehydration Altered length of feed Reduced milk supply Bottle feeding difficulties exist too- Clicking, long feeds, air entrapment, dribbling Maternal Experience Pain Nipple Damage Bleeding, Blanching, Distortion Mastitis Pain on Latch or losing latch Sleep Deprivation due to baby being unsettled Depression/Sense of Failure Difficulties with transition to solid food- Gagging, coughing, choking, vomiting, spitting out, food refusal Child on restrictive diet or self-limited diet Mealtimes longer Food Aversions-taste, texture, temperature, color, size/shape Graze Poor or suboptimal weight gain The Impact of Lingual Frenulectomy on Transition to Solid food for the pediatric patient identified to have a tongue tie 9 months- 3 years target, studying kids all ages Retrospective, then prospective Questionnaire preop/postop lingual frenuloplasty SLP and ENT evaluation 2

3 Decreased articulation of the sounds l, r, t, d, n, th, sh, and z. Know developmental standards: 3 year olds should have 75% intelligible speech Many children with a tongue tie can still articulate well. Speech Therapy may be helpful before considering surgery. Difficult in infancy to predict future speech articulation difficulties. Dental- clearing food from teeth, maintaining saliva Wind Instruments- Social- Behavioral Self Confidence Tools: (Babies)Nice Head set & Groove Director or tongue blade Measuring (Maybe ok for some kids) Kotlow,

4 Jaw/Tongue Position: Jaw/tongue position- Low jaw position- cup in middle of tongue Low jaw position- tongue humped and tip depressed Jaw Structure, Jaw sliding Forlenza GP, et al. Pediatrics, Palate- High Palatal Vault? Mobility/Lateralization of the tongue Lingual Frenulum- Extension/elongation Tongue elevation- Restrictive, cupping Food mastication Food Pooling Clearing food/swallowing Side-side mobility of tongue Free mobile segment of the tongue Jaw/Palate Lip Tie, Maxillary Tie Restricted upper labial frenulum May effect infant feeding or childhood dentition Infants- Breast feeding difficulties- Pain, Latch difficulties, poor feeding and growth Assess upper lip mobility and latch Children- Band of tissue dividing upper incisors/gumline. Rarely speech concerns- M 4

5 Office based frenulectomy (lingual/labial) Most infants < 6 months Intraoperative Lingual +/- Labial Frenuloplasty Klockars T, Pitkaranta A, Int J Ped ORL, Varying techniques In general tongue is elevated, lingual frenulum is clearly identified and incised with Iris scissors. Care is taken to avoid Wharton s ducts infantfrenulectomyofficedkpart2.mov Kupietzky A, Botzer E, Ped Dent, More extensive repair. Lingual Frenulum is still incised with scissors typically (some centers use laser) Deeper incision, Sutures used. IMG_2274.mov Kupietzky A, Botzer E, Ped Dent,

6 Office based: Labial Frenulum is clipped with Iris scissors, Cautery with silver nitrate Intraoperative: Labial Frenulum is clipped with Iris scissors, sutured. Informational Sheet as to what to expect after the procedure- Discomfort Whitened scab under tongue, lip Transition with feeding IMG_2273.mov **Post labial frenulectomy exercises!! **May need continued work with Lactation Consultant Sutures are dissolvable No restrictions Pain relief- Acetominophen, Ibuprofen Recheck in 1-2 weeks Return to speech/feeding therapy when comfortable. Lactation Consultants Speech Pathologists- for feeding and speech Websites- Useful resources Support Parents- Length of time child may need ongoing therapy may relate to length child has had feeding issue 6