Simplified patient decision-aid for tongue-tie surgery for breast-fed infants

The number of infants receiving surgery for ankyloglossia (tongue-tie) has surged in recent years, likely fuelled in part by parents accessing misinformation available on social media (1). It has been remarked, “suboptimal breastfeeding is a complex issue and every nursing dyad with painful or ineffective feeding should have a complete breastfeeding assessment before any treatment is offered” (2). It is therefore recommended to undertake a multidisciplinary evaluation (paediatricians, lactation specialists, feeding therapists, surgeons) prior to the decision for surgical intervention for ankyloglossia in breastfeeding infants (2). “Most infants with ankyloglossia are asymptomatic and do not exhibit feeding problems” (3). Further, there is “no clear connection between ankyloglossia and speech disorders” (4). Scoring severity of ankylglossia (e.g., tongue assessment tool for tongue-tie in breastfed babies [TABBY] assessment tool) combined with breastfeeding assessment informs surgical decision-making (5). A patient decision-aid can help in the shared decision-making process to inform parents regarding the risks and benefits (if any) of surgery for ankyloglossia in infants with difficulty breastfeeding. The decision-aid should provide evidence-based information on whether surgery for ankyloglossia improves infant’s breastfeeding, mother’s nipple pain, and potential complications of the surgical procedure. This article summarily reviews the above three aspects and presents a simplified patient decision-aid to assist parental decision-making regarding surgery for ankyloglossia in breastfeeding infants. Does surgery for ankyloglossia improve infant breastfeeding? A Cochrane systematic review “did not find a consistent positive effect on infant breastfeeding” after frenotomy and noted the paucity of scientific rigour with few randomized controlled trials (6). A birth cohort study found no association between ankyloglossia and exclusive or total breastfeeding duration (1, 4 and 6 months) (7). It has been reported that consistent multidisciplinary assessment for infants with ankyloglossia and breastfeeding difficulties reduced surgical intervention rates (11% ➡ 4%) over a two-year period (8). Lactation support to optimize latch should therefore be the primary strategy for infants with difficulty breastfeeding. The uncertainty of benefit of surgery indicates that surgical intervention for ankyloglossia should be reserved for select infants. Surgical procedure for ankyloglossia spans from the commonly performed frenulum division with scissors in an office setting to procedures requiring dissection under general anaesthesia for cases with greater severity (9). Does surgery for ankyloglossia reduce nipple pain for mothers? The evidence indicates that frenotomy may reduce nipple pain for breastfeeding mothers in the short term (2,6,10). Simple strategies (modifying latch and position; using nipple shields) may also alleviate nipple pain (11). “The definitive benefit of frenotomy on maternal nipple pain remains unproven” due to studies of low quality with considerable risk of bias (10). It should, however, be noted that breastfeeding mothers can have nipple pain from unrelated causes, such as mastitis or even from personal care practices (using tight bras or certain products on nipples) (12). Further, a study of primiparous women found nipple pain gradually declined in the postpartum period from 79% upon initiating breastfeeding to 20% at 8 weeks (13). Are there complications after surgery for ankyloglossia in infants? While the surgical procedure for ankyloglossia in infants is generally safe, a risk of complications exists. Complications include poor feeding, weight loss, pain, wound infection, Ludwig’s angina, bleeding, scarring, submandibular oedema, submandibular abscess, hypovolemic shock, anaemia, acute airway obstruction, apnoea, negative pressure pulmonary oedema, infected haematoma and mucocele (14,15). Also, the surgical procedure may delay diagnosis of alternative underlying medical conditions afflicting the infant (14). A 24-month study in New Zealand reported an annual incidence rate following frenotomy of 13.9 complications per 100,000 infants (14). Even infant fatality following surgery for ankyloglossia has been reported in the news media (16). Based on available evidence, a patient decision-aid was developed incorporating behavioural economic principles of ‘nudging’ (framing, default option, and traffic-light-colour-coding) for use in physician-guided shared decision-making (Figure 1). The decision-aid presents information framed to dissuade parents from selecting frenotomy as an initial treatment option to improve infant feeding—the default treatment option is to not undertake frenotomy. The decision-aid also provides information on potential complications of frenotomy procedure. Traffic-light-colour-coding was added to the decision-aid to leverage “established associations between traffic light colours and actions to stop or proceed” (17): Simplified patient decision-aid for tongue-tie (ankyloglossia) surgery in breastfeeding infants. Advising caution prior to undertaking frenotomy (yellow signal) Suggesting positive benefit to breastfeeding mothers with possible relief of nipple pain following frenotomy (green signal) Increasing awareness of potential complications following frenotomy (red signal) The decision-aid is easy to read with Flesch Reading Ease score of 64.7, Flesch-Kincaid Grade level of 7.5 and 32% passive sentences. In conclusion, the use of a simplified patient decision-aid may help reduce surgical overtreatment for ankyloglossia in breastfeeding infants and alleviate consequent morbidity. No funding was received. The author has no conflict of interest. Author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

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