Issues & concerns - babies

Breastfeeding and Other Foods

Introduction

Breastmilk is the only food your baby needs until about 6 months of age. There is no advantage to adding other sorts of foods or milks to breastmilk before about 6 months, except under unusual circumstances. Many of the situations in which breastmilk seems to require addition of other foods arise from misunderstandings about how breastfeeding works and/or originate from a poor start at establishing breastfeeding. In other words, if your baby is breastfeeding well and gaining weight well, then add solids only when the baby shows signs of being ready to eat solids. see the information sheet Increase intake of breastmilk

Supplementing during the first few days

It is thought by many that there is “no milk” during the first few days after the baby is born, and that until the milk “comes in” some sort of supplementation is necessary. This idea seems to be born out by the fact that babies, during the first few days, will often seem to feed for long periods and yet, not be satisfied. However, the key phrase is that “babies seem to feed” for hours when in fact, they are not really feeding much at all (see the video clips of young babies, younger than 2 days, breastfeeding very well and getting milk well, at the website ibconline.ca). A baby cannot get milk efficiently when he is not latched on properly to the breast, particularly when the supply is not yet abundant. Note, it is not supposed to be abundant in these early days. But during the first few days, if the baby is not latched on properly, he cannot get milk easily and thus may “seem to feed” for very long periods. There is a difference between being “on the breast” and drinking milk at the breast. The baby must latch on well so he can get the mother’s milk that is available in sufficient quantity for his needs, as nature intended. In the first few days, the mother does have the appropriate amount of milk that baby requires. She is not supposed to have a large amount and nobody has proved that the large amount of formula a baby will take in the first few days is good for him or safe! Yes, the milk is there even if someone has proved to you with the big pump that there isn’t any. How much does or does not come out in the pump proves nothing—it is irrelevant. Also note, no one who squeezes a mother’s breast can tell whether there is enough milk in there or not.

A good latch is important to help the baby get that milk that is available. If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby may want to be on the breast for long periods of time worsening the soreness. Or the baby may fall asleep at the breast and seem to have fed well; but babies tend to fall asleep at the breast when the flow of milk is slow.

  1. A baby who drinks well (see video clips at the website ibconline.ca) and falls asleep at the breast > that’s the way it should be.
  2. A baby who drinks poorly and then falls asleep at the breast > that’s not the way it should be. The mother and baby need help with the breastfeeding.

When the mother’s milk becomes more plentiful, after 3-4 days, the baby may do well even if he is not well latched on (the mother may be sore, but even this is not necessarily so—many mothers just put the baby to the breast any old way and both she and the baby do fine). If a better latch, and compression (see the information sheet Breast Compression) do not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid (see the information sheet Lactation Aid). The lactation aid is a far better way to supplement than finger feeding or cup feeding, if the baby is taking the breast. And it is much, much better than using a bottle. But remember, getting the baby well latched on first and using compressions will work most of the time and no supplements will be needed. Using a lactation aid before helping the mother and baby with the breastfeeding is not appropriate just because a bottle is not being used to supplement.

Water

Breastmilk is over 90% water. Babies breastfeeding well do not require extra water, even in summer, even in the hottest weather. If they are not breastfeeding well, they also do not need extra water, but rather, the mother and baby need help so that breastfeeding works better.

Vitamin D

It seems that breastmilk does not contain much vitamin D, but it does have a little. We must assume this is as nature intended not a mistake of evolution. In fact, breastmilk is one of the few natural foods that does contain some vitamin D. We were obviously meant to get our vitamin D from being exposed to sunlight. The baby stores up vitamin D during the pregnancy and he will remain healthy without vitamin D supplementation for at least a couple of months, unless the mother herself is vitamin D deficient during the pregnancy. Vitamin D deficiency in pregnant women in Canada and the USA is uncommon, but it does exist. Outside exposure also gives your baby vitamin D even in winter, even when the sky is cloudy. A few minutes of exposure very late on a summer’s day is ample. Thirty minutes during a summer week, and an hour or so in winter, gives your baby more than enough vitamin D even if only his face is exposed.

Under unusual circumstances, it may be prudent to give the baby vitamin D. For example, in situations where exposure of the baby to ultraviolet rays of the sun is not possible (Northern Canada in winter or if the baby is never taken outside), giving the baby vitamin D drops would be advised. If you have had very little outside exposure yourself (women who are veiled are particularly at risk, especially if they are dark skinned), make sure your intake of vitamin D during the pregnancy is higher than usually recommended. Your baby may need vitamin D supplementation as well. Recent studies suggest that high intake of vitamin D while breastfeeding (4000 IU a day—10 times the usual recommended dose) does in fact increase the amount of vitamin D in the milk to levels that will protect the baby from rickets.

Iron

Breastmilk contains much less iron than formulas, especially the iron-enriched formulas, and this is as it should be. Actually, the low levels of iron in breastmilk are thought to give the baby extra protection against infection, as many bacteria require iron in order to multiply. The iron in breastmilk is very well utilized by the baby (about 50% is absorbed), while being unavailable to bacteria and the breastfed full term baby does not need any additional iron before about 6 months of age. However, introduction of iron containing foods should not be delayed much beyond 6 months of age.

Solid Foods (see also the information sheet Starting solid foods

Exclusively breastfed babies do not usually require solid foods before about 6 months of age. Indeed, many do not require solid foods until 9 months or more of age, if we can judge by their weight gain and iron status. However, there are some babies who will have great difficulty learning to accept solid food if not started before 7-9 months of age. Because the six-month-old baby will also soon need to have an additional source of iron, it is generally recommended and convenient that solids be introduced around 6 months of age. Some babies show great interest in grabbing food off your plate by 5 months, and there is no reason not to allow them to start taking the food and playing with it and putting it in their mouths and eating it.

It has been the habit of physicians to suggest that babies be started first on cereals and then other foods be added. There is nothing magic about cereal and babies do fine without it. In fact, other than calories and added iron there is not much of nutritional value in cereals. The easiest way for the baby to get additional iron is by eating meat, not by cereals from which the iron is poorly absorbed and the vast majority comes out with the baby’s bowel movements. Furthermore, cereals tend to be constipating. Real food that you eat is best for baby.

There is no good reason why a baby needs to eat or be introduced to only one food per week or why vegetables should be started before fruits. Anyone worried about the sweetness of fruit has not tasted breastmilk. The six-month-old can be given almost anything off his parents’ plate that can be mashed with a fork. If you eat healthy, then baby will eat healthy. Far fewer feeding problems will occur if a relaxed approach to feeding is taken.

Breastmilk, Cow’s Milk, Formula, Outside Work and Bottles. 
(See also the information sheet What to feed the baby).

In modern industrial societies we have so long fed babies with bottles that we cannot imagine that a baby can be fed without one. The “need” for baby to take a bottle is purely a manufactured one and marketing continues to emphasize this need. No baby needs to take a bottle as an entrance requirement for kindergarten—instead all children will eventually learn to drink from a cup (not a “sippy” cup which is, essentially, a bottle). It is true that an older baby will often not take a bottle if not used to it. This is no great loss. So, why not teach baby to use a cup? Babies can learn to take a cup at birth, though there is not usually a reason to for them to do so. See the video clips of a 2 or 3 week old baby drinking from a cup at the website ibconline.ca. In this case the baby is being cup fed to avoid a bottle. He is not yet able to latch on to the breast.

However, if mother needs to be separated from her baby for any reason, the baby can drink her milk by cup. This is best learned when baby is not ravenous (see the information sheet Finger & cup feeding). At about 6 months or even younger, the baby can start learning to use a cup, even if he has never done this before and usually will be quite good at drinking from a cup by about 7-8 months of age, if not sooner. If the mother is returning to paid work at about 6 months or before, there is also no need to start bottles or formula. In this situation, solids may be started somewhat earlier than 6 months of age (say 4 or 5 months of age), so that by the time the mother is working outside the home, the baby can be getting most of his food and liquid, when the mother is not with him, off a spoon. As he gets older, the cup may be used more and more for liquids. You and the baby can manage without his taking bottles. Do not try to starve the baby into taking a bottle if he refuses to accept one. Your baby is not being stubborn; rather, he does not know how to use an artificial nipple. He also may not like the taste of formula, which is understandable.

Note that too many workers in daycares do not realize any of this and are surprised or dismayed or unhappy that the baby of 6 months of age, say, does not take a bottle. Educate them, nicely, of course.

There has been a lot of publicity recently about not giving babies cow’s milk until at least 9 months. The breastfeeding baby can take some of his milk as cow’s milk after about 6 months of age, especially if he is starting to take substantial amounts of a wide variety of solids as well. The breastfed baby, who has been supplemented with formula as mentioned above, can get that formula mixed with solids or that formula can be replaced with cow’s milk. Certainly, cow’s milk is less expensive. Goat’s milk is an alternative. Many breastfeeding babies will not drink formula because they do not like the taste. Actually, the breastfeeding baby can get all the milk he needs from the breast without his requiring other sorts of milk, even if he is breastfeeding only a few times a day. see the information sheet What to feed the baby.

My 4 month old is hungry on breast only. Solids or Formula?

There is no advantage in this situation of giving formula, especially by bottle and there may be some important disadvantages. Even at this age a baby may start to prefer the bottle if he seems not to be getting enough from the breast (if, in fact, he will accept a bottle). On the other hand, if the baby does accept the bottle and if your milk supply has decreased, as it might have, giving the baby a bottle may almost guarantee that the baby will soon refuse the breast. see the information sheet Slow weight gain for reasons your milk supply may have decreased. It would be preferable in this circumstance to give solids off a spoon rather than to give formula in a bottle. (Frequently, however, this situation can be remedied differently by improving the breastfeeding—get help!). If you wish to mix formula with solids, that does not cause the same sort of problem as giving formula or even expressed milk in a bottle. If the baby seems hungry after breastfeeding, feed him solids off a spoon. However, it may be possible with a few simple techniques, to get the baby gaining well, and/or to be satisfied with breastfeeding alone. Check with your doctor.

Breastfeeding and Other Foods, 2009© 
Written and revised (under other names) by Jack Newman, MD, FRCPC, © 1995-2016 
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009©

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.

Breastfeeding and Jaundice

Introduction

Jaundice is due to a buildup in the blood of bilirubin, a yellow pigment that comes from the breakdown of old red blood cells. It is normal for old red blood cells to break down, but the bilirubin formed does not usually cause jaundice because the liver metabolizes it and gets rid of it into the gut. The newborn baby, however, often becomes jaundiced during the first few days because the liver enzyme that metabolizes bilirubin is relatively immature. Furthermore, newborn babies have more red blood cells than adults, and thus more are breaking down at any one time; as well many of these cells are different from adult red cells and they don’t live as long. All of this means more bilirubin will be made in the newborn baby’s body. If the baby is premature, or stressed from a difficult birth, or the infant of a diabetic mother, or more than the usual number of red blood cells are breaking down (as can happen in blood incompatibility), the level of bilirubin in the blood may rise higher than usual levels

Two Types of Jaundice

The liver changes bilirubin so that it can be eliminated from the body (the changed bilirubin is now called conjugated, direct reacting, or water soluble bilirubin--all three terms mean essentially the same thing). If, however, the liver is functioning poorly, as occurs during some infections, or the tubes that transport the bilirubin to the gut are blocked, this changed bilirubin may accumulate in the blood and also cause jaundice. When this occurs, the changed bilirubin appears in the urine and turns the urine brown. This brown urine is an important clue that the jaundice is not “ordinary”. Jaundice due to conjugated bilirubin is always abnormal, frequently serious and needs to be investigated thoroughly and immediately. Except in the case of a few extremely rare metabolic diseases, breastfeeding can and should continue.

Accumulation of bilirubin before it has been changed by the enzyme of the liver may be normal— “physiologic jaundice” (this bilirubin is calledunconjugated, indirect reacting or fat soluble bilirubin). Physiologic jaundice begins about the second day of the baby’s life, peaks on the third or fourth day and then begins to disappear. However, there may be other conditions that may require treatment that can cause an exaggeration of this type of jaundice. Because these conditions have no association with breastfeeding, breastfeeding should continue. If, for example, the baby has severe jaundice due to rapid breakdown of red blood cells, this is NOT a reason to take the baby off the breast. Breastfeeding should continue in such a circumstance.

So-called Breastmilk Jaundice

There is a condition commonly called breastmilk jaundice. No one knows what the cause of breastmilk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breastmilk jaundice also have had exaggerated physiologic jaundice. The baby should be gaining well, with breastfeeding alone, having lots of bowel movements, passing plentiful, clear urine and be generally well (see the information sheet Is my Baby Getting Enough Milk? and see also the video clips at the website ibconline.ca). In such a setting, the baby has what some call breastmilk jaundice, though, on occasion, infections of the urine or an under functioning of the baby’s thyroid gland, as well as a few other even rarer illnesses may cause the same picture. Breastmilk jaundice peaks at 10-21 days, but may last for two or three months. Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. Only very occasionally is any treatment, such as phototherapy, necessary. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued “in order to make a diagnosis”. If the baby is truly doing well on breast only, there isno reason, none, to stop breastfeeding or supplement even if the supplementation is given with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the fact that the formula feeding baby is the model we think is the one that describes normal infant feeding and we impose it on the breastfed baby and mother. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down. Thus, the formula feeding baby is rarely jaundiced after the first week of life, and when he is, there is usually something wrong. Therefore, the baby with so called breastmilk jaundice is a concern and “something must be done”. However, in our experience, most exclusively breastfed babies who are perfectly healthy and gaining weight well are still jaundiced at five to six weeks of life and even later. The question, in fact, should be whether or not it is normal not to be jaundiced and is this absence of jaundice something we should worry about? Do not stop breastfeeding for “breastmilk” jaundice.

Not-Enough-Breastmilk Jaundice

Higher than usual levels of bilirubin or longer than usual jaundice may occur because the baby is not getting enough milk. This may be due to the fact that the mother’s milk takes longer than average to “come in” (but if the baby feeds well in the first few days this should not be a problem), or because hospital routines limit breastfeeding or because, most likely, the baby is poorly latched on and thus not getting the milk which is available (see the information sheet Is my Baby Getting Enough Milk? and see also the video clips at the website ibconline.ca). When the baby is getting little milk, bowel movements tend to be scanty and infrequent so that the bilirubin that was in the baby’s gut gets reabsorbed into the blood instead of leaving the body with the bowel movements. Obviously, the best way to avoid "not-enough-breastmilk jaundice" is to get breastfeeding started properly (see the information sheet Breastfeeding—Starting Out Right). Definitely, however, the first approach to not-enough-breastmilk jaundice is not to take the baby off the breast or to give bottles (see the information sheet Protocol to Manage Breastmilk Intake). If the baby is breastfeeding well, more frequent feedings may be enough to bring the bilirubin down more quickly, though, in fact, nothing really needs be done. If the baby is breastfeeding poorly, helping the baby latch on better may allow him to breastfeed more effectively and thus receive more milk. Compressing the breast to get more milk into the baby may help (see the information sheet Breast compression). If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings (see the information sheet Lactation aids). See also the information sheet: Protocol to Manage Breastmilk Intake. See also the website video clips at the website ibconline.ca to help use the Protocol by showing how to latch a baby on, how to know the baby is getting milk, how to use compressions, as well as other information on breastfeeding.

Phototherapy (Bilirubin Lights)

Phototherapy increases the fluid requirements of the baby. If the baby is breastfeeding well, more frequent feeding can usually make up this increased requirement. However, if it is felt that the baby needs more fluids, use a lactation aid to supplement, preferably expressed breastmilk, expressed milk with sugar water or sugar water alone rather than formula.

Breastfeeding and Jaundice, 2009© 
Written and revised (under other names) by Jack Newman, MD, FRCPC, © 1995-2016 
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009©

Ankyloglossia or tongue-tie

Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic Patient handout

A tongue-tie (ankyloglossia) is membrane under the tongue extending further than usual towards the tip of the tongue.

Tongue-ties can cause problems with breastfeeding:

  • Nipple pain
  • Latch problems
  • Poor weight gain.

Research shows that “frenotomy”, or clipping of the tongue-tie, is a safe and effective treatment. Frenotomy, like all procedures, may present some risks. They include bleeding at the incision site, infection, and salivary gland trauma.

Not all tongue-ties need to be clipped, only those that are causing breastfeeding problems. Severe tongue-ties may also lead to speech problems and a higher risk of dental cavities in the future.

Consent form

You will be asked to sign a consent form before the frenotomy is done. The staff at the Breastfeeding Clinic is happy to answer any questions you may have about this condition and procedure.

There are two types of tongue-ties. Both can cause problems with breastfeeding.

Anterior tongue-ties are attached to the tip of the tongue, and are very obvious to see.

The frenotomy takes a few seconds, and is done with the parents present. The baby goes straight to the breast afterwards, as breastmilk helps with healing and soothing. Many mothers feel less nipple pain and a better latch almost immediately.

Posterior tongue-ties are thicker and further back. These tongue-ties are not always seen with the eyes, but felt with the fingers.

For posterior tongue-ties, the frenotomy can sometimes cause a bit more pain and bleeding. We give the infant Tylenol™ before the procedure, and use Orajel™ (topical anaesthetic) to freeze the area. Again, the frenotomy itself only takes a few seconds. Any bleeding is immediately stopped with pressure. The baby goes straight to the breast afterwards, as breastmilk helps with healing and soothing. The mother may not feel a difference right away, and it may take up to 2 weeks to feel a difference in latch or nipple pain.

After the procedure

No special care is needed.

We ensure that the bleeding has completely stopped before you leave the clinic.

We will show you some tongue exercises for your baby that you can try at home 24 hours after the procedure. However, if these exercises make your baby irritable or seem painful, please stop them and call us as needed.

For posterior tongue-ties, you may want to give another dose of Tylenol™ that night if baby is very fussy or irritable.

It is important to breastfeed as often as possible, to help the baby extend the tongue. Usually, a follow-up is booked after 1 to 2 weeks to make sure feeding is going well.

If you have any concerns, or your baby has more bleeding or is irritable:

  • Please feel free to call the Breastfeeding Clinic during the week at 514-340-8222 local 3269.
  • If it is overnight or on a weekend, you may need to go to the emergency room of a hospital that sees babies (such as the Montreal Children’s Hospital or Ste Justine’s hospital).
  • If you do go to an emergency room, please bring this information sheet with you, so that the doctors will know what kind of procedure your baby had.

The Goldfarb Breastfeeding Clinic receives referrals for tongue-ties from all over the Montreal area. About 4 to 6 procedures are performed every week. Each baby is evaluated carefully, and only those tongue-ties that are clearly interfering with breastfeeding will be treated. Sometimes, it takes a few visits to decide whether or not treatment is needed.

The information contained in this patient handout is a suggestion only, and is not a substitute for consultation with a health professional or lactation specialist. This handout is the property of the author(s) and the Goldfarb Breastfeeding Clinic. No part of this handout can be changed or modified without permission from the author and the Goldfarb Breastfeeding Clinic. This handout may be copied and distributed without further permission on the condition that it is not used in any context in which the International Code for the Marketing of Breastmilk Substitutes is violated. For more information, please contact the Goldfarb Breastfeeding Clinic, Herzl Family Practice Centre, SMBD Jewish General Hospital, Montreal, Quebec, Canada. © 2009

Ankyloglossia and breastfeeding

Paediatrics & Child Health 2002; 7(4), 269-70 Reference No. CP02-02

Index of position statements from the Community Paediatrics Committee

Community Paediatrics Committee, Canadian Paediatric Society (CPS).

Etiology, physiology and possible pathology • Management • Conclusion •References

The term 'ankyloglossia' comes from the Greek words 'agkilos' for crooked or loop and 'glossa' for tongue (1,2). Ankyloglossia ('tongue-tie', short frenulum) is observed in newborns and children when the lingual frenulum is too short and attached to the very tip of the tongue, limiting its normal movements. It is defined in terms of function, rather than on the basis of objective anatomical measurement (3-5). This condition is diagnosed when a patient cannot protrude his/her tongue past the incisial edge of the lower gingiva; when he/she attempts to do so, the tip of the tongue becomes heart-shaped and remains behind the lower gum edge. When the mouth is open, it is impossible for the patient to touch the roof of his/her mouth with the tip of the tongue. However, little research has identified a causal relationship between tongue-tie, lactation problems, speech disorders and other oral motor disorders (eg, problems with swallowing or licking) (6-9). The present statement focuses specifically on the evidence surrounding the association of ankyloglossia and breastfeeding difficulties.

Etiology, physiology and possible pathology

During early development, the tongue is fused to the floor of the mouth. Cell death and resorption free the tongue, with the frenulum left as the only remnant of the initial attachment (10. Tongue-tie is the result of a short fibrous lingual frenulum or a highly attached genioglossus muscle 4, affecting from 0.02% to 4.4% of newborn infants 11-13. The lingual frenulum usually becomes less prominent as a natural process of the child’s growth and development, when the alveolar ridge grows in height and the teeth begin to erupt 9. This process occurs during the first six months to five years of life. Ankyloglossia is defined as complete if there is a total fusion between the tongue and the floor of the mouth or partial if it arises from a short lingual frenulum, the latter being by far the most common type 8,9.

The role of a short lingual frenulum as a cause of breastfeeding difficulties has been described in multiple anecdotal reports linking partial ankyloglossia to decreased tongue mobility and a potential inability to latch on properly 3, 14-18.

It is important to remember that the swallowing mechanism of the newborn and infant is different from the adult or older child. It has been noted that for successful nursing to occur, the infant must latch on to the mother’s areola with his/her upper gum ridge, buccal fatty pads and tongue. Suckling begins with the forward movement of the jaw and tongue. The tongue helps to make a better seal, but with minimal active action. The anterior edge of the tongue thins, cupping upwards to begin a peristaltic ripple back toward the throat. At the same time, the lower jaw squeezes milk from the ductules. Finally, the posterior part of the tongue depresses to allow milk to collect in the oropharynx before swallowing 18. It is clear that restriction of the tongue movements must be quite extreme to interfere with sucking and swallowing 3, 9, 19.

Messner et al 10, in a prospective study, reported the incidence of ankyloglossia in a well baby population and tried to determine whether patients with this condition experienced breastfeeding difficulties. Only 50 babies of the 1041 newborns that were screened in the well baby nursery had tongue-tie as defined by their very broad definitions. This incidence of 4.8% corresponds with what is reported in the literature 11-13. No cases of complete ankyloglossia were identified. Thirty-six mothers of affected infants were paired with 36 mothers of control infants. They all breastfed for a period of two to six months. Thirty (83%) of the 36 infants with ankyloglossia were successfully breastfed during the study period compared with 33 (92%) of the 36 control infants (P=0.29). Mothers of infants with ankyloglossia reported more breastfeeding difficulties than mothers of controls. However, as stated above, the duration of breastfeeding was similar in both groups 10.

Management

Management of tongue-tie is usually conservative, requiring no intervention beyond parental education and reassurance. Infants must be observed closely when a complete fusion of the tongue is found, and frenulectomy must be performed 20. For partial ankyloglossia, if a tongue-tie release is deemed necessary, a referral to an ear, nose and throat specialist, oral surgeon or a physician experienced with the procedure should be made. Release of the tongue-tie appears to be a minor procedure, but may cause complications such as bleeding, infection or injury to Wharton’s duct 21. A simple incision or ’snipping' of a tongue-tie (frenectomy) is the most common procedure performed for partial ankyloglossia. However, postoperative scarring may limit tongue movement even more 20,21. Excision with lengthening of the ventral surface of the tongue or a Z-plasty release is another procedure with less postoperative scarring, but has the inherent risks of general anesthesia11.

Conclusion

Ankyloglossia is relatively uncommon in the newborn population. Most of the time, it is an anatomical finding without significant consequences for the newborn or infant affected by this condition. Current evidence seems to demonstrate that despite ankyloglosssia, most newborns are able to breastfeed succesfully 7,10. Surgical intervention is not usually warranted, but may be necessary if the association between significant ankyloglossia and major breastfeeding problems has been identified 20. More definitive recommendations must await more precise criteria for diagnosis along with the appropriately designed clinical trials.

References

  1. Newman DWA. The American Illustrated Medical Dictionary. Philadelphia: WB Saunders Co, 1985.
  2. Wellington JH, Hoerr NL, Blakistons OA, eds. New Gould Medical Dictionary, 1st edn. Toronto: The Blakiston Co, 1949.
  3. Fletcher SG, Meldrum JR. Lingual function and relative length of the lingular frenulum. J Speech Hear Res 1968;11:362-90.
  4. Scully C, Welbury R. Color Atlas of Oral Diseases in Children and Adolescents. London: Wolfe, 1994:10.
  5. William NW, Waldon CM. Assessment of lingual function when ankyloglossia tongue-tie is suspected. J Am Dent Assoc 1985;110:353-6.
  6. Kaban LB. Pediatric Oral and Maxillofacial Surgery. Philadelphia: WB Saunders Co, 1990:131-40.
  7. Messner AH, Lalakea LM. Ankyloglossia: Controversies in management. Int J Pediatr Otorhinolaryngol 2000;54:123-31.
  8. Salinas CF. Orodental findings and genetic disorders. Birth Defects Orig Artic Ser 1982;18:98-9.
  9. Wright JE. Tongue-tie. J Paediatr Child Health 1995;31:276-8.
  10. Messner AH, Lalakea LM, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000;126:36-9.
  11. Catlin FI. Tongue-tie. Arch Otolaryngol 1971;94:548-57.
  12. Friend GW, Harris EF, Minler HH, Fong TL, Carruth KR. Oral anomalies in the neonate, by race and gender, in an urban setting. Pediatr Dent 1990;12:157-61.
  13. Jorgenson RJ, Shapiro SD, Salinas CF, Levin SL. Intraoral findings and anomalies in neonates. Pediatrics 1982;69:577-82.
  14. Conway A. "Ankyloglossia" to snip or not to snip: Is that the question? J Hum Lact 1990;6:101-2.
  15. Berg KL. Tongue tie (Ankyloglossia) and breast feeding: A review. J Human Lact 1990;6:109-12.
  16. Notestine EG. The importance of the identification of ankyloglossia as a cause of breast feeding problems. J Hum Lact 1990;6:113-5.
  17. Marmet CH, Shell E, Marmet R. Frenotomy may be necessary to correct breastfeeding problems. J Hum Lact 1990;6:117-21.
  18. Wight NE. Management of common breastfeeding issues. Pediatr Clin North Am 2001;48:321-44.
  19. Sarin YK, Zaffar M, Sharma AK. Tongue-tie: Myths and truths. Indian Pediatr 1992;29:1585-6.
  20. Levy PA. Tongue-tie: Management of a short sublingual frenulum. Pediatr Rev 1995:16:345.
  21. Bernam S, Johnson C, Chan K, Kelley P. Oral congenital malformations.

In: Hay W Jr,
Hayward AR, Groothius JR ,Levin MJ, Sondheimer JM, eds.
Current Pediatric Diagnosis & Treatment, 15th edn.

New York: McGraw-Hill, 1995:491.
Community Paediatrics Committee

Members: Drs Cecilia Baxter, Edmonton, Alberta; Fabian P Gorodzinsky, London, Ontario; Moshe Ipp, Toronto, Ontario, Denis Leduc, Montreal, Quebec (chair); Cheryl Mutch, Burnaby, British Columbia; Linda Spigelblatt, Montreal, Quebec (director responsible); Sandra Woods, Val-d'Or, Quebec

Liaison: Dr Somesh Barghava, Ottawa, Ontario (representing the Community Paediatrics Section, Canadian Paediatric Society)

Principal authors: Drs Fabian Gorodzinsky, London, Ontario; Joseph Telch, Unionville, Ontario The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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