Fit to be tiedFit to be tied

Cliff OCliff O’’Callahan, MD, PhD, FAAP, Middlesex Hospital, Middletown, Oct 201Callahan, MD, PhD, FAAP, Middlesex Hospital, Middletown, Oct 20111

Nic Sinclair

22•SOME IMAGES MAY BE DISTURBING.

ADVISORY

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HarryHarry

!! 3 week old with feeding problems and 3 week old with feeding problems and challenging weight gain and frustrated mother in challenging weight gain and frustrated mother in a lot of pain when breastfeeding.a lot of pain when breastfeeding.

!! prior 39 wk prior 39 wk gestgest born born vagvag in hospital with in hospital with healthy course apart from a little jaundicehealthy course apart from a little jaundice

!! Has seen the lactation consultant in the hospital Has seen the lactation consultant in the hospital and in his pediatricianand in his pediatrician’’s office. Even worked with s office. Even worked with one in the community.one in the community.

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More about HarryMore about Harry

!! The hospital nursery team clipped his subThe hospital nursery team clipped his sub--lingual frenulum on DOL 2lingual frenulum on DOL 2

!! HeHe’’s had 2 s had 2 craniosacralcraniosacral sessionssessions

!! HeHe’’s barely back to birth weights barely back to birth weight

!! HeHe’’s not the happiest infant on the blocks not the happiest infant on the block

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HarryHarry’’ss feeding characteristicsfeeding characteristics

!! He chomps and flicksHe chomps and flicks

!! He tends to get frustrated and fall off the He tends to get frustrated and fall off the breast despite positioningbreast despite positioning

!! Feeding can go for 30Feeding can go for 30--50 minutes and 50 minutes and then hethen he’’s back to feeding again an hour or s back to feeding again an hour or two latertwo later

!! He clicksHe clicks

!! He sputters a bit on the bottle of EBMHe sputters a bit on the bottle of EBM

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HarryHarry’’ss mothers storymothers story

!! It hurts when Harry is feeding at breastIt hurts when Harry is feeding at breast

!! Sometimes less pain with nipple shield but he Sometimes less pain with nipple shield but he still doesnstill doesn’’t transfer mucht transfer much

!! Nipple skin broken down, bleb, healing crackNipple skin broken down, bleb, healing crack

!! Nipple Nipple ““lipstickedlipsticked”” after feed but not blanchedafter feed but not blanched

!! Every feed demands her full attentionEvery feed demands her full attention

!! SheShe’’s exhausted and worried and not having funs exhausted and worried and not having fun

!! (She secretly wonders if a scar under the tongue (She secretly wonders if a scar under the tongue would be as bad as one on the forehead)would be as bad as one on the forehead)

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ObjectivesObjectives

!! Review understanding of ankyloglossia Review understanding of ankyloglossia and maxillary tieand maxillary tie

!! Discuss the relevance of above to Discuss the relevance of above to breastfeedingbreastfeeding

!! Who and what is being done to address Who and what is being done to address the challengesthe challenges

!! Share some preliminary local dataShare some preliminary local data

!! Open discussionOpen discussion

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Upper labial maxillary tieUpper labial maxillary tie

!! No uniform No uniform classificationclassification

!! Thickness, insertion Thickness, insertion point on gingival point on gingival surface, indentation surface, indentation at papilla, ability to at papilla, ability to flange lip back against flange lip back against nosenose

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Ankyloglossia classificationAnkyloglossia classification

!! Various interpretationsVarious interpretations

!! HazelbakerHazelbaker, Murphy, , Murphy, KotlowKotlow, , CorrylosCorrylos, Fernando, , Fernando, Griffiths, Griffiths, SrinivasanSrinivasan, Garcia , Garcia PolaPola, , RuffoliRuffoli, , MarchesanMarchesan

!! Generalized Type 1 to 4Generalized Type 1 to 4

!! Broader anterior vs. posterior Broader anterior vs. posterior

!! Diaphanous, opaque, beefy?Diaphanous, opaque, beefy?

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Ankyloglossia Ankyloglossia anatomy vs. functionalityanatomy vs. functionality

Hazelbacher ScoreMurphy classification

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Suck evaluationSuck evaluation

!! Tip to hardTip to hard--soft palate soft palate junctionjunction

!! (Issue of value without (Issue of value without liquid)liquid)

!! Sensing motion or Sensing motion or pressure along fingerpressure along finger

!! Chomping, cupping, Chomping, cupping, strength of strength of negneg pressure, pressure, difficulty to break sealdifficulty to break seal

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IncidenceIncidence

!! Wide variation in literature 0.2 to 10%Wide variation in literature 0.2 to 10%

!! About 4%?About 4%?

!! Lack of universal clarity in what is being Lack of universal clarity in what is being identifiedidentified

!! Unclear sex distributionUnclear sex distribution

!! Strong genetic componentStrong genetic component

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Another environmentalist plot?Another environmentalist plot?

!! Bible Bible (Moses had a late frenotomy?!)(Moses had a late frenotomy?!)

!! Midwife pinkie nailsMidwife pinkie nails

!! Much written about in 1700Much written about in 1700’’ss

!! Common in USA up to 1940Common in USA up to 1940’’s and the s and the elevator is elevator is stillstill in our circ kitsin our circ kits

!! Formula cultureFormula culture

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Embryogenic originsEmbryogenic originsTongue cells differentiate from bottom of oral pit.

Apoptosis creates the space

Frenulum is remnant of separation process

Ankyloglossia is incomplete separation resulting in diaphanous membrane or thicker fibrous band or strands of genioglossus muscle

1818From Brian Palmer, DDS in Kansas City from his 2003 lecture

1919From Brian Palmer, DDS in Kansas City from his 2003 lecture

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2121From Brian Palmer, DDS in Kansas City from his 2003 lecture. Original source not known.

2222From Brian Palmer, DDS in Kansas City from his 2003 lecture

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Images originally from Donna Geddes, PhD

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Tongue and lip as vital body partsTongue and lip as vital body parts

!! SwallowingSwallowing

!! Creating suctionCreating suction

!! Molding palate & nasal cavityMolding palate & nasal cavity

!! Teeth orientation and stabilityTeeth orientation and stability

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2626Brian Palmer, DDS

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Censored

My Mom will be on the call

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Responses to this crisis!Responses to this crisis!

!! HistoricallyHistorically

!! StickStick--on pinkie nail scalpelson pinkie nail scalpels

!! Head in sand and say itHead in sand and say it’’ll stretchll stretch

!! Find an ENT or dentist or Oral SurgeonFind an ENT or dentist or Oral Surgeon

!! Primary care educationPrimary care education

!! Lactation consultants, chiropractorsLactation consultants, chiropractors

!! Make awareness a basic competency?Make awareness a basic competency?

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33332007-2009: 341 youth birth to 24 weeks age

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Frenotomy for lip & tongueFrenotomy for lip & tongue--tietie

!! FrenotomyFrenotomy is a simple clipping of the is a simple clipping of the frenular tissue.frenular tissue.

!! FlenulectomyFlenulectomy is more involved, is more involved, removing or reorganizing tissue through removing or reorganizing tissue through ZZ--plastyplasty, , cauterycautery, or laser ablation., or laser ablation.

!! Office based without anesthesiaOffice based without anesthesia

!! Within hours to days of birth, to months to Within hours to days of birth, to months to years, depending on the provideryears, depending on the provider

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Instruments and emergency kitInstruments and emergency kit

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Documenting & CodingDocumenting & Coding

!! Consult: 99242 (30 minutes)Consult: 99242 (30 minutes)!! Reason, birth & feeding history, bleeding Reason, birth & feeding history, bleeding hxhx!! Consent and time out.Consent and time out.!! Copy to PMD and family. Copy to PMD and family.

!! Ankyloglossia 750.0Ankyloglossia 750.0!! Coordination disorder 315.4Coordination disorder 315.4!! Feeding problem infant 783.3Feeding problem infant 783.3!! Benign neoplasm lip 210.0Benign neoplasm lip 210.0

!! Frenotomy (incision tongue fold) 41010Frenotomy (incision tongue fold) 41010!! Incision lip fold 40806Incision lip fold 40806

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ComplicationsComplications

!! Parental anxietyParental anxiety!! understandingunderstanding

!! DiscomfortDiscomfort!! 22% sucrose22% sucrose

!! NO NO BenzocaineBenzocaine 20%20%

!! BleedingBleeding!! More than with membranousMore than with membranous

!! Needs direct pressureNeeds direct pressure

!! Epinephrine swab, Epinephrine swab, GelfoamGelfoam, silver nitrate, silver nitrate

!! InfectionInfection

!! No effectNo effect!! Scar knot, muscular bands, other entitiesScar knot, muscular bands, other entities

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ImpressionsImpressions

!! Started in Dec 2006Started in Dec 2006

!! Have done about 500 in office and <50 in nurseryHave done about 500 in office and <50 in nursery

!! Mostly a referral population CT and western MAMostly a referral population CT and western MA

!! Trending to Trending to mostly posteriorsmostly posteriors

!! Greater proportion previously clipped elsewhereGreater proportion previously clipped elsewhere

!! Significantly less repeat clips due to scarring since Significantly less repeat clips due to scarring since swipe and liftswipe and lift

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ImpressionsImpressions

!! Familial tendency: a large number have siblings Familial tendency: a large number have siblings and relatives with various degrees of and relatives with various degrees of ankyloglossiaankyloglossia

!! Remarkable improvement in the vast majority Remarkable improvement in the vast majority with significant decrease in pain and improved with significant decrease in pain and improved ability to breastfeed efficiently, happily, and for ability to breastfeed efficiently, happily, and for longer overall time frame.longer overall time frame.

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AcknowledgementsAcknowledgements

!! Betty Betty CorrylosCorrylos

!! Jennifer TowJennifer Tow

!! My office staffMy office staff

!! Drs Drs KotlowKotlow and Palmerand Palmer

!! Stephanie Clemente & Susan MacaryStephanie Clemente & Susan Macary

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ResourcesResources

!! http://tonguehttp://tongue--tied.net/tied.net/ International Affiliation of International Affiliation of TongueTongue--Tie ProfessionalsTie Professionals

!! http://www.brianpalmerdds.com/http://www.brianpalmerdds.com/ Brian Palmer Brian Palmer DDS, Kansas CityDDS, Kansas City

!! http://www.kiddsteeth.com/http://www.kiddsteeth.com/ Larry Larry KotlowKotlow DDS, DDS, AlbanyAlbany

!! TongueTongue--TieTie. Alison K. . Alison K. HazelbakerHazelbaker 2010. Aidan 2010. Aidan and Eva Press. and Eva Press. www.aidanandevapress.comwww.aidanandevapress.com