Dental Asia May/June 2018

Clinical Feature
Tongue-tie (ankyloglossia) can cause distress for a
mother attempting to breastfeed and lead to early
cessation and reliance on bottle feeding. If quickly
diagnosed, anatomic anomalies can be corrected using
appropriate surgical intervention. The mother can then
feed more eciently, and the child will benet and continue to thrive.
palate, and spends little time in contact with the infant’s teeth. 4,5
However, if an infant is only latched to the nipple, rather than the
surrounding breast tissue, the nipple is situated more anteriorly in
the mouth so milk comes into contact with the teeth more frequently.
Structural defects such as lip-tie and tongue-tie can restrict
t h e m o v e m e n t o f t h e u p p e r l i p a n d t o n g u e , r e s p e c t i v e l y ,
Factors of Poor Breastfeeding
Effciency and Appropriate Management
for Tongue-tie and Lip-tie
By Dr. Lisa M Bowden, Assoc. Prof. Robert P Anthonappa, Prof. Nigel M King
Introduction
Although maternal breastfeeding is known to be a natural activity
that provides the infant with sustenance and immunological factors
that promote health and normal development, it is not practiced
in all communities. For example, in some developing countries,
breastfeeding has been shunned in favour of bottle feeding with
formula milk; the latter being considered to be more sophisticated.
Furthermore, “customs have an important inuence when it comes
to mothers rearing their children. This inuence is often negative” 1 .
However, due to concerns regarding the purity and hence the safety
of some brands of formula milk, bottle feeding has started to decline
in popularity. Although there have been advancements in the
equipment available, the risk of contamination from poorly sterilised
bottles and teats remains a potential hazard. An association of
bottle feeding with formula milk with childhood obesity has also
been identied. 2 These issues have led to at least one country to
ban the advertising of infant formula, in favour of breastfeeding. 3
Nevertheless, there may be both maternal and infant factors
that prevent successful breastfeeding. Thus, it is important
to identify and correct these problems because ineffective
breastfeeding can lead to maternal distress and complications for
the infant, including early childhood caries (ECC).
Two separate meta-analyses that were conducted in 2015
concluded that breastfeeding was associated with a decreased risk
of ECC. 4-5 However, these meta-analyses only assessed whether or
not an infant was breastfed, and did not specically investigate
infants with poor feeding techniques. Unfortunately, very little
research has been conducted into the relationship between poor
nursing ecacy and the risk of ECC. Epidemiological studies have
identied an association with increased frequency and duration
of breastfeeding with increased rates of dental caries. 6-9 The
association between dental caries and increased breastfeeding
frequency may be due to poor nursing ecacy because the infant
needs to feed more frequently in an attempt to increase the intake
of nutrients. The main argument against breastfeeding contributing
to ECC is that the breastmilk is ejected into the mouth near the soft
which in turn may cause milk to stagnate in the buccal sulcus
around the teeth and prevent self-cleaning by the tongue. 10 Other
physiological factors can aect an infant’s ability to accomplish
successful breastfeeding. For example, it has been claimed that
the presence of natal or neonatal teeth can make breastfeeding
uncomfortable or there may even be laceration of the nipple,
while the infant may suer ulceration of the ventral surface of the
tongue. 11 Case studies have reported mothers ceasing breastfeeding
early due to complications from natal teeth. 12-13
Recently, the roles of tongue-tie and lip-tie in breastfeeding
ecacy have been a controversial topic. Often it is recommended
that these physical abnormalities be surgically corrected to allow
normal breastfeeding to commence. However, the oral physiology
of breastfeeding is a complex and debatable topic. Nevertheless,
it is important to consider all possible factors that may relate
to poor feeding ecacy and their appropriate management. If
it is determined that a frenal attachment is the cause of poor
breastfeeding technique, dierent surgical methods are available
to manage this condition. Therefore, the aim of this article is to
focus on tongue-tie and lip-tie in the infant as factors that can
cause unsuccessful breastfeeding. To fully understand the nature
of these problems, the physiological mechanism of breastfeeding
will be reviewed prior to explaining the management of these two
conditions.
Oral physiology of breastfeeding
The precise nature of the mechanism by which an infant obtains
milk from a breast is still somewhat controversial. Nevertheless, it
is proposed to review the current knowledge on the mechanism
of breastfeeding.
Infant reexes are important for successful breastfeeding;
the reexes involved in breastfeeding are rooting, suckling and
swallowing. 14-15 The rooting reex occurs when something touches
an infant’s lips or cheek. The infant’s head will turn to locate
the stimulus, the mouth will open and the infant will lower and
protrude the tongue. When something touches an infant’s palate,
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DENTAL ASIA
MAY / JUNE 2018