Short Lingual Frenulum a Risk Factor for Sleep-Disordered Breathing in Kids

By Scott Baltic

November 26, 2019

NEW YORK (Reuters Health) - Having a short lingual frenulum, also called ankyloglossia or tongue-tie, is associated with a significant increase in risk of sleep-disordered breathing (SDB) in school-age children, Italian researchers have found.

The study, online October 23 in Sleep Medicine, shows that the 23% of children with ankyloglossia had three times greater odds than other children of having findings suggestive of SDB.

"We speculate that a short lingual frenulum promotes craniofacial changes which ultimately limit the size of the upper airway lumen and predispose children to SDB," Dr. Maria Pia Villa of Sapienza University of Rome told Reuters Health by email.

"An early multidisciplinary approach and screening for SDB are indicated when this anatomical abnormality is recognized," she added.

Ankyloglossia is a congenital anomaly defined as a free tongue length of 16 mm or less, Dr. Villa explained. The condition restricts tongue movement, altering its function, the shape of the dental arches, and their occlusion.

Previous work by other researchers had found evidence that a short lingual frenulum at birth is associated with obstructive sleep-apnea syndrome (OSAS) later in life and with abnormal development of the oral cavity.

The current study recruited 504 children (ages 6-14, mean age 9.6) from a school in Rome. For each participant, the researchers completed a sleep clinical record (SCR) including an OSAS score; abnormalities in the nose, oropharynx, dental, and craniofacial occlusion; and symptoms of inattention and hyperactivity.

An SCR score of 6.5 or more is considered "positive" and is associated with high risk of OSAS, defined as an obstructive apnea−hypopnea index of more than one one episode per hour.

Forty-two participants (8.3%) had a positive SCR score. These children had higher prevalences of malocclusion, nasal septum deviation, arched palate, oral breathing, adenotonsillar hypertrophy, and short lingual frenulum than children with lower SCR scores.

After adjusting for other OSAS risk factors such as age, sex, tongue strength and obesity, children with a short lingual frenulum had 2.98 times higher odds of having a positive SCR compared with those with a normal-length frenulum (P=0.012).

Dr. Villa, who is also head of the Regional Sleep Disorders Center at Sant'Andrea Hospital, Rome, told Reuters Health that depending on the severity of ankyloglossia, pediatric dentistry offers various treatment options, such as observation, speech therapy, frenotomy and frenectomy.

Dr. Carol L. Rosen, a professor of pediatrics at Case Western Reserve University School of Medicine, Cleveland, who was not involved in the study, told Reuters Health by email, "Short frenulums have generated a lot of popular interest because of their potential causal role in breast-feeding difficulties. Many providers are now recommending and/or offering a surgical clip of the frenulum to help newborns with breast-feeding difficulties."

She pointed out a few of the study's limitations, including whether the recruitment approach might have selected families with greater concerns about their child's breathing and/or upper airway, dental or orthodontic features.

Dr. Rosen also noted that some of the SCR score components might have selected children more likely to have a shorter frenulum, and that SDB was not actually measured by sleep study or cardiorespiratory monitoring.

"While oral and upper airway anatomy and nasal, facial, and jaw shape play some role in risk of collapse of the upper airway and OSAS, there are other OSAS risk factors, including the development of enlarged tonsils and adenoidectomy, airway reflexes, and control of breathing that may be important as well," she said.

Dr. Rosen concluded, "What's important to remember is that when parents are concerned that their child has habitual snoring, trouble breathing at night, and daytime symptoms like sleepiness or trouble with attention or behavior, think about OSAS and talk to your doctor or a sleep-medicine specialist about the next steps for evaluation and management."


Sleep Med 2019.