Diagnostic Assessment of Ankyloglossia and Association With Infant Feeding Challenges: A Systematic Review and...

Purpose: To assess the diagnostic criteria for restrictive lingual frenum and the association with feeding difficulties in mother-infant dyads. Methods: The protocol was registered with PROSPERO (CRD42024482618). Ovid MEDLINE, CINAHL, Embase, and Cochrane Library databases were searched from 1946 to May 2025 for studies meeting inclusion criteria. The population included mother-infant dyads with or without feeding difficulties, where infants had a restrictive frenum. Outcomes measured included diagnostic accuracy of tools assessing ankyloglossia and the association of ankyloglossia with feeding difficulties. Fourteen reviewers screened studies, performed data extraction, and assessed risk of bias using risk of bias and Office of Health Assessment and Translation tools. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach determined the quality of evidence. Results: Fourteen out of 20 included studies qualified for analysis, examining 5 ankyloglossia-specific diagnostic tools. For diagnosing ankyloglossia, the Bristol Tongue Assessment Tool/Tongue-tie and Breastfed Babies Assessment Tool (BTAT/TABBY) demonstrated high discriminative accuracy (AUC ROC=0.95, >2000 clinical cases), acceptable internal consistency (α=0.708) and strong correlation with the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF, r=0.89). Ten of the included studies examining feeding difficulties showed a trend favoring association with restrictive lingual frenum. Infants with ankyloglossia had a higher odds of maternally reported feeding difficulties (pooled OR= 5.57, 95% CI 0.44-70.02), though the effect did not reach statistical significance (P=0.18) and heterogeneity was substantial (I 2=96%). Conclusion: Very-low certainty evidence supports the use of standardized anatomical and functional (tongue mobility) assessments for restrictive lingual frenum. A consistent direction of association between restrictive lingual frenum and feeding difficulties was observed across studies, though pooled estimates did not reach statistical significance.