Diagnostic assessment of ankyloglossia and association with infant feeding challenges: A systematic review and meta-analysis-part 1

Authors

• Vineet Dhar, Clinical Professor and Chair, Department of Orthodontics and Pediatric Dentistry, University of Maryland, School of Dentistry, Baltimore, MD, USA.
• Abdullah A. Marghalani, Associate Professor, Department of Preventive Dentistry, College of Dental Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.
• Homa Amini, Clinical Professor, Division of Pediatric Dentistry, College of Dentistry, The Ohio State University and Department of Dentistry, Nationwide Children's Hospital, Columbus, Ohio, USA.
• Tegwyn Brickhouse, Professor, Department of Pediatric Dentistry, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA.
• Erica Caffrey, Clinical Assistant Professor, Department of Orthodontics and Pediatric Dentistry, University of Maryland, School of Dentistry, Baltimore, MD, USA.
• Jayakumar Jayaraman, Pediatric Dentist in Private Practice, Richmond, VA, USA.
• Martha Ann Keels, Adjunct Associate Professor, Department of Pediatrics, Duke University, Durham, NC and an Adjunct Professor, Department of Pediatric, University of North Carolina, Chapel Hill, NC, USA.
• Anna Messner, Professor, Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA.
• Kimberly K. Patterson, Clinical Associate Professor, and interim chair, Department of Orthodontics and Pediatric Dentistry, Stony Brook School of Dental Medicine, Stony Brook, NY, USA.
• Nikhila Raol, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA.
• Poojan Shrestha, Associate Professor, Department of Pediatric Dentistry and Dental Public Health, Adams School of Dentistry and an Adjunct Associate Professor, Department of Epidemiology Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
• Christopher M. Stark, Neonatologist, Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.
• Harlyn K. Susarla, Pediatric Dentist, Department of Dentistry, Seattle Children???s Hospital and a Affiliate Assistant Professor, University of Washington School of Dentistry, Seattle, WA, USA.
• Jennifer Thomas, Advocate Health - MidwestFollow

Recommended Citation

Dhar V, Marghalani AA, Amini H, et al. Diagnostic Assessment of Ankyloglossia and Association With Infant Feeding Challenges: A Systematic Review and Meta-Analysis-Part 1. Pediatr Dent. 2026;48(2):82-68E.

Abstract

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.

Document Type

Article

PubMed ID

42050817