# Development and Pilot Use of the TOMARA Questionnaire for Midwifery-Led Assessment of Ankyloglossia in Newborns

## TL;DR

A new Greek-language questionnaire called TOMARA was developed to assess tongue-tie in newborns, showing that frenotomy improved breastfeeding outcomes for mothers and infants.

## Contribution

The TOMARA questionnaire was developed and validated for midwifery-led assessment of ankyloglossia in newborns.

## Key findings

- Poor latch and prolonged feeding duration were the most common breastfeeding difficulties observed.
- Persistent maternal pain and cracked nipples were frequently reported by mothers of infants with ankyloglossia.
- Frenotomy significantly improved breastfeeding outcomes, with 86.4% of mothers continuing to breastfeed for more than six months.

## Abstract

Background

Ankyloglossia, commonly known as tongue-tie, is diagnosed in neonates when a restrictive lingual frenulum limits tongue mobility and impairs function. This study presents initial data from the newly developed Greek-language questionnaire (Tongue Observation and Mobility Assessment for Oral Restrictions due to Ankyloglossia (TOMARA)), used in conjunction with the Assessment Tool for Lingual Frenulum Function (ATLFF). The objective was to document clinical examination findings of the infant oral cavity and the breastfeeding challenges experienced by each mother-infant dyad under midwifery-led management.

Methodology

The psychometric properties of the TOMARA questionnaire were evaluated by assessing internal consistency, construct validity, and predictive validity. Of the 347 neonates examined, 51 showed clinical indications of ankyloglossia; the diagnosis was confirmed in 48 cases, and 44 subsequently underwent frenotomy. The breastfeeding difficulties of the dyad were recorded before and after the intervention.

Results

The most frequently observed breastfeeding difficulties included poor latch (82.4%) and prolonged feeding duration (82.4%). Mothers frequently reported persistent pain during breastfeeding (84.3%), along with irritated (94.1%) and/or cracked nipples (39.2%). Functional limitations of the lingual frenulum were significantly associated with both maternal (p = 0.041) and neonatal symptoms (p = 0.004). In treated cases, most symptoms significantly improved or resolved. This was reflected in breastfeeding duration, with 86.4% of mothers continuing to breastfeed for more than six months, in alignment with World Health Organization recommendations.

Conclusions

Despite the relatively small size of our study, the findings suggest that effective management of ankyloglossia relies on the careful selection and thorough evaluation of tongue-tied infants. The functional performance of the lingual frenulum is associated with fewer breastfeeding difficulties for both mother and infant.