Pre-conceptional folic acid supplementation: A possible cause for the increasing rates of ankyloglossia

Background: There is an increasing awareness to ankyloglossia (tongue-tie) in infants, with marked increase in its report in the medical literature. Some reports indicate increase in prevalence. Whether the increase ankyloglossia rate is a real phenomenon or merely reflects increased awareness and reports has to be determined. One explanation for the increasing ankyloglossia rates is the growing trend of breast feeding initiation, often impaired by ankyloglossia, which brings it to medical attention. We propose an alternative hypothetical explanation based on increasing utilization of periconceptional folic acid supplementation for the prevention of neural tube defects (NTDs). Inadequate folic acid supply during organogenesis impairs cell division, and the mid-line structures are at the highest risk. We postulated that higher folic acid supply during organogenesis might enhance tissue synthesis with tighter closure of mid-line structures including the lingual frenulum, resulting in ankyloglossia. Methods: To assess this hypothesis, we undertook an observational case control study comparing folic acid utilization before pregnancy in mothers of infants with and without ankyloglossia. Infants with ankyloglossia (n = 85) were compared to a control group without ankyloglossia (n = 140). Results: There was a slight, insignificant elevated frequency of reported utilization of folic acid (“any intake”) among mothers of infants with ankyloglossia compared with controls (74.1% and 66.4%, respectively). This difference was slightly higher, yet insignificant when folic acid intake “in most days” was considered (65.9% and 53.6%, respectively, OR = 1.67, 95%CI = 0.93–3.05, P = 0.07). In contrast, the reported intake of pre-conceptional folic acid “on a regular basis” was significantly higher among mothers of infants with ankyloglossia compared with controls (54.1% and 25.7%, respectively, OR = 3.41, 95%CI = 1.85–6.27, p < 0.0001). Interpretation: The reported association between higher frequency of regular pre-conceptional folic acid intake and ankyloglossia, supports the hypothesis for this association. More studies are required to test this hypothesis.