Frenotomy: The Not So Evidenced-based Practice of Cutting a Baby’s Tongue

Ankyloglossia, also known as tongue tie, is when the band of tissue that attaches the bottom of the tongue’s tip to the floor of the mouth is short or thick. Tongue ties can restrict the tongue’s range of motion and can interfere with feeding, particularly breastfeeding.

Given that breast milk is recommended as the best nutrition for babies, many moms who have a difficult time breastfeeding may wonder if their newborn has a tongue-tie. This is a valid concern as up to 10% of newborns have a tongue-tie. However, there is little evidence that tongue-tie revision, or frenotomy, directly improves breastfeeding. This also brings into question why there was an 866% increase in reported frenotomies from 1997 to 2012. 

How Are Tongue Ties Diagnosed?

If the tongue tie is significant, your pediatric provider will likely be able to make the diagnosis after your newborn’s physical exam. However, some tongue-ties are more subtle and may not be discovered until a mom experiences problems with breastfeeding, such as nipple pain. These babies may then be referred to a lactation consultant who makes the diagnosis. 

How Are Tongue Ties Treated?

If your baby’s provider makes a diagnosis of ankyloglossia, they will often refer them to a pediatric ear, nose, and throat (ENT) specialist or a pediatric dentist. The ENT or dentist will then perform a frenotomy in which they remove the connective tissue with medical scissors or a laser. Although frenotomies are a quick procedure, the cost is often high. One study reported that the cost of a frenotomy without general anesthesia was $850.  Furthermore, this cost is often not covered by insurance when the frenotomy is performed by a dentist. 

Are There Any Adverse Events Associated With Frenotomies?

In 2022, The International Breastfeeding Journal surveyed physicians and dentists who had infant patients undergo a frenotomy. Of the 211 providers, 37% reported caring for an infant with a complication after having a frenotomy. The most significant complications included needing to have a repeat frenotomy, oral aversion, and scarring at the frenotomy site. 

Can Tongue-Ties Be Misdiagnosed?

According to the same survey mentioned above, 47% of physicians and dentists reported having a patient who was misdiagnosed with a tongue-tie. A few of the misdiagnoses included neuromuscular dysfunction, inadequate breastfeeding support, and abnormal orofacial anatomy. 

Does a Frenotomy Improve Breastfeeding?

Often, the main goal of a frenotomy is to improve breastfeeding; however, few studies have demonstrated a positive association between frenotomies and improved breastfeeding. A 2017 review found that a frenotomy reduced breastfeeding mothers’ nipple pain in the short term, but the review did not find a consistent positive effect on infant breastfeeding.  

According to a prospective study from 2020, a frenotomy only modestly improved an infant’s breastfeeding ability according to the mother. This raises questions about frenotomies’ effectiveness in solving breastfeeding problems.  

The few studies that have found frenotomy to be beneficial in improving an infant’s breastfeeding ability have had small sample sizes. A cohort study from Ireland found that 91% of its participants reported an overall improvement in breastfeeding post-frenotomy. This study also found a significant reduction in pain in breastfeeding. Although this study did demonstrate the benefits of a frenotomy in the short-term, it reported that at a 1-month follow-up, formula feeding increased two-fold. A few primary reasons for stopping breastfeeding included the infant’s inability to latch correctly, nipple pain, and no improvement post-frenotomy. 

Can Tongue-Ties Be Treated Without a Frenotomy?

A study from 2019 found that after a comprehensive feeding evaluation, more than half of infant babies referred for a frenotomy, ended up not needing one. In this study, infants and their mothers were first evaluated by a speech and language pathologist to determine the primary cause of feeding difficulty. Once this cause was identified, interventions were offered in an attempt to avoid a frenotomy. After this evaluation, 62.6% of infants did not undergo frenotomy. 

This study demonstrates that if an infant does have a tongue-tie, there may be alternate interventions to improve their breastfeeding ability. 

Can Tongue Ties Lead to Problems As A Child Ages?

If a baby has a tongue-tie and does not undergo a frenotomy, parents may wonder if the tongue-tie will affect their child later in life. One of the biggest concerns parents have is regarding speech delays or speech impediments. However, there is little evidence showing that a frenotomy during infancy improves speech outcomes later in life. A study from 2020 found no significant differences in speech production or intelligibility among children treated for a tongue tie in infancy versus those not treated for a tongue tie or for those who did not have a tongue tie. 

Takeaway

Although tongue-ties have been reported to interfere with an infant’s breastfeeding ability, there is limited evidence demonstrating that cutting tongue-ties leads to better breastfeeding outcomes. Going forward, if an infant is found to have a tongue-tie, it should be evaluated by a multidisciplinary team before the decision to proceed with a frenotomy is made.