frenotomies (4%) had to be repeated be- cause the initial procedure did not divide sufficient frenulum. Out of 99 frenotomies,. 64% of the mothers noticed a small ...
What We Know and Don’t Know about Tongue-tie by Judy Slome Cohain Abstract: About 5 to 10% of newborns are born with tongue-tie. The majority of newborns with tongue-tie have no problem breastfeeding or bottle-feeding and their mothers do not suffer nipple pain. This includes some babies born with a frenulum completely attached to the tip of the tongue. The majority of nipple pain from breastfeeding resolves by itself within two weeks. Among women with unresolved nipple pain from breastfeeding, nipple pain was decreased significantly if the baby either had a frenotomy or a sham frenotomy in which the baby was taken into a room for five minutes as if she were going to have a frenotomy. In four of the five studies, actual frenotomy improved nipple pain slightly more than the sham procedure, but in one study both real and sham had the same effect. Frenotomy
should be painless for the baby, cause at most two drops of blood loss, and the baby should not cry more than 10 seconds. The only thing hard about snipping the frenulum is holding the mouth open during the one-second-long procedure. About 4% of tongue-ties may grow back together and need repeat frenotomy.
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ongue-tie, or ankyloglossia, is a normal variation in which the tongue is tied to the floor of the mouth by the frenulum—such that it is impossible to protrude the tip of the tongue over the lower gums or teeth. Sometimes this condition makes the tongue look slightly “heart-shaped” when it is lifted up. Some degree of tongue-tie has been reported to occur in between 5 to 10% of newborn infants, consistently appearing about twice as often in males as in females.
Photograph | Jennifer Hamilton—jhmamarazziphotography.com
Babies and adults with tongue-tie have a limited ability to stick out their tongue but do not necessarily have feeding problems. Nipple pain in the presence of tongue-tie appears in about 1% of births (Buryk, Bloom, and Shope 2011). About 70% of mothers of newborns with tongue-tie experience no breastfeeding issues, while the others experience sore nipples and/or poor infant weight gain. Before the 1950s tongue-ties were routinely cut in the UK. Then, textbooks and British pediatricians began to suggest referring to a lactation consultant or advise abandoning breastfeeding in favor of artificial feeding. However, the more recent trend to encourage breastfeeding recommended cutting tongue-ties to improve breastfeeding rates. Breastfeeding is a marriage between baby and mother. The size and shape of
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nipples, skin type, personalities, sleep needs, patience, and hunger of both mother and baby combine to make a unique mating called breastfeeding. Nipple pain and sleepy newborns are common complaints regarding early breastfeeding. Bottle-feeding mothers also complain of issues with sleepy, dribbling, gassy, or slow-eating babies and sometimes they attribute those problems to tongue-tie. Whether the frenulum is cut or left intact, feeding always improves as a mother and newborn gain experience and the newborn grows bigger. All children outgrow breastfeeding problems. “Regardless of the treatment used, for most women nipple pain [is] reduced to mild levels after approximately seven to ten days’ postpartum” (Dennis, Jackson, and Watson 2014). No Adverse Effect of Cutting the Frenulum
Because tongue-tie is not a problem in the majority of cases and because nipple pain is significantly reduced in most cases after 10 days without frenotomy, some believe that the frenulum rarely needs to be cut. Others recommend that all babies with a suspicion of tongue-tie have their frenulum cut. It has been conclusively established that cutting the frenulum causes no significant adverse effects when done by a competent practitioner. All of the research studies show that the procedure takes less than five minutes and causes no significant bleeding or crying. A mother can even cut her own baby’s frenulum with a blunt-end scissor. Some tongue-ties that are not cut are later torn by the child’s lower teeth or by a spoon or toy in the mouth. Parents are advised to be cautious about consulting private doctors who insist that every baby needs a frenotomy or who cut in a way that the baby is in pain after the procedure. Such doctors also tend to routinely recommend a repeat procedure, even though it is usually not needed. In most cases, if done correctly, frenotomy is a simple, minimally invasive procedure. When to Do a Frenotomy
Frenotomy done “too early” risks criticism that the baby may still feed well without it, whereas frenotomy done ‘‘too late’’ may cause more mothers to stop breastfeeding. An optimum time to do a frenotomy has
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not been identified. In published studies, the procedure was performed at different times—between six days and four months. Which Babies Should Get a Frenotomy?
The answer to this question is not clear. While the procedure has been established as safe and, when done correctly, is not traumatic, its effectiveness and the criteria for which babies should get it has not. Studies to date have not conclusively answered the clinically relevant question of whether frenotomy in tongue-tied infants results in longer-term breastfeeding success or whether it is responsible for resolution of maternal pain. The total number of infants randomized to have frenotomy in partially blinded studies so far is a total of 150 babies. In all five of those studies, the researchers had the preconceived belief that frenotomy reduces nipple pain. While frenotomy decreased but did not eliminate nipple pain for most women, sham frenotomy, i.e., pretending to do a frenotomy but actually doing nothing, also decreased nipple pain for most women. The question as to when and for whom frenotomy should be done in the presence of moderate tongue-tie has still not been answered. Don’t Evaluate Tongue-tie; Evaluate Feeding Problems
The presence and degree of tongue-tie is not predictive of feeding problems. In fact, most tongue-tied babies will have no feeding problems. Therefore, it is logical, instead, to evaluate feeding problems such as nipple pain and lack of weight gain rather than the degree of tongue-tie. Nevertheless, an assessment tool, the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), was published in 2006 to try to improve on the previous assessment tool—which did not predict breastfeeding problems. Neither of these tools has been shown to be useful. The baby can get 10 possible points for appearance and 14 possible points for function. The makers of the scoring system recommend frenotomy for a function score below 11 with failing lactation or an appearance score lower than 8. Parents should not depend on the results of this scoring system until it is established to be reliably predictive of improved outcomes.
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What Does Research Teach about Frenotomy for Nipple Pain and Feeding Problems?
On the subject of tongue tie, Cochrane Systematic Review found five randomized, controlled trials on the subject, but all are problematic (O’Shea et al. 2017). “They included small sample sizes, and only two studies blinded both mothers and assessors; one did not attempt blinding for mothers or for assessors. All studies offered frenotomy to controls, and most controls underwent the procedure, suggesting lack of equipoise (genuine uncertainty in the expert medical community over whether a treatment will be beneficial). No study was able to report whether frenotomy led to long-term successful breastfeeding.” The basic tenet of a randomized trial is that the investigator does not know which arm of the trial is the best treatment for the patient and they can therefore invite patients to enter the trial by saying that “the best treatment is unknown.” Unfortunately, in these five trials, the authors held preconceived beliefs that cutting tongue-ties would relieve nipple pain and improve feeding. The five studies were published between 2005 and 2014 and are summarized below. 1. Hogan, Westcott, and Griffiths 2005 (UK): In 2002, the authors undertook the
first randomized, controlled trial of tonguetie division in breast- and bottle-feeding babies with feeding problems. These babies were randomized to either intensive support, advice, and help from the lactation consultant for 48 hours (N=29) or immediate division of the tongue-tie (N=28). Either a frenotomy or sham frenotomy was done and mother given the baby, which she fed immediately with either breast or bottle (without knowing which had been done). Many mothers with tongue-tied babies refused to be in the study, because they wanted immediate frenotomy, rather than to be randomized to one group or the other—which indicates practitioner bias towards frenotomy. In the study group, 20 breastfed and eight bottle-fed babies were randomized to frenotomy. The mean age at frenotomy was three weeks old. In the end, 56 babies underwent frenotomy, which improved feeding for 54 of them. Help from a lactation consultant only improved one of the 29 babies in the control group and the other 28 women in the non-
frenotomy (control) group asked to have a frenotomy done immediately upon finding out they found out they were in the control group. The improvement in breast- or bottle-feeding after frenotomy was usually immediate (80%). However, if the nipple was sore or cracked, then improvement among breastfeeding women sometimes took 48 hours (20%). One baby took seven days after frenotomy to breastfeed normally. It is unknown if this was related to frenotomy. There was no relationship between tongue-tie length (severity) and feeding difficulty. The incidence of tongueties of all degrees observed among 1866 live births was 10.7%. Among the babies with tongue-tie, 66% had no feeding problems, while 44% had a problem with breastfeeding or artificial feeding. It was impossible to predict just by looking at the tongue-tie which ones would cause problems, even in babies with the frenulum connected to the end of the tongue. The issue was not the length of tongue-tie, but the symptoms it was allegedly causing. For those with feeding problems in this study, frenotomy improved feeding for 96% of mothers and babies, which was significantly better than the intensive, skilled, professional support of the lactation consultant. 2. Dollberg et al. 2006 (Israel) studied 25 women who presented with a complaint of nipple pain and tongue-tie. Fourteen were randomized to have a frenotomy and then to nurse once. The other 11 were randomized to have a sham frenotomy, then nurse. The women scored their pain only on the first nurse, which is not easy to judge, particularly in women with sore nipples. One nice thing about this study is that they documented that: “cutting tongue-tie followed by applying mild pressure for several seconds to several minutes, leads to either no bleeding or at most one or two drops of blood easily absorbed by a bit of gauze…. Infant crying lasted a few seconds only … the infant usually cried for less than 10 seconds during the procedure ... and the procedure, including going in and out of the room, takes 5 minutes.” Parents should expect and know that if there is a lot of bleeding or pain, the practitioner has not done it right. The title of the article “Immediate nipple pain relief after frenotomy,” reveals a bias since not all women had relief or immediate relief
after frenotomy. “[T]he authors claim that overall pain score of the 25 participants improved immediately more after frenotomy than after sham, although it also improved significantly after sham procedure. After frenotomy, the average pain score decreased from 7 out of 10 (+/- 2) to 5 out of 10 (+/2).” The authors neglected to report the change in pain scores after sham procedure. 3. Buryk, Bloom, and Shope 2011 (USA) studied 30 infants who underwent
and the L.A.T.C.H. scales to assess the breastfeeding (Latch, Audible swallowing, nipple Type, Comfort, Hold to assess breastfeeding). There were 52 in the frenotomy group and 43 in the control group. In this study, frenotomy did not lead to any improvement in breastfeeding difficulties over sham procedure in mild to moderate tongue-tie. Complications: Four out of 99 frenotomies (4%) had to be repeated because the initial procedure did not divide sufficient frenulum. Out of 99 frenotomies, 64% of the mothers noticed a small white patch at the base of the frenulum, which took an average of seven days (range 1–30 days) to heal.
frenotomy and 28 who underwent a sham procedure on average six days after birth. Nipple pain was assessed immediately after and at a two-week follow-up. The sham procedure reduced nipple pain significantly, but not quite as much as the actual procedure. All but 1 of the 28 in the sham Summary group then elected to have a frenotomy To date, no study reported whether freperformed at two weeks, reflecting a bias notomy led to longer breastfeeding versus toward frenotomy. changing over to bottle-feeding. We don’t 4. Berry, Griffiths, and Westcott 2012 know how long to wait before doing a fre(UK): Twenty-seven infants underwent a notomy when a woman presents with nipple frenotomy and 30 infants had a sham fre- pain because nipple pain most often resolves notomy between the ages of six days and without any treatment within 10 days. four months—on average at one month old. In the group that underwent a sham References: J, M Griffiths, and C Westcott. 2012. “A doublefrenotomy, 14 of the 30 mothers felt that Berry,blind, randomized, controlled trial of tongue-tie breastfeeding was easier after the sham division and its immediate effect on breastfeeding.” Breastfeed Med 7(3): 189–93. placebo procedure, whereas in the group Buryk, M, D Bloom, and T Shope. 2011. “Efficacy of neothat had frenotomy, 21 of the 27 mothers natal release of ankyloglossia.” Pediatrics 128(2): 280–88. said they felt breastfeeding was easier after CL, K Jackson, and J Watson. 2014. “Interventhe intervention. Three of the 27 mothers Dennis, tions for treating painful nipples among breastfeeding women.” Cochrane Database Syst Rev 12: reported a small amount of bleeding near CD007366. the cut at home following the frenotomy. Dollberg, S, et al. 2006. “Immediate nipple pain relief af5. Emond et al. 2014 (UK) tried to evalter frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study.” J Pediatr Surg uate whether frenotomy is effective for mild 41(9): 1598–1600. and moderate tongue-tie (HATLFF score Emond, A, et al. 2014. “Randomised controlled trial of early frenotomy in breastfed infants with mild6–12). Only full-term babies less than two moderate tongue-tie.” Arch Dis Child Fetal Neonatal weeks old were included. Babies (HATLFF Ed 99(3): F189–95. Free full text: http://fn.bmj.com/ content/99/3/F189. score
