Frenotomy and Breastfeeding

Nancy Danoff, MD, MPH, FAAP
Monica Richter, MD, PhD, FAAP
WCAAP Key Contacts: Breastfeeding

A common finding estimated to affect 4-11% of newborns, tongue-tie or ankylossia can significantly impact the newborn’s ability to breastfeed. It is defined as an unusually short, thick or tight band of tissue that tethers the bottom of the tongue’s tip to the floor of the mouth. An anterior tongue-tie causes a heart-shaped indentation and can limit forward tongue mobility while a posterior tie limits upward motion, thereby inhibiting effective milk transfer and producing significant maternal nipple pain. In addition to interfering with efficient latch in breastfeeding, tongue-tie may affect the way a child eats, speaks and swallows. Over the past 10 years, frenotomy has been increasingly performed to allow for freer tongue movement, allowing for improved breastfeeding effectiveness and decreased nipple pain.  There are currently no studies comparing the use of lasers versus scissors for lingual frenotomy.

At this time, studies have shown mixed results on the effectiveness of frenotomy. A 2017 Cochrane review based on five small studies from 2005 to 2013, Frenotomy for tongue-tie in newborn infants by O’Shea et al, found that frenotomy reduced breastfeeding mothers’ nipple pain in the short run, but did not find a consistent positive effect on infant breastfeeding success. Ghareri et al in Breastfeeding Improvement following tongue-tie and lip-tie release: A Prospective Cohort Study (2017) found significant improvement in average breast milk intake post procedure at 1 week and 1 month and improved breastfeeding self efficacy scores. In a second study, Revision Lingual Frenotomy Improves Patient reported breastfeeding outcomes: A Prospective Study (2018) Ghareri et al noted that no conclusions about the efficacy of tongue tie release could be done if the first tongue tie release was poorly performed. Using both the BTAT (Bristol Tongue assessment tool) along with a comprehensive feeding assessment before referral for frenotomy, Dixon et al in A multifaceted  programme to reduce the rate of tongue-tie release surgery in newborn infants: Observational study used a systematic approach in New Zealand that reduced the frenotomy rate from 11.3% to 3.5% without impacting breastfeeding.  Described by Ingram et al in The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY) (2019) the TABBY assessment tool provides the similar information as the BRAT for patients with tongue tie in pictorial form.

So far, the research in this area suggests that focusing solely on tongue tie as a cause for ineffective breastfeeding is too simplistic. A comprehensive feeding assessment and interventions are vital to breastfeeding success. The first few hours of life offer the perfect opportunity to help the mother-baby dyad establish a good pattern of breastfeeding and thereby also reduce frenotomy rates. The Baby Friendly Hospital Initiative recommends that mothers initiate breastfeeding within one hour of birth. It also requires breastfeeding training to all health care staff involved in the care of the mother and baby.  As pediatricians we can also help mothers achieve their breastfeeding goals. Three good resources for providers and parents are:

  1. The BreastFeeding Series of the Global Health Media Project 
  2. Jane Morton’s videos including A Perfect Latch and Breastfeeding in the First Hour, It’s in Your Hands, and
  3. Jack Newman’s International Breastfeeding Center

With additional education and support we can help parents whose babies have been diagnosed with tongue-tie by focusing on the task of establishing successful breastfeeding. Referring only those patients whose tongue ties are truly interfering with their ability to breastfeed effectively and gain weight is best practice for now. A statement on this topic is forthcoming from the AAP’s Section on Breastfeeding section possibly in 2020. The Academy of Breastfeeding Medicine is also working on a policy statement.