Study questions if tongue-tie surgery for breastfeeding is always needed

"We have seen the number of tongue-tie and upper lip tether release surgeries increase dramatically nationwide without any real strong data to show these are effective for breastfeeding," says Christopher J. Hartnick, MD, MS, Director of the Division of Pediatric Otolaryngology and the Pediatric Airway, Voice and Swallowing Center at Massachusetts Eye and Ear. "We don't have a crystal ball that can tell us which infants might benefit most from the tongue-tie or upper lip release, but this preliminary study provides concrete evidence that this pathway of a multidisciplinary feeding evaluation is helping prevent babies from getting this procedure."

Tongue-tie, or ankyloglossia, is a condition an infant is born with wherein a piece of tissue, called the lingual frenulum, connects too tightly from the tongue to the floor of the mouth. Infants can also experience upper lip ties when a different tissue, the frenulum of the upper lip, is connected to the gum. In some cases, this restriction in movement can result in difficulty with breastfeeding or in rarer cases, may affect dental health or speech later in childhood.

Breastfeeding is recommended by numerous health organizations worldwide as a preferred method of infant feeding for the newborn's growth and development. When there are difficulties breastfeeding, including the baby not latching on, or gaining weight, or when the mother is in pain, many new parents seek a consultation, which may result in surgery to clip the tongue tie, sometimes called a frenotomy, frenectomy, or frenulectomy.

Despite a lack of medical literature linking the surgery to improved breastfeeding, the number of these procedures has been rapidly rising in recent years, the authors point out, noting that the Kids' Inpatient Database in the United States estimated a 10-fold increase in tongue-tie surgeries from 1,279 in 1997 to 12,406 in 2012.

Prompted by these rising rates and an influx of parents seeking second opinions, Dr. Hartnick and colleagues formed a multidisciplinary feeding evaluation program at the Pediatric Airway, Voice, and Swallowing Center at Mass. Eye and Ear, consisting of clinicians from different medical specialties such as pediatric otolaryngology, pulmonology, gastroenterology, and speech language pathology, including staff from Massachusetts General Hospital.

The researchers examined 115 newborns who were referred to the clinic for tongue tie surgery with a pediatric ENT. There, each mother-newborn pair met with a pediatric speech-language pathologist, who performed a comprehensive feeding evaluation including clinical history, oral exam and observation of breastfeeding. They then offered real-time feedback and strategies to address the hypothesized cause of their breastfeeding challenges.

Following the multidisciplinary feeding evaluation, 62.6 percent of the newborns did not undergo the surgeries. Although all of the referrals were for tongue tie surgery specifically, 10 (8.7 percent) underwent a lip tie surgery alone and 32 (27.8 percent) underwent both lip and tongue tie surgery.

Future multicenter trials are planned, and the researchers also plan follow-up outcomes studies comparing infants who did and did not undergo tongue-tie surgery longer term.

They study's authors call for best practice guidelines to be developed to help with this decision-making throughout the medical community.

"We've learned that an interdisciplinary collaboration is key to a thorough feeding evaluation " says study co-author Cheryl Hersh, MS, CCC-SLP, a pediatric speech-language pathologist at MassGeneral Hospital for Children, who sees patients at the Mass. Eye and Ear Pediatric Airway, Voice, and Swallowing Center. "This is still a work in progress, but we have learned a great deal about what we can do differently to help our patients and their families. In doing so, we have been able to identify many babies who are having breastfeeding problems that are not related to their lip and tongue anatomy.

Tongue-tie and upper lip tether release surgery are relatively safe outpatient procedures performed with local anesthetic, with risks being similar to any surgical procedure, including pain and infection. Parents have also reported experiencing psychological pain, or guilt from the feeding difficulties and resulting surgery. There can be significant out of pocket costs for the procedure given there is much variation related to providers performing a frenotomy, with dental professionals, pediatric otolaryngologists, and neonatologists providing this service with often unpredictable cost and coverage by medical insurance.