Will A Baby Benefit From A Frenectomy?
The Grades May Surprise You!
Making a decision on intervention for feeding difficulties in infants is difficult. The initial point of support should be a lactation consultant to help support the process. Below you will find the brief synopsis of research on frenectomy I am aware of. The term frenotomy is also found in the research and the name difference is on the extent of the tissue removed. A frenectomy, therefore, is more likely to involve the removal of more posterior tissue. This is often done with a laser in babies. I will be using the term frenectomy to refer to both procedures. If the research reaches a point where differentiation is warranted I will be more exact.
I have made every attempt to be as complete and inclusive of the research. Preference has been given to randomized controlled trials and systematic reviews when there are conflicting outcomes. If you feel I am missing any studies of value in this informative report for families please contact me by email at Bryan Nichols.
Grades are based on assigning confidence to recommendations
- A: Strong positive effect
- B: Moderate positive effect
- C: Weak effect
- D: Conflicting effect
- E: Theoretical effect
- F: Based on expert opinion
For families who have made a decision on any specific support I fully believe you are doing what you feel is best for your child with the information you have available. With my heart, I know many decisions, even ones providers minimize, can be hard to sit with. I believe your child will be better in the long run as you put the thought and care into raising them. For that I thank you.
Identifying Baby Who Is Unlikely To Benefit From Frenectomy – A
The diagnosis comes in many ways. The bristol tongue assessment tool (BTAT) however is the only measure that has been used to compare overall breastfeeding outcomes when used in a cohort vs not. Utilization of the BTAT reduced frenectomy rates by 69% from 11.3% of the population to 3.5%(16). The same study found no difference in breastfeeding outcomes in up to the 6 month time period. The BTAT compared to the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) has a strong correlation (0.89) indicating the simpler BTAT could be used in place of the more detailed assessment (17).
How Laser & Scissor Frenectomy Compare – A
Comparing laser vs scissor frenectomy there is a small, non-meaningful difference between laser and scissor frenectomy. In a review of available literature nipple pain was reduced by 2.7 by laser, 3.6 by scissor, and 1.85 for sham or fake treatment (2). Furthermore, the study found that for breastfeeding conventional, laser, and Z-plasty were all similar in outcomes. Another study comparing conventional vs z-plasty was found to have similar outcomes on tongue mobility (22). These studies suggest that the type of frenectomy may not matter when it comes to tongue mobility and maternal pain improvements.
Infant Reflux After Frenectomy – C
Studies considering infant reflux as a primary outcome have not found a benefit by improvement on the Infant Gastroesophageal Reflux Questionnaire (I-GERQ). Reported reflux improvement with the I-GERQ is found at an average change of -5.7 points on the scale 13. The brief study which was a cohort analysis found an average of -4.314. Another cohort study found a change of -3.3 after 1 week (10.) A 3rd cohort study also found a -3.8 point change (15). There is limited evidence for a nonimportant change with no study reaching the average change that is associated with improvement.
Maternal Pain After Frenectomy – C
Maternal pain is the only area of consistent reduction after frenectomy. This is found in numerous studies (1-6.) The reduction in pain however when compared to no procedure is a 1.2-point reduction on a 0-10 scale. A minimal detectable change is not established for breast pain however other studies support a reduction of 1.5-2 points as an important number (7,8.) Furthermore, when comparing breastfeeding pain and sore nipples of mothers of babies with and without tongue tie there was no difference in pain scores.
Directed Exercise & Manual Therapy To Reduce Frenotomy Rates – C
A 2019 study used a treatment paradigm that found a 62.6% decrease in frenotomy rates due to goals being met with conservative interventions(25). The remaining infants were provided the procedure due to not meeting their feeding goals. The study did not look at the efficacy of the frenotomy but rather what babies could benefit from a nonsurgical approach. This suggests that even those diagnosed with a tongue tie may not need the procedure.
Infant Breastfeeding Ability After Frenectomy – D
Breastfeeding ability is measured in a number of ways. The LATCH score, breastfeeding self-efficacy scale (BSES-SF), and infant fatigue with breastfeeding. For the LATCH and BSES-SF, there is a lack of evidence to support an overall positive effect with meta-analysis and randomized controlled trials finding non-significant change to no change (9-11.) For infant fatigue, one study found in the first-month babies with tongue tie was more likely to have issues with latch (27.9% to 16.6%), infant exhaustion (14.4% to 6%), and lengthy breastfeeding sessions (14.4% to 4%) (12.)
Long-Term Breastfeeding After Frenectomy – D
Many studies lose 30% or more of babies to follow-up (1,18,19,20.21.) Those families that do report longer-term breastfeeding outcomes find at 3 months breastfeeding still occurred in 20% (18) and 65% (1). At 6 months exclusively breastfed babies were found to occur at 33.46% (21).
Post-Care Exercises After Frenectomy – F
Of the randomized controlled trials the intervention mentioned is simply frenectomy. There is no mention of post-care exercises. Many providers demonstrate post-care exercises however with the goal of limiting the potential for re-adherence. At this time I am unaware of any studies supporting the benefit of post-frenectomy exercises in children under 2.
I have spent a lot of time learning about how to best support babies physically. The prevalence of a procedure should be in line with the benefit. As highlighted above there is a paucity of high-quality evidence to support frenectomy in all cases except a minimal reduction in breastfeeding pain. The strongest evidence is in the ability to rule out babies who should get a frenectomy(16,17). The truth is we do not have statistics available in the US. If you use the research done in New Zealand it is likely upwards of 75% of procedures being done in the US are not warranted.
For any surgical procedure or body modification the presentation of the baby should be the driving factor, not the provider they go to. The latter however tends to be the truth. When research on anything is, in the same breath, called experimental and usual care, as is done in many of the wait-and-see studies, there should be time for pause. Thank you for taking this pause with me.
BONUS: What About Manual Therapy & Bodywork For Breastfeeding Or Instead of Frenotomy?- C
When it comes to breastfeeding bodywork has been found to have a positive benefit but the evidence is from two case series. The musculoskeletal assessment found altered muscle tone in 72% of babies presenting with breastfeeding issues (23.) The most common hyperactive muscles were the occipital (40%), internal pterygoids (40%), and submandibular muscles (60%). The temporalis and masseter muscles also displayed increased tone. Vertebral motion assessed with craniosacral techniques found the occiput to be the most limited in 92% of infants. Treatment with craniosacral therapy, myofascial release, and massage to reduce hypertonic muscle activity were provided along with low-force specific treatment to the cervical spine and condyles. 80% of infants experienced an improvement in their ability to breastfeed within 1-12 treatments(23).
In another study that looked at the treatment of 114 infant cases with breastfeeding difficulties physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). 78% were exclusively breastfed after 2-5 visits over a 2-week time period(24).
- Berry, J. M., Griffiths, M., & Westcott, C. (2012). A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. Breastfeeding Medicine, 7(3), 189–193. https://doi.org/10.1089/bfm.2011.0030
- Khan, U. A., MacPherson, J., Bezuhly, M., & Hong, P. (2020). Comparison of frenotomy Techniques for the Treatment of Ankyloglossia in Children: A Systematic Review. Otolaryngology-Head and Neck Surgery, 163(3), 428–443. https://doi.org/10.1177/0194599820917619
- O’Shea, J. E., Foster, J. P., O’Donnell, C. P., Breathnach, D. B., Jacobs, S. E., Todd, D., & Davis, P. G. (2017b). frenotomy for tongue-tie in newborn infants. The Cochrane Library, 2021(6). https://doi.org/10.1002/14651858.cd011065.pub2
- Costa-Romero, M., Espínola-Docio, B., Jm, P., & Díaz-Gómez, N. M. (2021). Ankyloglossia in breastfeeding infants. An update. Archivos Argentinos De Pediatria, 119(6). https://doi.org/10.5546/aap.2021.eng.e600
- Hogan, M., Westcott, C., & Griffiths, M. (2005). Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health, 41(5–6), 246–250. https://doi.org/10.1111/j.1440-1754.2005.00604.x
- Riskin, A., Mansovsky, M., Coler-Botzer, T., Kugelman, A., Shaoul, R., Hemo, M., Wolff, L. B., Harpaz, S., Olchov, Z., & Bader, D. A. (2014b). Tongue-Tie and Breastfeeding in Newborns—Mothers’ Perspective. Breastfeeding Medicine, 9(9), 430–437. https://doi.org/10.1089/bfm.2014.0072
- Visual Analogue Scale. (n.d.). Physiopedia. https://www.physio-pedia.com/Visual_Analogue_Scale
- Salaffi, F., Stancati, A., Silvestri, C., Ciapetti, A., & Grassi, W. (2004). Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. European Journal of Pain, 8(4), 283–291. https://doi.org/10.1016/j.ejpain.2003.09.004
- O’Shea, J. E., Foster, J. P., O’Donnell, C. P., Breathnach, D. B., Jacobs, S. E., Todd, D., & Davis, P. G. (2017). frenectomy for tongue-tie in newborn infants. The Cochrane Library, 2021(6). https://doi.org/10.1002/14651858.cd011065.pub2
- Ghaheri, B. A., Cole, M., Fausel, S. C., Chuop, M., & Mace, J. C. (2017). Breastfeeding improvement following tongue‐tie and lip‐tie release: A prospective cohort study. Laryngoscope, 127(5), 1217–1223. https://doi.org/10.1002/lary.26306
- Emond, A. M., Ingram, J., Johnson, D., Blair, P. S., Whitelaw, A., Copeland, M. W., & Sutcliffe, A. G. (2014). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-fetal and Neonatal Edition, 99(3), F189–F195. https://doi.org/10.1136/archdischild-2013-305031
- Riskin, A., Mansovsky, M., Coler-Botzer, T., Kugelman, A., Shaoul, R., Hemo, M., Wolff, L. B., Harpaz, S., Olchov, Z., & Bader, D. A. (2014). Tongue-Tie and Breastfeeding in Newborns—Mothers’ Perspective. Breastfeeding Medicine, 9(9), 430–437. https://doi.org/10.1089/bfm.2014.0072
- Kleinman, L., Rothman, M., Strauss, R., Orenstein, S. R., Nelson, S. P., Vandenplas, Y., Cucchiara, S., & Revicki, D. A. (2006). The Infant Gastroesophageal Reflux Questionnaire Revised: Development and Validation as an Evaluative Instrument. Clinical Gastroenterology and Hepatology, 4(5), 588–596. https://doi.org/10.1016/j.cgh.2006.02.016
- Slagter, K. W., Raghoebar, G. M., Hamming, I., Meijer, J., & Vissink, A. (2021). Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study. Clinical Oral Investigations, 25(6), 3431–3439. https://doi.org/10.1007/s00784-020-03665-y
- Ghaheri, B. A., Cole, M., & Mace, J. C. (2018). Revision Lingual frenotomy Improves Patient-Reported Breastfeeding Outcomes: A Prospective Cohort Study. Journal of Human Lactation, 34(3), 566–574. https://doi.org/10.1177/0890334418775624
- Dixon, B. C., Gray, J. C., Elliot, N., Shand, B., & Lynn, A. (2018). A multifaceted program to reduce the rate of tongue-tie release surgery in newborn infants: Observational study. International Journal of Pediatric Otorhinolaryngology, 113, 156–163. https://doi.org/10.1016/j.ijporl.2018.07.045
- Ingram, J., Johnson, D., Copeland, M. W., Churchill, C., Taylor, H., & Emond, A. M. (2015). The development of a tongue assessment tool to assist with tongue-tie identification. Archives of Disease in Childhood-fetal and Neonatal Edition, 100(4), F344–F349. https://doi.org/10.1136/archdischild-2014-307503
- Bundogji, N., Zamora, S., Brigger, M. T., & Jiang, W. G. (2020). Modest benefit of frenotomy for infants with ankyloglossia and breastfeeding difficulties. International Journal of Pediatric Otorhinolaryngology, 133, 109985. https://doi.org/10.1016/j.ijporl.2020.109985
- Parent-reported infant and maternal symptom relief following frenotomy in infants with tongue-tie. (2022, April 21). PubMed. https://pubmed.ncbi.nlm.nih.gov/35485787
- De Lima, A. M. J., & Dutra, M. R. P. (2021). Influence of frenotomy on breastfeeding in newborns with ankyloglossia. CoDAS, 33(1). https://doi.org/10.1590/2317-1782/20202019026
- Wongwattana, Panuwat. The effect of frenotomy on long-term breastfeeding in infants with ankyloglossia. Int J Pediatr Otorhinolaryngol. 2022 Jan; 152:11983 doi: 10.1016/j.ijporl.2021.110983
- Yousefi, J. (2015, March 1). Tongue-tie Repair: Z-Plasty Vs Simple Release. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4409957/
- Vallone S. Chiropractic evaluation and treatment of musculoskeletal dysfunction in infants demonstrating difficulty breastfeeding. J Clin Chiropr Ped. 2004;6(1):349–368
- Miller J, Miller L, Sulesund A, Yevtushenko A. Contribution of chiropractic therapy to resolving suboptimal breastfeeding: a case series of 114 infants. J Manip Physiol Ther. 2009;32(8):670–674.
- Caloway, Christen, et al. “Association of Feeding Evaluation with Frenotomy Rates in Infants with Breastfeeding Difficulties.” JAMA Otolaryngology–Head & Neck Surgery, 11 July 2019, jamanetwork.com/journals/jamaotolaryngology/fullarticle/2737712, https://doi.org/10.1001/jamaoto.2019.1696. Accessed 19 Aug. 2019.