Low-risk snip may help tongue-tied infants breastfeed
=====================================================

* Lauren Vogel

Lack of training remains an obstacle to treatment of a relatively common cause of breastfeeding problems, warn experts.

An estimated 4%–10% of babies have “tongue-tie,” or excess tissue anchoring the tongue to the floor of the mouth. Also known as ankyloglossia, the condition can make it difficult for some infants to breastfeed, resulting in slow weight gain, colic and early weaning. It’s also linked to poor milk supply, nipple trauma and infections in nursing moms.

But the simple fix — a quick snip of the offending tissue with surgical scissors or a zap with a laser to release the tongue — seldom features in pediatric literature or training. Called a frenotomy, the procedure has almost “no risk if done correctly” and often results in immediate improvements in both the ease and comfort of feeding, says Lawrence Kotlow, a pediatric dentist from Albany, New York. He performs the surgery six to eight times a day.

“It doesn’t require anesthesia or stitching, it takes maybe 20 seconds to do, the baby is put on the breast immediately afterwards and most parents find a significant difference because now the baby can have a deeper latch.”

Even so, it can be difficult to find a physician to perform the procedure, as both diagnosis and treatment of tongue-tie remain a longstanding source of controversy in the medical community.

The Canadian Paediatric Society hedges that the procedure “cannot be recommended,” except in cases where “the association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed necessary.” A recent *CMAJ* Practice article suggests reserving the procedure for feeding difficulties caused by “severe” tongue-tie. A systematic review of 17 studies suggested that “frenotomy is a safe procedure that may facilitate breastfeeding in women who may otherwise have given up,” but acknowledged that most studies were not randomized and therefore not a good indication of “any true benefit” (*Arch Dis Child* 2011;96:A62-3).

One such trial recently showed that frenotomy for infants with mild or moderate tongue-tie “did not result in an objective improvement in breastfeeding” at the end of a five-day period. However, the study’s authors noted that 17% of those randomized to “usual care” did not last five days before demanding a frenotomy and 15% switched to bottle feeding. After the five days, most women in the comparison group opted for a frenotomy for their infants.

In the absence of clear-cut evidence, few doctors outside of specialty breastfeeding clinics even assess for tongue-tie, says Dr. Howard Mitnick, a breastfeeding management expert at the Goldfarb Breastfeeding Clinic at Jewish General Hospital in Montréal, Quebec. His clinic is “overwhelmed” with frenotomy referrals from across the province. “There are major chunks of Canada where no one’s doing them … because you don’t look for something you can’t deal with.”

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/186/1/20/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/186/1/20/F1)

Is this baby tongue-tied? Few doctors seem to agree on how best to find out.

Image courtesy of © 2014 Thinkstock

Adding to the confusion, there’s no standard way in which physicians diagnose the condition. Some doctors identify it solely on anatomical criteria, such as the degree of fusion between the tongue and the floor of the mouth. Others look for signs of limited function, such as an inability to raise or stick out the tongue. In both cases, it’s hard to attribute feeding problems to tongue-tie without a “baseline expertise” to rule out other possible causes, says Mitnick. “Lots of the women I see are struggling with breastfeeding, and the baby has the anatomy of a tongue-tie, but it’s not a tongue-tie problem; it’s a confidence, knowledge or positioning problem.”

According to Dr. Jack Newman, founder of the International Breastfeeding Centre in Toronto, Ontario, “most physicians have no idea how to diagnose a tongue tie, at least the more subtle ones.”

“We see babies in our clinic who have very significant tongue ties, yet the parents were told by the doctor that there was no tongue-tie,” he writes in an email. “And most physicians will not release a tongue-tie because they don’t know how.”

The fact that dentists and lactation consultants often know more about the condition than physicians can further complicate the issue. “If the family doctor doesn’t recognize it, and a nonphysician says it’s there, you run into a conflict,” says Kotlow.

Ultimately, the losers in these scuffles are the babies and parents, who may spend months bouncing from one provider to another in search of a solution. Mitnick argues that the wait-and-see attitude adopted by many physicians puts mothers at unnecessary risk of having to supplement poor milk supply with formula or giving up breastfeeding entirely. “We know very well that if babies are not exclusively breastfed there are genuine medical concerns, so if the alternative is frenotomy, it should be seriously considered, especially when the risks of the procedure are so low.”