The little band of tissue under the tongue, known as the lingual frenulum, has become a source of heated discussions, and even angry arguments, in social media settings, parent groups, and in physician and dental circles. And more recently, this debate now includes the band of tissue in the center of the inner upper lip, known as the lip (or labial) frenulum.
While the debate is relatively new, the diagnosis and treatment are not. Assessment and treatment of tongue tie, known as ankyloglossia, dates back centuries, as tethering of this tissue can interfere with latching for breastfeeding, as well as the infant’s ability to maintain a latch and feed adequately. The procedure to divide this band, known as tongue tie release, frenectomy, frenulotomy and frenuloplasty, date back centuries as well. In recent decades, formula feeding and pumped breast milk administered to newborns and infants with bottles became increasingly utilized, and the evaluation and treatment of tongue tie in newborns fell a bit to the wayside. But many women are motivated to breastfeed, but become rightly frustrated in the early days and weeks postpartum, suffering from nipple pain, difficulty getting a newborn to remain latched for a feed, and soon developing concerns about infant growth due to insufficient feeding. If a tongue tie is suspected,
evaluation and treatment of this by surgically cutting the tongue tie, if, indeed, a tight frenulum is the source of challenging breastfeeding, can be a life-changing event, enabling breastfeeding to occur smoothly and painlessly, and successfully. Many families seek help from lactation consultants, who will refer newborns to ear, nose, and throat specialists (otolaryngologists), oral surgeons, or dentists to perform the procedure. In some cases, pediatricians will perform a frenulotomy in the newborn nursery or the office. It is estimated that the incidence of ankyloglossia in newborns is in the 4-11% range.
The diagnosis and treatment of this minor, yet extremely frustrating, problem can make or break a mother and child’s comfort in the early weeks of life. This is a good thing. But as with many good things, especially when surgical intervention is involved, it can go a bit overboard. The diagnosis and surgical treatment of tongue tie has increased 10-fold between 1997 and 2012 in the United States, and 3-fold between 2008 and 2013 in Canada. The likely explanation is due to increased awareness and assessment, not to an evolutionary change of producing more babies with this variant. Lip ties are also being noted more frequently, also in large part due to increased awareness of the entity.
This tiny area has become a large battleground for many practitioners and families. While emphasis and support of breastfeeding, especially in the early weeks and months of a newborn’s life is important, chalking up difficult breastfeeding to a tongue tie and/or lip tie may be a bit of a stretch, so to speak. There are, as yet, no standardized guidelines for this procedure, and many practitioners are concerned that it’s become an overused enterprise, feeding on the anxiety of new parents who are trying their best to feed their child. Dr. Brian Wiatrak, Clinical Professor of Otolaryngology at the University of Alabama and Co-Director of the Aerodigestive Program at The Children’s Hospital of Alabama, has been in practice for close to three decades. He has some serious concerns about the increase in numbers of this procedure being performed. He notes that tongue tie release surgery “can play an important role for babies who have significant problems with breastfeeding when they have a physical examination that clearly demonstrates tethering and restriction of tongue mobility.” Further, Dr. Wiatrak states that “other types [of procedures] such as lip tie...have been treated with...lasers...which may cause complications such as [oral burns] and excessive scarring.”
Dr. Wiatrak mentions that there continues to be ongoing questions about the necessity of this procedure, as well as those involving lip ties, without clear indications or physical abnormalities deeming an infant a surgical candidate.
A recent study published in JAMA Otolaryngology-Head and Neck Surgery investigated a group of infants referred to an otolaryngology practice for tongue tie release surgery, aiming to assess how many of these procedures are actually necessary, and whether or not there are alternative options. The study, based at the Massachusetts Eye and Ear Infirmary and the Massachusetts General Hospital, both in Boston, looked at over 100 babies referred to an otolaryngology surgeon for surgical repair of a tongue tie. The average patient age was 34 days old. All patients were enrolled in a multidisciplinary feeding evaluation by speech and language pathologists. Prior to going ahead with surgery, families were offered techniques to improve quality of breastfeeding. Following this program, over 60% of infants referred for surgery of the tongue or lip fold did not need it.
This finding underscores the importance of recognizing that infants have many reasons to have challenges with feeding, and, while surgery of a tethered tongue and/or lip may, indeed, relieve this difficulty, in more than half the cases, it may not be necessary. Many practitioners, including dentists, oral surgeons,and otolaryngologists, offer in-office laser procedures for tongue and lip ties. While, for the most part, these procedures are safe and effective, they are not without risk. And they may not be necessary at all.