When breastfeeding isn’t working, parents may want to peek under their baby’s tongue. Some children are born with a tongue tie, a thick strip of tissue called a frenulum that connects the bottom of the mouth to the tip of the tongue. The frenulum typically separates before a baby is born, but it stays attached in about 5 percent of newborns. If the tongue-tie causes problems with breastfeeding or, later in childhood, speech issues, parents may opt for a simple surgery called a frenotomy that snips the tongue free. There are few risks to tongue-tie surgery, so many parents are eager to arrange for it — likely too many.
Frenotomy is growing in popularity. From 1997 to 2012, the number of tongue-tie surgeries increased nearly ten-fold, according to a study from Johns Hopkins University researchers. This jump is likely unwarranted. “It’s probably being slightly overdiagnosed and overtreated at this point because it is pointed out as a possible barrier to breastfeeding,” says Adva Buzi, an ear, nose, and throat specialist at the Children’s Hospital of Philadelphia. “But there are many things that go into successful breastfeeding.”
Not all babies with a tethered tongue have trouble breastfeeding, and only those who do face issues are diagnosed with a tongue tie, also known by the medical term ankyloglossia. Pediatricians may mistakenly refer a baby for a frenotomy when breastfeeding issues are caused by a problem unrelated to a tongue tie. For example, a study of 115 infants found that 63 percent of babies referred for a frenotomy ended up not needing the surgery after a breastfeeding assessment.
A tongue-tie can impede breastfeeding by disrupting the baby’s latch onto the nipple. A baby must keep their tongue over their lower gums to get a good latch while breastfeeding. A tongue-tie can stop a baby from keeping their tongue in the right position, which can lead the baby to chew on the nipple instead of sucking on it, according to the Mayo Clinic. This can lead to issues sucking out milk and can cause nipple pain.
Frenotomy is a simple solution: Doctors make a small incision to release that frenulum, and voila, no more tethered tongue. Many doctors will perform it right in the doctor’s office. Easy enough, but does it work?
“Anecdotally, a lot of the kids do have improvement and parents feel like things go better after frenotomy.” But there isn’t enough hard evidence to prove the surgery leads to better breastfeeding. “There are some studies that do show an improvement,” Buzi says. However, she points out these studies are small and many don’t have control groups to compare the tongue tie surgery against.
A 2017 review article found that there wasn’t enough evidence to conclude whether tongue-tie surgery improves breastfeeding, although it does reduce nipple pain. In fact, nipple pain is one of the stronger reasons for Buzi to perform a frenotomy. There is a large trial currently investigating the link between frenotomy and breastfeeding, and it should eventually offer more answers.
One of the reasons frenotomies are increasing despite weak evidence is that there isn’t much of a downside to the surgery. “The risks are low. A little bit of risk of bleeding is really the biggest one,” Buzi says. But that doesn’t mean you should charge ahead with tongue-tie surgery at the first sign of breastfeeding troubles. Because tongue clipping may not fix your issues. Instead, see a lactation consultant first to test if shifting your positioning or any other factor can improve breastfeeding. “I personally encourage most breastfeeding mothers to see a lactation consultant,” Buzi says. “Breastfeeding is not as natural as some people make it out to be.”
Parents may schedule frenotomies for other issues, particularly related to speech. “It’s not that a baby or a child would not be able to develop speech because of ankyloglossia. It would be more like certain sounds or letters wouldn’t be articulated correctly because of limited tongue movement,” Buzi says. Parents should only consider frenotomy for speech issues only if a child has difficulty talking that can be traced back to the tongue tie. The risks of frenotomy aren’t higher in older children, though they may need to go under general anesthesia, so don’t worry about waiting to get the surgery.