Volume 33 Number 1

January 2012
www.aapnews.org

Focus On Subspecialties

Frenotomy for breastfed tongue-tied infants:

a fresh look at an old procedure
by Diana R. Mayer, M.D., FAAP
Recent randomized controlled studies have led some experts to take
a second look at frenotomy for nursing infants with ankyloglossia.
Lingual frenotomy is a procedure wherein the lingual frenulum is
incised without subsequent suturing. Suturing of lingual frenulum tissue
generally is not needed due to its poor blood supply in infancy and rapid
healing. Sparse, brief post-procedure bleeding is the norm.
Primary care physicians have performed infant frenotomies for centuries. However, the procedure fell out of favor in the 20th century in
response to studies showing little or no improvement in speech later in
childhood. Additionally, problems associated with ankyloglossia in nursing infants may have been concealed by the concomitant emergence of
infant formula use and plummeting breastfeeding rates in this era. As
breastfeeding rates began rising in the 1970s, reports of feeding difficulties
associated with ankyloglossia began resurfacing.
Ankyloglossia, also known as tongue-tie, is defined as an impairment
of tongue movement and function. It almost always is associated with
a lingual frenulum; however, the mere presence of a lingual frenulum
does not always result in ankyloglossia.
An oral motor assessment helps identify nursing infants who will
benefit from frenotomy. This includes evaluating tongue elevation (at
least halfway to the roof of the mouth), protrusion (at least beyond the
gum ridge but preferably beyond the lower lip) and lateralization (reflexive
movement of tongue toward the lateral gum line when the gum is
touched). These maneuvers have good validity and inter-rater reliability.
Another tongue movement known as cupping (tongue hugging of
the areola or of a gloved finger) is thought to have strong validity but
poor inter-rater reliability.
Though assessment tools vary in criteria, one tool suggests that failure
of at least one tongue maneuver, in combination with documented feeding difficulties, predicts infants who will benefit from the procedure.
Feeding difficulties include latch problems, poor milk retrieval and
maternal nipple pain. If left unchecked, infant weight loss, maternal
nipple trauma and mastitis become potential sequelae.
Ankyloglossia usually is classified by using the tongue tip as a reference
point. Anterior tongue tie (94% of cases) exists when the lingual frenulum
begins anywhere from the tip of the tongue to the point just before the
tongue underside meets the floor of the mouth. Posterior tongue tie
exists when a lingual frenulum is present where the underside of the
tongue meets the floor of the mouth.

Copyright 2012 AAP News

B. Wilson-Clay, K. Hoover. The Breastfeeding Atlas (4th edition) 2008.

Nursing infants under 4 months of age with anterior tongue tie and
who have translucent (whitish) lingual frenula are candidates for
frenotomy, where the lingual frenulum is incised without subsequent
suturing.

Nursing infants under 4 months of age with anterior tongue tie and
who have translucent (whitish) lingual frenula would be suitable candidates for frenotomy performed by primary care physicians.
Recent studies support use of frenotomy in a subset of nursing infants
with ankyloglossia.
One randomized controlled study compared sham and frenotomy
groups of young nursing infants with significant ankyloglossia (Buryk
M, et al. Pediatrics. 2011;128:280-288). A corrected F test determined
that the subject number in this study was acceptable. Breastfeeding
quality scores improved only in the frenotomy group (p=.029). Both
groups experienced decreased maternal nipple pain, but the frenotomy
group improved significantly more than the sham group (p<.001).
After completion of the initial phase of this study, sham group participants were offered frenotomy. Following frenotomy in this subsequent
crossover, the original sham group then demonstrated the same degree
of improvement in breastfeeding quality and diminished pain as the
original frenotomy group.
Another randomized controlled trial compared frenotomy with 48

hours of intensive feeding consultation (Hogan M, et al. J Paediatr Child

Health. 2005;41:246-250). All but one infant in the frenotomy group
showed improvement in feeding (p<0.001). Only one infant in the
intensive feeding consultation group improved. A subsequent crossover
of the control group showed improvement in feeding following frenotomy, resulting in 95% overall feeding improvement.
An intraoral ultrasound study showed that tongue movement improves
following frenotomies done in breastfeeding infants with ankyloglossia
(Geddes GT, et al. Pediatrics. 2008;122:e188-e194). The study also
demonstrated a significant improvement in infant latch (p<.05 ) and
diminishment in maternal pain (p<.05) following frenotomy.

Copyright 2012 AAP News

Promising results of these studies have prompted new interest in resurrecting frenotomy in a subset of nursing infants with feeding difficulties
and ankyloglossia who may benefit from the procedure.
Dr. Mayer is a member of the AAP Section on Breastfeeding. She also is an International Board Certified Lactation Consultant.