With a Little Help

Evaluation program may prevent tongue-tie surgery, improve breastfeeding

baby under woman's shirt breastfeeding

New research raises questions about whether too many infants are getting tongue-tie and upper-lip tether surgery (also called frenulectomy) to help improve breastfeeding despite limited medical evidence supporting the procedure. 

In research published July 11 in JAMA Otolaryngology–Head & Neck Surgery, nearly 63 percent of children who were referred to a pediatric ear, nose and throat surgeon for tongue-tie and/or upper-lip tether surgery ended up not needing the procedure, and were able to successfully breastfeed following a thorough feeding evaluation by a multidisciplinary team of clinicians, including a speech-language pathologist. A feeding evaluation program implemented on a wider scale may prevent surgeries that might not be beneficial in improving breastfeeding, according to the study’s authors.

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"We have seen the number of tongue-tie and upper-lip tether release surgeries increase dramatically nationwide without any real strong evidence that shows they are effective for breastfeeding," said Christopher Hartnick, HMS professor of otolaryngology head and neck surgery and director of the Division of Pediatric Otolaryngology and the Pediatric Airway, Voice and Swallowing Center at Massachusetts Eye and Ear.

“We don’t have a crystal ball that can tell us which infants might benefit most from the surgeries, but this preliminary study provides concrete evidence that this pathway of a multidisciplinary feeding evaluation is helping prevent babies from getting this procedure," Hartnick said. 

Present at birth, tongue-tie, or ankyloglossia, is a condition in which a piece of tissue, called the lingual frenulum, connects the tongue to the floor of the mouth too tightly. Infants can also experience upper-lip ties when a different tissue, the frenulum of the upper lip, is connected to the gum. In some cases, this restriction in movement can result in difficulty with breastfeeding or, in rarer cases, may affect dental health or speech later in childhood.

Breastfeeding is recommended by numerous health organizations worldwide as a preferred method of infant feeding for the newborn’s growth and development. When there are difficulties breastfeeding, including the baby not latching on or gaining weight, and when the mother is in pain, many new parents seek a consultation, which may result in surgery to clip the tongue-tie, which is sometimes called a frenotomy, frenectomy or frenulectomy.

Despite a lack of medical literature linking the surgery to improved breastfeeding, the number of these procedures has been rapidly rising in recent years according, to the study’s authors. They note that the Kids’ Inpatient Database in the United States estimated a 10-fold increase in tongue-tie surgeries, from 1,279 in 1997 to 12,406 in 2012.

Prompted by these rising rates and an influx of parents seeking second opinions, Hartnick and colleagues formed a multidisciplinary feeding evaluation program at Mass. Eye and Ear. It consists of clinicians from different medical specialties, including pediatric otolaryngology (ear, nose and throat), pulmonology, gastroenterology and speech-language pathology, which includes staff from Massachusetts General Hospital.

The researchers examined 115 newborns who were referred to the clinic for tongue-tie surgery with a pediatric otolaryngologist. There, each mother-newborn pair met with a pediatric speech-language pathologist who performed a comprehensive feeding evaluation, including clinical history, oral exam and observation of breastfeeding. They then offered real-time feedback and strategies to address the hypothesized cause of their breastfeeding challenges.

Following the evaluation, 62.6 percent of the newborns did not undergo surgery. Although all of the referrals were for tongue-tie surgery specifically, 10 (8.7 percent) underwent a lip-tie surgery alone and 32 (27.8 percent) underwent both lip- and tongue-tie surgery.

Future multicenter trials are planned as well as follow-up outcomes studies comparing infants who did and did not undergo tongue-tie surgery longer term.

The study’s authors call for best practice guidelines to be developed to help with decision making throughout the medical community.

“We’ve learned that an interdisciplinary collaboration is key to a thorough feeding evaluation,” said study co-author Cheryl Hersh, a pediatric speech-language pathologist at MassGeneral Hospital for Children, who sees patients at the Mass. Eye and Ear Pediatric Airway, Voice and Swallowing Center. "This is still a work in progress, but we have learned a great deal about what we can do differently to help our patients and their families. In doing so, we have been able to identify many babies who are having breastfeeding problems that are not related to their lip or tongue anatomy.”

Tongue-tie and upper-lip tether release surgeries are relatively safe outpatient procedures performed with local anesthetic, with risks similar to those of any surgical procedure, including pain and infection. Parents have also reported experiencing psychological pain or guilt from the feeding difficulties and resulting surgery. There can also be significant out-of-pocket costs given the variation in who performs these procedures. Dental professionals, pediatric otolaryngologists and neonatologists often provide these services with unpredictable cost and coverage by medical insurance.

Additional authors included Christen Caloway and Gillian Diercks of HMS and Mass. Eye and Ear, as well as Rebecca Baars and Sarah Sally of Mass General. No funding was secured for this study.

Adapted from a Mass. Eye and Ear news release.

Image: iStock/FatCamera