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Tuesday, March 8, 2005

My Son's Tongue-tie

Freeing the Infant Tongue: Frenotomy and Breastfeeding

Original version published in Birthkit Fall 2005
by Denise Punger

Firsthand Experience

Birth experiences and other events often alert us to our lack of knowledge and motivate us to initiate change. My second son was born with ankyloglossia (tongue-tie). At the time I didn't know much about the issues surrounding this minor congenital defect. My son's cry caught my attention. There was something aesthetically bothersome about his cry: His tongue was held back by a piece of tissue in the midline underneath his tongue - a sublingual frenulum. As he tried to move his tongue forward, the tissue held his tongue down, making his tongue look notched or "heart-shaped" at the tip and wide-based laterally. I just didn't like the looks of it and knew something had to be done to fix this. I asked the postpartum nurse if she knew anything about it. "That's a tight frenulum," she explained, "but no one does anything about them anymore." 

Being fresh out of residency and never having encountered any discussion on newborn frenula, I tended to believe her. But I wasn't satisfied and kept asking around. The hospital lactation consultant was familiar with the breastfeeding problems a tight frenulum can cause. I wasn't having a nursing problem, but I still wanted my son's tongue released. In retrospect, I think breastfeeding was not a problem for him because my milk supply was well-established; my 22-month-old nursed throughout my pregnancy and beyond. All my baby had to do was open wide, and the milk poured in! 

I asked an otolaryngologist (ENT doctor), with whom I had rapport, about releasing this tissue, and he was willing to do it. The lactation consultant thought I was lucky to get my needs resolved. She concurred with the postpartum nurse that physicians generally don't treat tight frenula, but further explained that there is a huge void in resources to help babies who are having breastfeeding problems because of a tight frenulum. It concerned me that it was easier to get the frenulum released for cosmetic reasons (perhaps a little vain of me!) than for greater ease and success with breastfeeding. 

My baby was scheduled to have his frenulum clipped in day surgery with a small dose of mask anesthesia. I thought this a bit much. I had a notion that I should just do this at home with a scissor, but being a vulnerable postpartum, I went along with the medical protocol. At the last minute we found out that day surgery didn't take babies under a year, so we were delayed a few more weeks and rescheduled for the operating room (OR). The OR required the formality of a hospital admission, so we admitted my little six week old to pediatrics and obtained blood work from him. The OR procedure also required NPO(nothing by mouth) status "to prevent aspiration." All this for a tight frenulum really did seem like overkill! The procedure my son actually had was a z-plasty. A frenotomy is a simple snip with scissors of a thin membrane, but my son's surgeon actually cut into the base of the tongue, realigned and put in a stitch. The procedure was very brief. 

Research and Practice

As the months passed and I continued to tandem breastfeed, I found myself involved more and more in the professional lactation community. I was surprised to hear how many babies had a tight frenulum and resultant problems breastfeeding (and subsequent weaning in the first week of life!) and how hard it was to find providers to snip the frenulum - just as the lactation consultant had told me. As I researched the references current at the time, I found that most of these babies need just a simple cut (with curved Iris scissors) of this transparent tissue. The tissue has no blood vessels or nerves, so cutting the thin membrane doesn't hurt the baby. The first office frenotomy I did was on an obstetrician's baby. I told him of the references I had studied, including the highly recommended "how-to" video by Evelyn Jain, MD, IBCLC. He watched the movie, too, and agreed it didn't seem to be a major operation. Like me, he wasn't interested in doing a procedure on his own baby. His wife was reporting breastfeeding problems, and the release helped. Their family had a history of tongue-tie, which is common. In our case, we could trace it to my father-in-law. The most uncomfortable thing for the baby is to be held down and have the tongue retracted. I find that simply swaddling the baby in a receiving blanket is sufficient restraint. If the baby cries, it actually puts the tongue in the best position for cutting the frenulum. No infection or life-threatening bleeding after a frenotomy has been reported, but I am required as a health care provider to warn parents of potential for bleeding, infection and even death in any procedure. Parents must sign a routine consent form. 

I explain, "The breastmilk will provide anti-infective properties, and the action of breastfeeding will apply appropriate pressure to stop bleeding." Professionals respecting lactation will let the baby nurse immediately after. There is no NPO before the office procedure, either. In my professional experience, the most blood I have seen is one controlled drop the size of a pearl under the tongue after the snip. In some cases I have seen no blood and second guessed whether I cut the tissue. 

I keep Hurricaine (benzocaine) gel in the office in case the baby needs an anesthetic, although I prefer not to use it. In a young baby with breastfeeding problems, an anesthetic can make it even more difficult for the baby to nurse and for me to assess the latch and transfer of milk afterwards. The Hurricaine® gel can also be applied afterward to control a bleed, if necessary. In addition, I have gel foam in the office as an option to control bleeding. 

Some conservative sources claim that if the frenulum is nontransparent or you can see structures like blood vessels, this is a contraindication to frenotomy. But experienced providers have ways to handle this. While I admit that I have cut through some tissue somewhat thicker than my protocols state, I have not seen any extra bleeding or other complications. I think time, more experience, more case reports of safety from frenotomy providers and a more relaxed legal community may redefine contraindications. I have also released a few frenula only to observe tight bands hidden underneath. Sometimes I have snipped deeper and sometimes not. Reducing the obvious one is a good start and may be all that is needed to improve breastfeeding. A referral to an ENT or Oral Surgeon can always be made to release the tighter, thicker bands if problems continue. 

Neglected Procedure

After doing about 15 frenotomies the first year, the hospital's malpractice carrier wanted "research" behind this "non-routine" procedure and told me to stop until they received this information. That was not the last time a malpractice carrier challenged the safety and appropriateness of my doing this office procedure. As a family practice doctor, I can easily get malpractice to cover laceration repairs, mole and skin tag removal and punch biopsy, all of which involve an injection of lidocaine and stitches, but the frenotomy they challenge because it is not routine. The only reason it is not routine is because most physicians are quick to suggest a bottle to correct any breastfeeding problems, negating the need for frenotomy. As with natural birth and breastfeeding, the medical community discards the importance of something they don't know. 

While doing my research, I had heard that midwives in the old days would cut the frenulum when ankyloglossia was identified immediately after birth. This is the best time to do a frenotomy. Prevention of an incorrect suck and the associated pain can go a long way. Since my practice is office-based family medicine, most of the frenotomies I have done have been on babies a few days or weeks old. Often parents will come to me as soon as they are discharged from the hospital, but I've done them a few hours old if the baby was home. 

Is a frenotomy a panacea to correct breastfeeding problems? No, a few babies needed further referral to oral motor therapy. A delay in doing the frenotomy may compound the condition, leading to a cascade of problems including weak suck, poor milk supply, mastitis and so on. I would prefer to do them as soon as the need is identified--as soon as possible after birth. The oldest child I have done a simple sublingual frenotomy in my office on was a three year old with speech delay. I did an upper lingual frenotomy on a two year old. 

Will all tongue-tie cause breastfeeding problems? Probably not, but another risk of not doing a frenotomy is potential speech problems (try talking while holding your tongue down at the base of your mouth). Brian Palmer, DDS, is also concerned about cavities and occlusion and sleep apnea. A tongue free to move involuntarily sweeps the gums and teeth, freeing food particles. Without this tongue lateralization, cavities are more likely. A tight frenulum also puts pressure on the gums and developing teeth, making the need for braces more likely. This was the case with the two year old. Mother wanted it released to help prevent buck teeth. 

Further Reading

Tongue-tie: Impact on Breastfeeding - Complete Management Including Frenotomy (video), by Evelyn Jain

Procedures for Primary Care Physicians, by John L. Pfenninger and Grant Fowler

Neonatal Ankyloglossia, The Academy of Breastfeeding protocol.

Frenum Presentation, by Brian Palmer.

Congenital Tongue-Tie and Its Impact on Breastfeeding, by Elizabeth Coryllos, Catherine Watson Genna and Alexander C. Salloum. American Academy of Pediatrics,

Updated March 2006 

If you enjoy this article, you will enjoy the book Permission to Mother which includes the updated version. 

(This is a video of the assessment and procedure. I'd like to point out a few differences in my procedure. For the frenotomy, we swaddle the baby in a blanket. One of the parents may stay in contact with the baby at the baby's head the entire time and my office assistant can be at the torso holding the babies arms under the blanket. The "snip" is the same. I give the baby right back to the mother for comfort and a feeding. 

I don't spend that much time blotting like the video shows. The baby in the video is real angry. I try to minimize the crying with parental comfort, swaddle, and speed. --D.P.)

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