Davis, T. Tongue-tie – to cut or not to cut?, Don't Forget the Bubbles, 2014. Available at:
The midwife asks you to review a 5-day old baby on the postnatal wards. The mum explains that the baby has tongue-tie and she’d like it to be released. The midwife agrees – the baby is having trouble latching on for breast-feeding and this would help. What do you do? Grab a knife and cut, or tell them there’s no indication for unnecessary surgery?
Tongue-tie, or ankyloglossia, is a congenital short, thick lingual frenulum resulting in reduced mobility of the tongue.
How can we assess tongue tie?
The most commonly used tool for assessment is the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF). It is a scoring system looking at:
- appearance of the tongue when lifted
- elasticity of the frenulum
- length of lingual frenulum when the tongue is lifted
- attachment of lingual frenulum to tongue
- attachment of lingual frenulum to inferior alveolar ridge
- lift of the tongue
- extension of the tongue
- spread of the anterior tongue
Each of these categories gets scored at 0, 1, or 2. You can see the full scoring system here.
This gives a total score with a max score of 10 for appearance and 14 for performance (a perfect tongue).
Interpreting the tools depends on how the scores compare in both categories. The key element of understanding the diagnosis is that the definition of tongue ties rests on performance and function, it is not simply an issue of impaired appearance.
On a less formal note, a good way to recognize tongue tie at a glance it to look for the heart shape in the tongue when they stick their tongue out.
What the problem with tongue-tie anyway?
Some people feel that tongue-tie can cause problems with: breast-feeding; speech and general enjoyment of life.
The thinking is that in order to be able to latch on well a baby needs to manipulate its tongue around the areola and the nipple. Babies with tongue-tie have a problem doing this and this can cause breastfeeding difficulties – incorrect attachment, painful nipples for mum, incomplete milk drainage, poor weight gain, mastitis for mum.
Messner et al (2000) carried out a prospective study to determine the incidence of tongue-tie and its effect on breastfeeding. Although, only a small number (50 out of 1041 newborns) had tongue-tie, those with tongue-tie did have significantly more difficulties with breastfeeding (latch and nipple pain).
An article by Ricke et al (2005) described a case-control study looking at the prevalence of breast-feeding problems in babies with tongue-tie as identified by using the HATLFF. They examined the mode of feeding (breast or bottle) at 1 week and then 1 month. They had 49 tongue-tied babies (and 98 control babies) – around 25% were lost at the follow-up stage. They found that at 1 week, tongue-tie babies were three times less likely to be exclusively breastfeeding (although 80% were still doing some form of breastfeeding). And by 1 month, there was no difference in breast-feeding and bottle-feeding between the two groups.
Although the author of the HATLFF was involved in teaching the use of the tool to the researchers in the Ricke et al paper, she was not a fan of the final article (and its conclusion) and Alison Hazelbaker replied in a letter to the journal. Here she stated the many issues she had with the way this study was conducted and the way the researchers used and interpreted her tool.
It has been suggested that babies with tongue-tie grow up to be children with speech and articulation difficulties. Webb et al conducted a systematic review in 2013. 20 studies were examined and 4 of these looked at speech outcomes following tongue-tie division. There was no difference in articulation errors or speech intelligibility between the groups. There has been a case series reporting self-reported speech improvements post frenotomy.
For those who speak English, it is unlikely to have significant speech implications – the only sounds that require you to press your tongue against your upper teeth are L and TH and there aren’t any sounds that need you to stick your tongue out any further than that.
General enjoyment of life
The list of other potential problems caused by tongue-tie in later life is growing and they have all had their own studies (Lalakea et al, 2003):
- Intra-oral hygiene (i.e. sweeping tongue around the mouth to clear food debris)
- Oromotor dysfunction, lower incisor deformity, and other dentition problems
- Licking ice cream
- French kissing
- Playing a wind instrument
- General ridicule from peers
How do we do a frenotomy?
The procedure itself is straightforward. The baby is restrained, the tongue is elevated (you can use a tongue depressor); some topical anaesthetic is applied, and then a small cut is made in the anterior frenulum.
Making the cut is done according to preference. Some people clamp the frenulum first to minimize bleeding and then make a cut; others will make a small anterior cut and then stretch the tongue upwards with the finger thus doing a blunt separate of the remaining tongue-tie.
It’s not a huge procedure, and there are not many adverse effects. Block describes his technique in an article in Pediatric Annals.
What can go wrong?
Bleeding is the most common complication but this is usually just a few drops and easily stopped with pressure. There has been a reported 3.7% recurrence rate of tongue-tie post frenotomy (Webb et al, 2013).
Two terrifying case studies describe two patients in Nigeria who sustained hypovolaemia secondary to profuse bleeding post-procedure. One had no indication for frenotomy and it had been carried out by a non-medically trained birth attendant, and the other was done using a new razor blade by a community health worker. Both babies were resuscitated successfully and discharged home within a week.
But essentially, if you do it correctly, all will be fine.
Does having a frenotomy improve breastfeeding?
Many studies do show improvement in breast-feeding performance post frenotomy. Ballard et al (2002) looked at around 3000 babies and found 127 with tongue-tie. Their breastfeeding was assessed before and after frenotomy (except for 4 babies who did not have the procedure). All these babies suffered either poor latch or maternal nipple pain prior to frenotomy. In all cases where poor latch had been a problem prior to the procedure, post-frenotomy all the mothers reported improved latch. And in those with nipple pain, there was a significant improvement in pain scores.
A more recent review in Archives of Disease in Childhood by Constantine et al (2011) reinforced this. The systematic review included 17 papers and agreed that nipple pain and latch seemed to improve post frenotomy. They also noted, however, that there was a lack of RCTs.
An RCT on 58 patients in 2011, randomized half of their infants with tongue-tie to receive frenotomy and the other half to receive a sham-surgery. The frenotomy group did show a significant improvement in breast-feeding and pain scores.
This year, there was another RCT published (Emond et al, 2014). They took 107 babies (less than two weeks old) with tongue-tie and randomized them to either frenotomy or standard breastfeeding support. At 5 days post-randomization, 17% of women in the non-intervention arm had opted for a frenotomy. Of those that remained untreated at 5 days, there was no difference in LATCH scores between the two groups. But, by the second measurement period (8 weeks) only 15% of the non-treatment group had not had a frenotomy, so there were limited useful statistics to be gleaned by that stage in the study.
So, the evidence in Emond et al showed no difference in breastfeeding at five days but, regardless of this, most parents still opted for a frenotomy. Interviews with these families revealed: immediate improvement with frenotomy; general worry around achieving successful breastfeeding; and concern about withholding a simple treatment from their child that may help.
So, what’s the verdict?
The studies demonstrate extremely mixed results. There is nothing that clearly shows an improvement in breastfeeding post-frenotomy but it does seem as though babies with tongue-tie struggle more with breast-feeding. In general, mothers seem happier post-procedure with improved self-scoring on pain and latch, and qualitative interviews report immediate improvement. Improving the happiness of new mums also has knock-on effects for the baby.
Anyone who has breastfed a baby knows that it is difficult and it is uncomfortable at the beginning. This is even more so if it’s your first child and you don’t have a clue what breastfeeding should feel like. Many women give up breastfeeding in the first few weeks. And for those who don’t give up, it is often difficult to begin with. Whether or not frenotomy impacts on this process is unclear.
It may be that those who have undergone a frenotomy feel more passionate about persisting with breastfeeding; or even more motivated due to having had an intervention. But it is not evident that less tongue-tie correlates with better breastfeeding.
In the words of the HATLFF author:
“Breast-feeding is a complex set of behaviors involving 2 people. My tool identifies only the deficits of those babies who have difficulty with one aspect of the breast-feeding relationship: the function of the tongue as a result of tongue-tie.”
In other words, even if tongue-tie has some effect on breastfeeding, it’s only a snippet of the whole picture.
However, frenotomy is only a minor procedure with no real risks to the baby, so if the family is keen to go ahead for the multitude of reasons discussed above, I cannot see why as doctors we would put our foot down and deny them this.
Constantine AH, Williams C and Sutcliffe AG, A systematic review for frenotomy for ankyloglossia (tongue tie) in breast fed infants), Arch Dis Child 2011 96: A62-A63. Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189–F195. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005, 18(1):1-7. Webb AN, Webba AN, Hao W, Hong P, The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review, International Journal of Pediatric Otorhinolaryngology, 2013, 77:635–646.
Constantine AH, Williams C and Sutcliffe AG, A systematic review for frenotomy for ankyloglossia (tongue tie) in breast fed infants), Arch Dis Child 2011 96: A62-A63.
Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, Sutcliffe A. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189–F195.
Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005, 18(1):1-7.
Webb AN, Webba AN, Hao W, Hong P, The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review, International Journal of Pediatric Otorhinolaryngology, 2013, 77:635–646.