Acta Pædiatrica ISSN 0803–5253

VIEWPOINT ARTICLE

Tongue-tie, breastfeeding difficulties and the role of Frenotomy

Manoj Kumar (manojk@ualberta.ca)1, Erica Kalke2,
1.Neonatal Division, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
2.Lactation Consultant, Stollery Children’s Hospital, Edmonton, AB, Canada

Keywords
Ankyloglossia, Breastfeeding, Frenotomy, Tongue-tie
ABSTRACT
A greater emphasis on exclusive breastfeeding in recent years has re-ignited the historical
Correspondence
M Kumar, M.D., M.Sc., (Clinical Epidemiology),
debate over the role of ankyloglossia (tongue-tie) in infants with breastfeeding difficulties.
Department of Pediatrics, University of Alberta, Several prospective cohort studies and randomized control trials have been published in
Edmonton, AB, Canada. this area in the last 10–15 years. We critically evaluated recent evidence and attempted to
Tel: 780-735-4670 |
Fax: 780-735-4072 |
answer two important clinical queries in this area, that is, (i) whether ankyloglossia is asso-
Email: manojk@ualberta.ca ciated with breastfeeding difficulties and (ii) whether frenotomy helps mother–baby dyad
Received
in such setting?
16 January 2012; revised 24 February 2012; Conclusion: Neonates with tongue-tie are at increased risk for breastfeeding difficul-
accepted 29 February 2012. ties. An early recognition of this association by primary care provider and prompt referral to
DOI:10.1111/j.1651-2227.2012.02661.x a lactation consultant is important. In cases with clearly documented breastfeeding difficul-
ties, frenotomy often results in rapid improvement in symptoms.

INTRODUCTION breastfeeding difficulties in systematically recruited cohorts

Realization of numerous benefits of breastfeeding from
well-conducted epidemiological studies has resulted in a
greater emphasis on establishing breastfeeding in neonates
in the recent years (1,2). With this increased emphasis on
breastfeeding, the historical debate over the role of ankylo-
glossia (tongue-tie) and the frenotomy procedure in
neonates facing breastfeeding difficulties has re-ignited
(3,4). Whilst the previous evidence was largely based on
anecdotal reports and retrospective studies (5,6), several
prospective cohort studies and randomized control trials
(RCTs) have been published in this area in the last
10–15 years. We critically evaluated evidence from these
studies and tried to answer two important clinical queries,
that is, (i) whether ankyloglossia is associated with breast-
feeding difficulties and (ii) whether frenotomy is helpful to
mother–baby dyads in such setting?
IS ANKYLOGLOSSIA ASSOCIATED WITH BREASTFEEDING
DIFFICULTIES?
A few moderate to large studies have attempted to answer
this question in recent years using two different method-
ologies, that is, either by measuring the incidence of
of babies with ankyloglossia or by measuring the incidence
of ankyloglossia in newborns with breastfeeding difficulties
as compared to a control group.
Hogan et al., (7) in a systematically recruited cohort of
201 newborn with ankyloglossia, reported a high incidence
of feeding difficulties (44%), with even higher rates in those
classified as severe. Other problems reported were maternal
sore nipples, continuous pattern of feeding, need for bottle
feeds and dribbling while feeding. In another study enrolling
36 neonates with ankyloglossia, Messner et al. (8) showed
higher incidence of latching difficulties (19% vs. 0%) and
breastfeeding difficulties (25% vs. 3%) in such neonates as
compared to a control group of neonates with no ankylo-
glossia.
On the other hand, Ballard et al. (9) compared the rates
of ankyloglossia in infants attending outpatient clinics with
breastfeeding difficulties with the general population of nor-
mal term newborns, and reported a four fold higher inci-
dence of ankyloglossia in infants with breastfeeding
difficulties (12.8% vs. 3.2%).
The evidence from the above-described studies clearly
demonstrates a strong association between the presence of
ankyloglossia and the breastfeeding problems in neonates.

ª2012 The Author(s)/Acta Pædiatrica ª2012 Foundation Acta Pædiatrica 2012 101, pp. 687–689 687
Tongue-tie, breastfeeding difficulties and frenotomy
IS FRENOTOMY HELPFUL IN THE SETTING OF ANKYLOGLOSSIA
WITH BREASTFEEDING DIFFICULTIES?
Three recent RCTs have evaluated the effects of frenotomy
on mother–baby dyads when infants’ feeding problems were
considered owing to ankyloglossia(7,10,11). Hogan et al.
randomized 57 such infants and showed 96% (27 of 28) of
the infants randomized to frenotomy group improved their
symptoms soon after the procedure as compared to 3%
(1 out of 29) of the infant in the control group. The
researchers then went on to offer frenotomy to 28 of the
control infants and noted similar dramatic improvement in
feeding difficulties within 48 h in 27 (96%) of those infants.
Overall, the division of tongue-tie resulted in the improve-
ment in feeding in 54 of 57 infants (7). Similarly, another
double-blind crossover RCT by Dollberg et al. (11) enrolling
25 patients showed decreased nipple pain scores and
improved latching scores, immediately following frenotomy
as compared to a sham procedure. More recently, Buryk
et al. (10) randomized 58 neonates with breastfeeding diffi-
culties and showed significantly greater reduction in nipple
pain scores and improvement in breastfeeding scores,
immediately following frenotomy as compared to a sham
procedure. The study also had duration of breastfeeding as a
prespecified secondary outcome; however, it could not be
assessed as parents of most (all but one) infants who were
randomized to the sham group elected for frenotomy after
2 weeks, as allowed by the study protocol.
In addition to the above-mentioned RCTs, several
other large cohort studies have demonstrated benefits of fre-
notomy in infants with ankyloglossia presenting with
breastfeeding difficulties (9,12). In a cohort study of 215
mother–infant dyads presenting with breastfeeding difficul-
ties, 80% (173 out of 215) were described as feeding better
within 24 h after the procedure (12). In another cohort of
123 infants with breastfeeding difficulties who underwent
frenotomy, there was dramatic improvement in latch (all
moms who had poor latch as presenting complaint reported
improvement) and in nipple pain (pain scores reduced from
6.9 to 1.2, p < 0.001) following the procedure (9). No signif-
icant side effects from the procedure were noted in any of
the studies. Similarly, other somewhat smaller studies enrol-
ling between 20 and <50 infants (13–16), showed significant
improvements of symptoms in mother–infant dyads (such
as problem latching at the breast, nipple pain and ⁄ or sore-
ness), with very high maternal satisfaction rates (75–100%)
soon after frenotomy.
CONCLUSION
With the publication of several well-planned studies in the
recent years, the debate about ankyloglossia and its relation
to breastfeeding difficulties should no longer remain based
on anecdotal reports or ideology. We think some of the con-
troversies in this area have resulted from attempts to find an
absolute relationship between ankyloglossia and breastfeed-
ing difficulties, instead of a relative one, where the first
increases the risk for the latter. Also, the existence of various
classification systems for the diagnosis and severity of
688 ª2012 The Author(s)/Acta Pædiatrica ª2012 Foundation Acta Pædiatrica 2012 101, pp. 687–689
Kumar and Kalke
ankyloglossia, ranging from a simple visual inspection of
anterior position of the lingual frenulum (7) to a more com-
plex multi-item scale such as Hazelbaker assessment tool for
lingual frenulum function (17), has been somewhat confus-
ing for the clinicians and has precluded consensus forma-
tion.
Similarly, for the evidence for efficacy of frenotomy, one
could say that there are limitations to the data available
from the existing RCTs, for example, variability in methods
used for making diagnosis of tongue-tie; small trial size (a
total of only140 patients randomized across all RCTs);
crossover design in one of the RCTs (11) or the offer of
frenotomy to the control group participants in the remain-
ing two RCTs (7,10), after demonstrating benefits in the
intervention group, preventing the study of duration of
breastfeeding as an outcome (study investigators considered
it unethical to withhold frenotomy from control participants
once the benefits were clearly documented in treatment
groups). However, the available evidence from these RCTs
and in the other large observation studies is best available
so far and consistent across studies.
We would like to conclude with three simple messages
for the readers based on the evidence presented earlier.
First, neonates with ankyloglossia are at increased risk for
breastfeeding difficulties. Such neonates could benefit from
specific follow-up after primary hospital discharge. While
asymptomatic cases would require no intervention at this
stage, those with breastfeeding difficulties should be
promptly referred to an experienced lactation consultant for
further assessment. Second, presence of ankyloglossia with
breastfeeding difficulties in an infant should constitute a
valid indication for referral for frenotomy. An early referral
for frenotomy in such an infant would be important
to prevent prolongation of unnecessary misery for the
mother–infant dyad. Lastly, when an association between
ankyloglossia and breastfeeding difficulties is established by
an experienced healthcare provider, there is strong evidence
that frenotomy often results in rapid improvement in those
symptoms.
AUTHORS’ CONTRIBUTION
Both authors conceptualized and drafted the report.
SOURCES OF SUPPORT
None.
CONFLICT OF INTEREST
None.
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