While there are many potential causes of breastfeeding problems, tongue tie and upper lip tie have recently gained attention as potential reasons that can be addressed. To date, all available evidence in the literature suggests that a frenotomy (release of the abnormally tight tissue in children with ankyloglossia) is beneficial in improving breastfeeding outcomes. However, there is still significant confusion among providers as to who is a good candidate for the procedure and when to intervene. Furthermore, many providers fail to recognize that there are many symptoms for both mom and baby that can be explained by tongue tie and that normal weight gain is not the only marker of successful breastfeeding.
Currently, there are no accepted criteria for when a child should undergo a frenotomy. Further clouding the issue is that to date, no studies have been done that definitively show that upper lip tie release is helpful in resolving breastfeeding issues. The variability of what symptoms mom and baby have, along with inexperience by many lactation consultants and primary care doctors, has the potential for delay of diagnosis and premature weaning. This post will try to clarify when a frenotomy may be beneficial.
Before deciding on when to intervene, it is important to demonstrate what symptoms can be caused by tongue or lip tie. For the baby, this can include poor weight gain, reflux or colic, popping on and off the breast, prematurely falling asleep at the breast, very short sleep episodes, sliding off the breast towards the end of the nipple, long feeding sessions, frustration with nursing, and obviously, a poor latch. For mom, the symptoms include nipple damage (bleeding, scabbing, fissures), blanching of the nipple, recurrent mastitis or thrush, incompletely drained breasts, plugged ducts, and most commonly, severe pain.
When families visit me for consultation, I try to gauge the impact of the problems on the dyad. If symptoms are minimal, I don’t think adopting a wait and see approach is wrong. It always allows the provider to return to the issue if things worsen. That being said, if the dyad is being seen at 2 months when symptoms are mild, a return visit at 4 months may be too late to intervene if things progressively worsen, so the provider needs to follow these dyads more closely. In general, I decide to intervene when I feel that the constellation of symptoms are a threat to the success of the breastfeeding relationship. I do not want moms to “fight through the pain” or for babies to go on reflux medication when an obviously poor latch is the cause of problems. Breastfeeding should be comfortable, efficient, and nurturing.
One of the most important things I try and emphasize to dyads, lactation consultants, and providers is that tongue tie and lip tie are only some of the potential reasons why breastfeeding can be abnormal. I feel quite strongly that a child should never have a frenotomy before assessment by an IBCLC (international board certified lactation consultant). First, the problems may not have anything to do with tethered oral tissue - muscle tension from a rough delivery or abnormal intrauterine positioning, poor muscle tone, extrinsic factors like jaundice causing lethargy, or poor latch technique can all cause symptoms. Second, the baby and mom will both need support after a procedure has been done. The procedure can be very disruptive and the latch can worsen significantly before it improves. IBCLC support during this post-procedure is critical and trying to find help at the last minute when the initial assessment hasn’t occurred is quite difficult.
Ultimately, the decision should be up to the family. I present them with the information, risks of the procedure, and most importantly, the risks of not intervening if it’s recommended. These dyads are at risk of weaning if close follow-up is not performed. In the end, however, the success rates of the procedure are quite high and the benefits are tremendous.