Is neonatal tongue-tie surgery the new tonsillectomy?


A New Zealand pediatrician is questioning the growing popularity of neonatal surgery for tongue-tie.

Dr. Pamela Douglas believes Deep cuts under babies’ tongues are unlikely to solve breastfeeding problems:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Babies are being cut on the theory that breastfeeding is always perfect and, therefore, it is babies who are “broken.”[/pullquote]

When I perform comprehensive breastfeeding assessments on babies with breastfeeding problems or fussiness, including those who’ve had oral surgery in the previous weeks or months, I find a range of underlying problems that have not been properly identified and addressed, though the women have usually seen multiple health professionals.

I regularly see babies who have become even fussier at the breast after they’ve had the deep laser or scissor cuts and the distressing wound-stretching exercises. We call this “oral aversion”.

Occasionally, I find other unexpected side-effects of frenectomies: an under-surface of a tongue partly separated into two, or stitches inserted under the baby’s tongue, or into the upper gum. Parents are told the stitches were because the tie was so bad. But stitches are only put in to control excessive bleeding.

The epidemic of tongue tie is surprising since the natural incidence of tongue-tie has been estimated as 1.7-4.8%

But releasing (snipping) the tongue tie is big business. The surgical fee for frenectomy/frenotomy is $850. I presume that $850 is what the doctor bills; what he or she is actually paid probably varies by insurance company.

How effective is surgery for tongue-tie in reducing breastfeeding problems?

Not very.

A recent review of the literature published in the journal Pediatrics, Treatment of Ankyloglossia and Breastfeeding Outcomes: A Systematic Review, found:

Twenty-nine studies reported breastfeeding effectiveness outcomes (5 randomized controlled trials [RCTs], 1 retrospective cohort, and 23 case series). Four RCTs reported improvements in breastfeeding efficacy by using either maternally reported or observer ratings, whereas 2 RCTs found no improvement with observer ratings. Although mothers consistently reported improved effectiveness after frenotomy, outcome measures were heterogeneous and short-term. Based on current literature, the strength of the evidence (confidence in the estimate of effect) for this issue is low. (my emphasis)

In Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance the authors note:

There is wide variation in prevalence rates reported in different series, from 0.02 to 10.7%. The most comprehensive clinical assessment is the Hazelbaker Assessment Tool for lingual frenulum function. The most recently published systematic review of the effect of tongue-tie release on breastfeeding concludes that there were a limited number of studies with quality evidence. There have been 316 infants enrolled in frenotomy RCTs across five studies. No major complications from surgical division were reported. The complications of frenotomy may be minimised with a check list before embarking on the procedure.

Conclusions: Good assessment and selection are important because 50% of breastfeeding babies with ankyloglossia will not encounter any problems. We recommend 2 to 3 weeks as reasonable timing for intervention. Frenotomy appears to improve breastfeeding in infants with tongue-tie, but the placebo effect is difficult to quantify. Complications are rare, but it is important that it is carried out by a trained professional.

That raises the question: is tongue-tie surgery the new tonsillectomy, a surgery that is necessary for certain narrow indications that became extremely popular to treat conditions that didn’t need treatment? In 1959, there were 1.4 million tonsillectomies performed in the United States. By 1987, the number dropped to 260,000. What was the reason for the dramatic change?

Physicians recognized that although tonsillectomy is necessary for enlarged tonsils that obstruct a child’s airway, they aren’t helpful for the reasons they were commonly performed — to prevent minor illnesses that would resolve on their own. As the authors of Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial explain:

Results: During the median follow up period of 22 months, children in the adenotonsillectomy group had 2.97 episodes of fever per person year compared with 3.18 in the watchful waiting group (difference −0.21, 95% confidence interval −0.54 to 0.12), 0.56 throat infections per person year compared with 0.77 (−0.21, −0.36 to −0.06), and 5.47 upper respiratory tract infections per person year compared with 6.00 (−0.53, −0.97 to −0.08). No clinically relevant differences were found for health related quality of life. Adenotonsillectomy was more effective in children with a history of three to six throat infections than in those with none to two. 12 children had complications related to surgery.

Conclusion: Adenotonsillectomy has no major clinical benefits over watchful waiting in children with mild symptoms of throat infections or adenotonsillar hypertrophy.

Are we making the same mistake with tongue-tie surgery as we made with tonsillectomy? While surgery is appropriate for babies with severe tongue-tie, is it being recommended for painful breastfeeding when it is not the cause and will not effectively treat the pain?

I am not an expert in tongue-tie and I have not reviewed the entire breadth of the literature, so I may be wrong, but I’m extremely dubious about surgery on babies because mothers are having pain breastfeeding. Is it really the baby’s fault? Are the small benefits of breastfeeding really worth subjecting babies to painful surgical treatments? The existing data suggests that surgery for tongue-tie is being overused for a problem that it may not even treat.

I’m also extremely dubious about any surgery recommended by the lactation industry. Instead of acknowledging that pain in breastfeeding is distressingly common and that breastfeeding may not be right for every mother and every infant, babies are being cut on the theory that breastfeeding is always perfect and, therefore, it is babies who are “broken.”

Only further research will answer these questions definitively, but until then mothers should seek second opinions on tongue tie surgery from someone other than lactation consultants and the doctors who perform the surgery. Mothers should ask themselves if the benefits of breastfeeding outweigh the risks of surgery. Should you really cut your baby’s tongue when bottles of pumped breastmilk or formula may solve the problem?