Is tongue-tie surgery the new episiotomy?

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They created the surgical procedure with the best of intentions. They wanted to prevent serious problems and it seemed to them the best way to do it. Unfortunately they were wrong and a lot of unnecessary suffering was the result.

I’m talking about episiotomy, but I could be talking about painful newborn tongue-tie surgery.

How did good people get things so wrong?

If you wouldn’t willingly undergo a painful episiotomy because it “might” be helpful, don’t force your baby to undergo painful tongue-tie surgery because it “might” improve breastfeeding.

Episiotomy was created to prevent both short term and long term complications of childbirth. Episiotomy was created on the theory that a controlled tear made by a scissors would create enough room at the vaginal opening so that the baby’s head would not tear it further down to the anal sphincter (3rd degree tear). The theory made sense.

It was also designed to prevent serious long term complications of childbirth like uterine prolapse and urinary incontinence. That theory made sense, too.

Unfortunately, both theories turned out to be wrong. Not only did episiotomy fail to prevent uterine prolapse and urinary incontinence (which are cause by weakening of muscles far above the vaginal opening) but — in an ugly irony — cutting an episiotomy actually made 3rd and 4th degree tears MORE likely.

Once routine, episiotomy is now recognized as only appropriate in some very specific situations such as the use of forceps.

Tongue-tie surgery was also created with the best of intentions.

What is tongue-tie?

If you look carefully at the photo above, you will see that underneath the infant’s tongue there is a small vertical membrane that connects the tongue to the floor of the mouth. Tongue tie occurs when the membrane (the frenulum) is abnormally shortened and or thickened, restricting the movement of the tongue itself. Since the motion of the infant tongue is critical in breastfeeding, it’s easy to see how tongue-tie can cause problems breastfeeding.

Signs and symptoms of tongue-tie include:

  • Difficulty lifting the tongue to the upper teeth or moving the tongue from side to side
  • Trouble sticking out the tongue past the lower front teeth
  • A tongue that appears notched or heart shaped when stuck out

The natural incidence of tongue-tie has been estimated as 1.7-4.8%.

There has been a recent dramatic surge in tongue-tie surgery. According to lactation consultant Nancy Mohrbacher:

What started as a problem for a small percentage of babies seems now to be an epidemic. Health-care providers report increasing numbers of breastfeeding mothers self-diagnosing tongue and lip ties in their babies, often based on online information, and asking for a tongue- or lip-tie revision …

The surgery can be very painful for babies, leading to a large open wound beneath the tongue as this photo shows:

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Think about how painful biting your tongue it; now imagine a gaping wound like that. Some babies who have undergone tongue-tie surgery have developed oral aversion. Breastfeeding (and even bottle feeding) are associated with so much pain that the babies refuse to eat even after the wound has healed.

The worst part is that — like episiotomy — tongue-tie surgery doesn’t work as this 2017 paper in Breastfeeding Review explains.

A 2014 systematic review by Power and Murphy concluded that half of breastfeeding babies with tongue-tie will not have problems. If there were difficulties, mothers reported improvements after frenotomies or frenectomies. But the authors note that it is difficult to determine how much of this effect is placebo.

A 2015 systematic review by Francis, Krishnaswami and McPheeters concluded that a small body of low to insufficient quality evidence indicates that frenotomy is associated with mother-reported improvements in breastfeeding and nipple pain, noting that the studies are short-term and of inconsistent methodology.

Even worse, the surgery is now being recommended in the absence of classic tongue-tie for conditions known as “posterior tongue-tie” upper lip-tie. Supposedly, these ties cause reflux due to air swallowing. As physician/lactation consultant Pamela Douglas notes:

…[T]here is no reliable evidence that the diagnoses of posterior tongue-tie and upper lip-tie are meaningful or useful for breastfeeding pairs.

And:

…[T]he hypothesis that reflux is caused by excessive air swallowing in infants with poor latch due to posterior tongue-tie and upper lip-tie … lacks credible physiological mechanisms or supporting evidence… This article argues that our breastfeeding women and their babies deserve the most rigorous scientific methods available, and acknowledgment of the biases inherent in less rigorous research, if we are … to prevent unnecessary oral surgery.

Tongue-tie surgery — like episiotomy — is appropriate in certain specific situations such as classic anterior tie that prevents a baby from moving her tongue to her teeth (and may contribute to future speech impairment).

But tongue-tie surgery is big business and its practitioners promote it. 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. Those mothers who don’t have health insurance may be forced to pay the entire fee out of pocket.

Why has there been a dramatic increase in the diagnosis of tongue-tie and a dramatic increase in expensive surgery to correct it?

Dr. Bobby Ghaheri insists that Diagnosing Tongue-Tie In A Baby Is Not A Fad:

One of the most frequent things I hear is that primary care providers say something to the effect of “Oh, diagnosing tongue-tie is just a fad” or “This tongue-tie business is just something new that some people are doing”.

So if pediatricians and ENT specialists think most tongue-tie surgery is unnecessary, who’s making the diagnoses? Mothers and lactation consultants.

Is tongue-tie surgery the new episiotomy?

I’m afraid it it. It’s a painful procedure created with the best of intentions, useful in certain specific circumstances, but it has become widespread without solid evidence that it works.

So if you wouldn’t willingly undergo a painful episiotomy because it “might” be helpful, don’t force your baby to undergo painful tongue-tie surgery because it “might” improve breastfeeding.

  • EC

    “The natural incidence of tongue-tie has been estimated as 1.7-4.8%.”

    Yet lactivists dismissively say that “only” 5% of women can’t breastfeed as though that means it happens to nobody.

  • Kim Thomas (casual)

    This was very interesting to read but surely a large portion of the blame must lie with doctors carrying out unnecessary surgery? The fact that they’re being asked to carry it out by parents or lactation consultants is no reason to do it, in the absence of evidence of efficacy.

  • Nicole Thomas

    One of my 3 kids had this done. She couldn’t stick her tongue out at all to even cover her gums. It would pinch in when she cried. I had black and blue nipples that the hospital LCs blamed on me. They even sent a letter to my pedi calling me “a nervous new mom” and that there were no issues. We both suffered for 7 weeks and once it was snipped everything was better. (and the letter from those jerky LCs got “lost” when we moved). I wanted to breastfeed (we can argue about the pressure to breastfeed but in my case I think I pressured myself because of IVF and feeling like I wanted to do one thing that my body should be able to do) and had that continued I would not have been able bear the pain anymore. A simple procedure helped that but even more importantly it helped her avoid a future surgery and speech therapy. There was no gaping wound. In general our views line up and I am not saying we should do this willy nilly but there a good reasons to take care of it sooner than later for kids with an actual tongue tie. My next two kids didn’t have them as severe and we let them be. I do have concern if it is characterized like this kids with actual issues will get swept under the rug like mine was in the beginning and then they will have to deal with more issues down the road. My experience was nothing like other women commenting here. She did scream when it was clipped but I calmed her down. There was very little blood. Having my other kids go through speech therapy for other issues I am glad to have spared her that with one little procedure.

    • demodocus

      Some kids are really helped by having ritalin. Thalium does have a specific theraputic use. Dr. T’s not saying it’s never helpful, but that it’s currently far over prescribed by people who are not pediatricians. My nephew needed one for speech therapy reasons, my son did not.

      • NT

        I am just saying that it gets missed in very bad cases and in my experience which is maybe a little out of date by a few years it was very underdiagnosed. No one even stuck a finger in my kid’s mouth to check for 7 weeks and blamed me for the bruises and called me a nervous new mom behind my back to our pediatrician all the while there was a very easy fix that saved my kid worse down the road. I didn’t know any better at that point so I suffered for no reason. It would be interesting to map the diagnosis vs other variables and look at who is doing these referrals and which ENTs are performing them the most. I’m sure there are unethical docs out there. I know the hospital I used a mom that was there the same time as me also had her kid go undiagnosed and needed surgery later.

  • Jamie

    I’m an IBCLC and a pediatric speech-language pathologist, and I share some of your concern about the rise in tongue-tie release procedures. But this statement — “Think about how painful biting your tongue it; now imagine a gaping wound like that” — is inaccurate. The lingual frenulum is poorly vascularized and innervated; the tongue is not.

    • Banrion

      Are you suggesting that this procedure is painless? If not that is a mighty fine nit to be picking when we are talking about infants who have no experience with pain and cannot understand what is happening to them or why.

    • rational thinker

      ok go slice your frenulum and see if it hurts

  • rosewater1

    OT: I’m a great aunt! My oldest nephew and his fiancee had a beautiful baby girl on Monday! 7 lbs 9 oz, 19.5 inches. They live a few states away, so I have only seen pictures, but she is PERFECT! This is the first Christmas without my mom…she died in February. Christmas spirit is a bit hard to come by this year. This little one is reminding me what a miracle new life is.

    • Congratulations! Enjoy your new great-niece. What a nice Christmas present.

      • rosewater1

        Thank you! I am! I’ll visit after the new year. Even if I could get off work (which I can’t) and afford a flight (which I also can’t with holiday prices), they don’t need me there right now. But it’s a struggle; I can’t WAIT to snuggle her!

    • demodocus

      Congrats!

  • Merrie

    I had to get a lip tie snipped as an adult, in combination with gum grafts, because it was doing weird things to my gums, and pulling them down. I’m not sure I understand the details. Something to do with braces moving my teeth forward and therefore less gum covering the teeth. If my kids end up having to have braces I’m going to investigate the lip tie angle. It didn’t seem to impact breastfeeding though (though we got a tongue tie snip with kid #2, which in hindsight I think was probably unnecessary).

  • Courtney

    Dr Amy, thank you THANK YOU for highlighting this problem.

    I had a traumatic birth and had low milk supply. Had PTSD. My inability to breastfeed sent me into a downward spiral of depression and anxiety. My baby had severe reflux. One day I met a highly-regarded lactation consultant who told me all my problems were due to a posterior tongue tie (“the kind that paediatricians aren’t trained to detect”) and lip tie. It would 100% work and would also solve my baby’s reflux. The pain is not bad – it’s just like vaccination pain. It will be best for your baby. It will solve all your problems. Well this was music to my very desperate ears.

    How I regretted this.

    I could hear my baby scream next door during the procedure. I then had to stretch the wound with my thumb every 4 hours (including night time) for 4 WEEKS. She would scream when I did this and I felt like the worst mother in the world. I had to wake myself and my baby up to do this otherwise it would reattach. I was severely sleep deprived but forced myself to do it.

    I saw the obligatory osteopath (LCs, dentists and osteopaths are in on this together) and he did some voodoo by touching her head and did basically nothing and charged several hundred dollars. I couldn’t believe it. But I was told that doing all of these things will end up with the ultimate best outcome.

    When breastfeeding didn’t improve, the LCs told me to wait another 2 weeks… another 2 weeks… more and more consultations… finally we did a weighted feed to see how much milk she got – hardly any. They investigated her mouth and concluded that the tongue tie had reattahced. I burst into tears. I had followed the procedure perfectly.

    I am so, so angry that I fell for such absolute bullshit.

    I am so, so angry that I had such pressure to breastfeed that it risked my child’s health and severely affected my own mental health.

    I am so, so angry that I listened to the doctor who said we can feed my newborn water to avoid formula (which I was told was the devil).

    I am so, so glad I finally listened to my instinct and fed my baby formula before it was too late.

    Amy – keep doing what you are doing. Your work is so important.

    Your #1 fan.

    • Hannah83

      All of this is so sad. I am sorry for you and very angry at the cruel people who did this to you and your baby. Do not be angry at yourself. Being a new mom makes you so vulnerable and whom should you trust, if not the “professionals” around you who pretend they want all the best for you and your baby?

      • Courtney

        Thank you Hannah. You are so right – I was a new mum and knew to stay away from too much internet in finding advice, but wasn’t expecting so much bad advice from paid professionals. Don’t even get me started on the doulas…

    • Courtney

      I forgot to mention that the LCs recommended I see the dentist again for another $900 revision.

    • MaineJen

      My god. What a nightmare you went through! I’m glad you are on the other side of it now…

    • Madtowngirl

      Hey Courtney. My situation was not as bad as yours, but I also got duped into clipping a tongue tie because of breastfeeding pressure. I also had low milk supply, and while I’ve not had any formal diagnosis of PTSD/D-MER, breastfeeding was an enormous trigger for my PPD, and even 3 years later, I am choosing to formula feed #2 because the thought of even attempting breastfeeding again makes me feel ill.

      I was also angry for a long time because I trusted the hospital LC who *should* have been trustworthy. Keep sharing your story. It’s important that we aren’t silenced. There’s no reason to be putting our children at risk at the altar of breastfeeding.

    • rational thinker

      Im so sorry for what you went through at least you learned from this many moms don’t and do it to the next child. Keep telling your story that is the only way this type of abuse on new moms and babies will stop.

  • AnnaPDE

    Let’s also not forget the wonderful overlap between the Tongue Tie for Everyone community and crunchy woo. It’s not enough to have the surgery, nope – you also need pre and post op chiropractic or osteopathy, and what’s worse, they highly discourage post-op pain relief. Apparently “it’s just a moment” and homoeopathic crap plus breastfeeding will be enough comfort… when moving the tongue during bf actively hurts. (Funnily enough the same groups tend to be strongly anti circumcision due to the pain involved, but then kick you out when you mention that mouths feel pain too.)

    My son had massive anterior tongue tie, and while it was a hassle finding out and trying to solve it over Christmas, it was also lucky that only the proper, qualified paediatric surgeon in the hospital was around to do it. According to him, those babies where the tie actually inhibited movement will do enough stretches by simply eating, and the rest shouldn’t be tortured. At least in our anecdotal case he turned out to be right.

  • Postpartum mom

    I have a tongue and lip tie. So does everyone in my immediate family. As a child I could not stick out my tongue, I was teased for it, and I worried incessantly about the impact on my kissing ability. I was embarrassed to eat ice cream cones in front of people. And while this may sound superficial, the ties and resulting restrictions always made me feel rather unequal as a sexual partner.

    My daughter was born with a tongue and lip tie. We were advised to have it revised by the LCs. It was rather traumatic to do, but nursing was excruciating, I didn’t want her to have speech difficulty (like my sister) or a tooth gap (like me) or be teased. I would never have been able to continue breastfeeding without the frenectomy—it felt like a piranha was chewing my nipples.

    Far more traumatic though were the mouth exercises we had to perform once a month 3x a day. She screamed throughout those. It made me cry sometimes to do them. In hindsight, it was awful but I am glad we did it. As a child I was angry with my parent for not having it fixed—and I did not want that for my daughter. My understanding is that some doctors can do it with a laser and that is far less painful and heals more easily. I would look into that if I ever had to do it again.

    However, I wish the lactation consultant had not pushed the frenectomy and exclusive breastfeeding so hard on me. I wish she had said that it would be ok to use formula, or supplement until we did the frenectomy at 3 weeks, or to just pump and give bottles. She was adamant about not using formula, and exclusive breastfeeding, and I nursed for three weeks crying many times we did and hating my daughter for hurting me. In hindsight, this exacerbated my postpartum mood issues, and my bonding to my daughter, and on reflection, seems somewhat abusive. The ENT was far more kind and generous, telling us the frenectomy choice was ours and not pushing any agenda.

    I still don’t know that I would change anything that I did, but I wish the LC had given me more choices and not been so dogmatic with her pressure to EBF.

  • Clarene Wong

    Exactly like circumcision

  • BeatriceC

    Every time this topic comes up I find myself playing with my upper lip tie. I’m 43. I think I can safely say it hasn’t caused me harm. I do recall ripping a tongue tie when I was 7 or 8. I fell out of a tree and busted myself up pretty good. I thought my tongue was falling out. It was a bloody mess. But other than a kid being freaked out by what seemed like a lot of blood coming out of her mouth, that also caused me no harm.

  • Isn’t it ironic that the same people who pooh-pooh interventions are themselves pushing an intervention that many times (not all, of course) is unnecessary? I imagine that many of them would react with horror to routine c_rc_mc_s__n (I don’t want to spell it out lest a horde of crazies descend), which has better-demonstrated health benefits than does the current crop of widespread tie-cutting.

    All of my kids were born with minor lip-ties, and at least one with a minor tongue-tie–diagnosed by actual neonatologists rather than lactation consultants. They all grew out of the ties, with no adverse effects on their speech, feeding, etc (although the only one who was able to nurse successfully, incidentally, was the only kid with BOTH a tongue-tie and lip-tie. Took him 8 months to be able to stick his tongue out of his mouth).

    • rational thinker

      wow you called that one

    • The Bofa on the Sofa

      I was thinking of the irony of the ones who insist that women designed to breastfeed and deny the likelihood that a woman has insufficient supply insist that a large number of babies are, apparently, unable to breastfeed.

      Where is the “if they couldn’t breastfeed we wouldn’t have survived” crowd now? Oh wait, that only applies to browbeating women.

      I think the motivation here is pretty clear.

      • Merrie

        Granny midwives used to keep a fingernail long to quickly slice newborns’ tongue ties. Dontcha know.

        • Actually, it was more for rupturing membranes….

          • MaineJen

            YUCK 😮

          • rational thinker

            now that’s a good way to get an infection

          • Merrie

            Ugh. I had not heard that. (And for clarity, I don’t endorse the viewpoint in my original comment. It’s something I have heard from others.)

    • Why aren’t we told to trust in baby’s tongues?

  • NoLongerCrunching

    Dr Ghaheri is an absolute nut job. Go look at his Facebook page. My favorite gem is where he lasers his own tongue even though he admits he has no signs or symptoms of a tongue tie.

  • demodocus

    My son had a bit of a lip tie (he ripped it a couple of times on apples, so it’s not really there anymore). I did bring it up to his doc, who seemed reluctant to even look. I got the feeling Dr. A. disapproves of tongue tie clipping and didn’t know I was just curious to see if my own thoughts were accurate.

  • MovingOn

    Performing surgery on babies just to breastfeed, when formula exists. Jesus christ. Do lactation consultants even hear themselves?

    • rational thinker

      no they don’t hear anything they just keep looking at their bank accounts