Oops! Wrongly done and poorly done tongue tie surgery.

Tongue tie surgery (frenotomy) is the new tonsillectomy. It’s a surgery that is necessary for certain narrow indications but has become extremely popular to treat conditions that don’t need treatment.

Even members of the Academy of Breastfeeding Medicine have been forced to conclude that it is often poorly done, often wrongly done and harms babies.

Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey was published in International Breastfeeding Journal earlier this year.

Tongue tie surgery has exploded in frequency and purported indications in the early 21st Century. As the authors explain:

In the past 10–15 years, there has been increased concern about ankyloglossia and its effect on infant breastfeeding. This has been associated with increased performance of frenotomy. Physicians and other healthcare professionals with expertise in breastfeeding have voiced concerns about complications related to the performance of infant frenotomy…

Only members of the Academy of Breastfeeding Medicine were surveyed about their professional experience.

What did they find from this small group?

Seventy-eight (37%) respondents reported caring for an infant with a complication, 100/211 (47%) reported caring for an infant with a misdiagnosis, 130/211 (62%) reported caring for an infant with a complication or a misdiagnosis with 81/211 (38%) of respondents reporting not caring for an infant with a complication or a misdiagnosis. Seventy-four (56%) of respondents who classified themselves as a breastfeeding medicine specialist reported caring for infants with complications or misdiagnoses compared to 58 (44%) who did not report being a breastfeeding specialist. There were no differences in location of practice, years in practice, gender of provider, or clinical time caring for breastfeeding patients between those who reported caring for a patient with a complication or misdiagnosis and those who did not.

The results are startling:

More than 80% of the ABM physicians surveyed had cared for babies who had major misdiagnoses. And the misdiagnoses were not subtle or subjective. Fully 42% of those babies were cut unnecessarily when neuromuscular dysfunction — not tongue tie — was the source of breastfeeding difficulties. A further 12% had major anatomic anomalies (cleft palate, Pierre Robin Syndrome, retrognathia) indicating that the diagnosis of tongue tie was made by someone who didn’t actually examine the baby or had no idea what normal infant anatomy looks like.

These misdiagnoses are not trivial issues because tongue tie surgery can have significant complications. In addition to babies who experience bleeding requiring medical attention, infection and abscess, ABM members reported that over 25% of complications involved oral aversion. Think about that for a minute: babies who were forced to undergo mouth surgery — simply so they could breastfeed instead of consuming pumped breastmilk or formula — experienced so much pain that they stopped eating altogether! Breastfeeding became NOT the close bonding experience promised by lactation consultants, but agony for the baby.

Further analysis revealed that the incidence of oral aversion was highest in babies subjected to more expensive forms of surgery:

Historically, frenotomy has been performed with scissors with use of the laser increasing… The pediatric ENT consensus statement concluded that there is “insufficient evidence to support claims that one technique of frenotomy, such as laser, is superior to other techniques”. We found that use of the laser/bovie/electrosurgery was significantly associated with oral aversion/feeding refusal as a frenotomy complication.

The authors conclude:

Infant frenotomy can have associated complications and misdiagnoses, some of which are associated with location and method of frenotomy. Recommendations for avoiding complications and misdiagnoses include the following. Physicians and dentists need to work closely with lactation professionals to optimize breastfeeding support and to evaluate for other causes of breastfeeding problems before referral for or performance of frenotomy. Physicians and dentists need to be able to engage in an informed discussion and shared decision making about ankyloglossia, its effects on breastfeeding, the frenotomy procedure and its possible complications before referral for or performance of frenotomy…

What should parents take away from this study:

1. Tongue tie is often misdiagnosed
2. Tongue tie surgery can cause severe pain for babies
3. Tongue tie surgery is almost never “necessary” because pumped breastmilk or infant formula can treat the problem without surgery and without pain for babies
4. Tongue tie surgery should not be done without a second opinion
5. Parents should be very wary about consenting to tongue tie surgery if a second opinion raises questions about the need for surgery.

It is important to note that this study is merely a survey of breastfeeding professionals, not a study of babies. The actual incidence of misdiagnoses and complications may be different from what the study implies. It is valuable nonetheless because even members of the Academy of Breastfeeding Medicine — the professionals most committed to promoting breastfeeding — are acknowledging major misdiagnoses and serious complications of a surgery that is more common than ever.