Recently, the discussion surrounding the practice of clipping tongue tie in newborns has become a hot topic, with divergent views shaping the narrative.

For example, The New York Times’ article “Inside the Booming Business of Cutting Babies’ Tongues” addressing the issue of how dentists and lactation consultants around the country are pushing “tongue-tie releases” on new mothers struggling to breastfeed.

The article sheds light on the booming industry surrounding the controversial practice of frenotomy in infants. The piece underscores the complexities and ethical considerations within this growing business, prompting critical reflection on the balance between medical necessity and the potential commercialization of healthcare interventions for newborns.

It begs the question: Are we doing more harm than good?

What is Tongue Tie?

Before we plunge into the debate, it’s essential to comprehend what a tongue tie is. Everyone has a lingual frenulum, the connective tissue connecting the ventral (underside) surface of the tongue to the floor of the mouth. It provides stability.

Ankyloglossia, or tongue-tie, is a congenital anomaly in which the lingual frenum is unusually short and thick or abnormally attached anteriorly (front) to the ventral surface of the tongue.

Its prevalence in the newborn population is about 4% on average. It mostly appears as a sole anomaly, though it is sometimes accompanied by other congenital anomalies such as cleft palate. As it has a hereditary nature, it occurs more commonly in male children and has been suggested to be related to the X-chromosome.

Tongue Tie Procedures

Although used interchangeably by many, terms for the different procedures are important to distinguish:

• Frenectomy/Frenulectomy: A surgical procedure in which a frenulum is removed completely
• Frenotomy/Frenulotomy: A medical procedure involving the incision or cutting of a frenulum.
• Frenuloplasty is defined as the surgical alteration of a frenulum.

The oral frenulum is typically not a very vascular or sensitive structure. However, doctors must take in careful consideration what’s around the frenulum such as the bilateral lingual arteries and nerves, the genioglossus muscle and bilateral Wharton ducts. Care must be taken with these structures in order to preserve sensation to the tongue, integrity of the salivary ducts and avoid serious bleeding.

Are we Overdiagnosing Tongue Ties?

Advancements in medical knowledge have brought increased awareness of tongue ties and their potential effects on breastfeeding and oral development. However, this heightened awareness has also given rise to concerns about overdiagnosis, where the condition may be identified even when it might not significantly impact the child’s well-being or the oral motor function. Overdiagnosing tongue ties can have consequences, both for the child and the healthcare system. Unnecessary interventions may expose infants to surgical risks without providing clear benefits. Additionally, the healthcare system may bear the burden of performing procedures that may not be medical.

There is no well-validated clinical method for establishing a diagnosis of ankyloglossia. Its definition and severity classification have not yet been clearly established.

It should be noted that only professionals with medical degrees are to diagnose a tongue-tie. While the group that grants credentials for lactation consultants says they should not diagnose tongue-ties if they don’t have medical degrees, many make this common practice, informing parents to have it clipped immediately. This is not best practice.

This lack of standardized criteria for diagnosing ankyloglossia in conjunction with the lack of high-quality research studies showing significant differences for those who receive tongue tie releases compared to those who don’t are two main reasons we should stand up and take notice. We must not allow pseudoscience to guide us; we must let science inform our practices.

The Importance of Parental Education and Involvement

Central to this debate is the concept of parental choice and informed decision-making. It is important for me as a clinician to empower parents with information about alternative solutions and encourage a thorough exploration of options before opting for a surgical procedure. Families are relying on me to provide them with all the wisdom, education, research and expertise I have. Then, parents can make an informed decision regarding medical care for their infant.

Frenotomy is a valuable tool in managing certain conditions associated with tongue ties. However, it is essential to recognize and address the potential burdens that may arise in its wake, including oral aversions, cessation of breastfeeding and infection. Healthcare professionals, in collaboration with parents, play a vital role in navigating the complexities of post-frenotomy care, ensuring that the benefits of the procedure outweigh any challenges.

Consider other options before opting for tongue tie surgery

A thorough evaluation and assessment for other causes of breastfeeding problems should be performed before proceeding with a potentially unnecessary surgical procedure. Before considering a frenectomy or frenotomy, I urge parents to consider all conservative measure first:

1. Evaluation by a Physical Therapist board certified in pediatrics
2. Evaluation by a Speech-Language Pathologist board certified in neonatal therapy, lactation or swallowing
3. Discuss with your medical provider other reasons your milk supply may be altered
4. Seek out a breastfeeding medicine specialist. This is a physician with advanced training in breastfeeding management and lactation disorders

Careful consideration and a comprehensive evaluation by a multi-disciplinary team is crucial in preventing unnecessary procedures and potential burdens associated with them. In my opinion, very few babies need a frenectomy or frenotomy. And if they do, an ENT/Otolaryngologist should evaluate the airway first and perform the oral surgery. If you choose a qualified dentist to perform the procedure, an ENT should be part of the multi-disciplinary team making recommendations.

Dr. Alison Hazelbaker of the Hazelbaker Lactation Institute encourages us to avoid aggressive aftercare, as there is no science related to this. “It’s not just bad science,” she says, “there’s no science. There are real harms to aggressive aftercare and no evidence of helpfulness. Instead, take a gentle approach, including breastfeeding, skin-to-skin and organic tongue play and movements.”

My Responsibilities as a Medical Professional

As a clinician and medical professional, I have to consider my ethical responsibilities. If there are less invasive, higher quality, evidence-based strategies available, I must recommend these first, because change can likely happen without a painful procedure.

As the debate on clipping tongue ties continues, it’s essential to foster a dialogue that considers both medical expertise and holistic perspectives. I advocate for a cautious and informed approach that challenges conventional practices, prompting a reevaluation of the best course of action for each mother-baby dyad. Ultimately, the welfare of the child should be at the forefront of the decision-making process, with a collaborative effort between parents and healthcare professionals to navigate the complexities of this evolving debate.