There has been a lot of discussion lately about tongue ties both nationally from the New York Times as well as locally with a recent blog published by Children’s Hospital of Wisconsin. We felt it was necessary to address some of the things discussed in these articles as well as clarify some areas as a practice of IBCLCs with advanced training surrounding the subject of tethered oral tissues.
What is a frenectomy?
A frenectomy is the procedure that releases tethered oral tissue (TOTs) like tongue and lip ties. This severs and releases the tight frenum allowing it freedom of movement. Usually this is done with laser or scissors by a dentist, ENT or other medical professional.
What we see in our practice
Our practice does see many babies with tongue ties. We typically don’t see families when breastfeeding is going well, although we do love those visits! Oral dysfunction and ties can be a big piece of why breastfeeding can be difficult. All of our IBCLC lactation consultants have taken additional training and continuing education hours on reflexes, oral exercises, oral habilitation, and TOTs. These trainings are not required to become an IBCLC so we are often sought out by families who are still struggling after seeing other providers.
We see everyday how frenectomies can save breastfeeding relationships but we also see that if the timing of the release isn’t right, the release is not complete or the baby & parent aren’t ready that it can do more harm than good. If you're curious what the signs & symptoms of tongue and lip tie are and what our process surrounding frenectomies looks like we have a great blog post you can read here.
Why the “clip and go” approach doesn’t work
Our training has taught us to always start with oral exercises and bodywork before referring to a provider for a frenectomy. A frenectomy should never be the first course of action when a suspected tongue, lip or buccal tie is identified. Just like you wouldn’t immediately go and have your knee replaced, you’d do therapy first to strengthen, we always suggest starting with oral exercises to strengthen the muscles and bodywork to release tensions.
Before referring a patient to a provider for a frenectomy we ensure that:
Latch and positioning is optimized
Baby’s feeding reflexes are firing
Oral exercises are performed to provide strength, coordination, and improve mobility
Bodywork is done to reduce tensions
Nursing parents milk supply is stable
Baby is gaining weight well
There are no other medical concerns
We continue to follow up with the family until those components are in place. We always are looking at both the lactating parent and baby to check for areas of improvement at each visit and where things might be plateauing. If we have reached a point that latch/positional changes, oral exercises and bodywork are no longer helping the dyad in reaching their feeding goals, then we would refer to a provider to assess, diagnose, and treat the oral tie/s. Our team of IBCLCs and Occupational therapists work closely with the family before and after the procedure to ensure that the post release stretches and therapy are understood and going well.
Are stretches after a frenectomy really necessary?
Aftercare wound stretches is a huge area of conflicting information and opinions. Is aftercare necessary if an oral tie is released? In our practice, the answer is a resounding YES. We have worked with thousands of babies and a large portion of the cases we see are of babies who have already had a frenectomy, were not instructed to do any aftercare, and are in the same or worse spot than they were before the release was done. Some cases by well meaning providers who didn’t know or understand the impact aftercare can have.
Scar tissue can form when stretches aren’t done or done correctly. Sometimes, the scar tissue can even be more restrictive than the tight frenulum and the situation is worse! Aggressive wound care or stretches post release are not necessary. However, we do want to make sure that we do the stretches in a way that provides mobility and keeps the tissue elastic. While there is no one protocol of stretches, we teach our clients how to gently, but effectively do the wound care stretches while closely following the family to ensure the baby is not overly stressed.
Scissors versus laser
The other question that we get often is scissors versus laser when the real question we should be asking is which provider is going to be doing the release and what their skill level and training is. In the Children’s Hospital of Wisconsin Article, they state that scissors are the way to go. However, we really need to be looking more at the training completed to be able to perform a complete release of the tissue. In southern Wisconsin and Northern Illinois, most of the providers we work with are pediatric dentists who use what’s called a CO2 laser.
A CO2 laser is a cold laser and for most is more accurate and effective than scissors. We do find that CO2 lasers decrease discomfort and speeds up the healing time after the procedure. Some providers can get a complete and effective release with scissors, however, in our experience if the baby has a midrange or posterior tie, it can be difficult to release the tissue fully with scissors unless the provider is very skilled. There are other lasers or tools similar to lasers that sometimes get lumped together in the laser category when they should not be because the way that they work is not the same.
Some examples of different tools are diode or fontana which uses a hot glass tip (about 950 degrees) to cut the tissue which can increase the risk of scar tissue. Another is babylase which breaks down hyaluronic acid in the fascia (tie) which can help release tension but it doesn’t actually release the restriction.
Another thing to consider is that some larger hospital providers including IBCLCs, pediatricians, ENTs etc. are often restricted on their ability to refer out of their system and may have limitations on what they can say or recommend during an evaluation.
Our thoughts on the recent articles
While these articles touched on some important areas, we found that they were missing crucial parts. In both articles, there is a brief discussion of “stretching, oral exercises, and therapy” but neither explains what each of those things are, when they are performed and why they are important. Let’s go into more detail about each of those things and how they differ.
Oral exercises are used to strengthen, release tension and increase range of motion before and after a frenectomy. This involves parents helping the baby get their tongue moving in different ways, stretching and massaging or suck training. Exercises given are based on findings in our full infant exam and tailored to each baby’s needs.
When the articles mention therapy we are assuming they are talking about bodywork done by a therapist. These therapists could be chiropractors, craniosacral therapists, osteopaths, myofunctional therapists, occupational therapists or physical therapists. Each practitioner uses their own modality of very gentle hands on manipulations of the baby's body to release tensions. This should also be done before and after the procedure as body tensions can lead to feeding problems. Referral to specific providers is based on the location of the family and what would best benefit the baby most.
The articles seem to really confuse wound stretching and oral exercises. These are not the same thing. Stretches of the wound are done after the frenectomy to keep the wound from healing tightly. We assume because these things aren’t clear in the articles that the authors do not truly understand what each of these things are and how they are important surrounding a frenectomy.
What did these articles get wrong?
We wanted to offer some of our thoughts on a few specific areas:
The NYT said “Lactation consultants and dentists have aggressively promoted the procedures, even for babies with no signs of genuine tongue-ties and despite a slight risk of serious complications, a New York Times investigation found.” Just like with anything else, there are going to be providers who have questionable motives. However, at Wisco Lactation we work tirelessly to ensure that if we are referring you to a release provider, there is justified cause. Additionally, the providers that we work closely with are excellent at determining if a release is necessary and only perform a frenectomy on an oral tie that they feel is restricted.
The NYT said: “A small fraction of babies are born with a bundle of tissue that attaches the tip of their tongue to the bottom of their mouth. In some pronounced cases, doctors snip that tissue. But many tongue-ties are harmless, and the evidence that cutting them improves feeding is scant.” In actuality, more current research is showing that about 25% of babies are born with tongue ties and the location of the tie can vary greatly. A tongue tie is a tongue tie. There is no gray area. However, if you’re working with a skilled provider, you want to ensure that the “bundle of tissue” is actually a tie versus tension in the body. This is why we work closely with bodyworkers and on oral exercises to rule this possibility out first.
The NYT said: “Serious complications are rare. But doctors said they had seen the cuts cause such pain that babies refused to eat, becoming dehydrated and malnourished. A few said newly floppy tongues blocked infants’ airways.” The first statement is true, serious complications are rare. However, both the parents and the baby have to be ready for the release. If the timing of the release is optimal, then these risks are greatly reduced.
CHOW said: “...even though their recommended stretching exercises have not been scientifically proven to reduce scarring, improve eating or breathing.” There is actually some research to support oral exercises before and after the procedure, wound stretches to prevent scar tissue, as well as shown improvement in eating and breathing. See below for references.
CHOW said: “Stretching exercises could delay a baby’s healing by reopening the wound. Pain from a laser surgery and stretching afterward can cause babies to develop an aversion to eating…” We see the opposite to be true that healing time drastically decreases when the frenectomy is done by a CO2 laser. We also know that in order to prevent scar tissue from forming the diamond shaped wound that results after a complete release of the tissue does need to be stretched to keep the tissue mobile and elastic. This is why we work closely with our families to ensure gentle wound care is being done.
CHOW said: “It’s always a good idea to start with your pediatrician for a comprehensive evaluation.” We first want to say that we love pediatricians and there are so many amazing providers in our community. We always work really closely with them and anyone else that might be on the families care team as we each have a different role to play and no one person can do it all. However, most pediatricians just don’t have the same training in oral habilitation that advanced skill IBCLCs do. Pediatricians do not specialize in breastfeeding or infant feeding because they have a million other things to know to keep your child healthy and do a great job! An IBCLC is the only professional that is specific to the breastfeeding dyad, looking at the nursing parent and baby together. Keep in mind that not all IBCLCs have the same education surrounding tethered oral tissue. Finding a team that has this additional knowledge is key in the success of your journey.
We know that navigating the big world of tongue ties can feel really overwhelming. Our team of lactation consultants and occupational therapist are here to help you every step of the way. Whether you need breastfeeding support or are exclusively bottle feeding we would love to help guide you through your infant feeding journey tongue tie or not.
At Wisco Lactation, we always want to have an open line of communication and collaboration between our clients and the providers on their care team. We invite all pediatric dentists, ENTs, pediatricians, and anyone else working with tethered oral tissue to meet with us so we can all work together in providing excellent care for our mutual clients. We’d love to set up a time to talk so please email us at hello@wiscolactation.com.
References:
Ghaheri, B., Cole, M., Fausel, S., Chuop, M. & Mace, J. (2016). Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope 127(5): 1217-1223. DOI: 10.1002/lary.26306
Baxter, R., Musso, M., Hughes, L., Lahey, L. L., Fabbie, P., Lovvorn, M., Emanuel, M., & Agarwal, R. (2018). Tongue-tied: How a tiny string under the tongue impacts nursing, feeding, speech, and more. Alabama Tongue-Tie Center.
Geddes, DT, et al. Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. Pediatrics 2008;122;e188
Baeza, C., Douglas, P., Hazelbaker, A., Kaplan, M., Martinelli, R., Marchesan, I., Murphy, J., Smillie, C. & Watson Genna, C. Incidence and Prevalence of Tongue Tie; Assessment ad Classification of Tongue Tie; Treating Tongue Tie; Posterior Tongue Tie; Complementary Techniques to Address Tongue Tie. Clinical Lactation, September Edition, (2017). Pages 89- 121.
Watson Genna, C. (2016). Supporting Sucking Skills in Breastfeeding Infants. Burlington, MA: Jones & Bartlett Learning.
Ghaheri, B. (2015, June). The importance of active wound management following frenotomy. DrGhaheri.com.
Berry, J, et al. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. BREASTFEEDING MEDICINE Volume 7, Number 3, 2012
Buryk, M, et al. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics 2011;128;280
Elad, D, et al. Biomechanics of milk extraction during breast-feeding. PNAS. 2014 Apr 8;111(14):5230-5
Ghaheri BA, Lincoln D, Mai TNT, Mace JC. Objective Improvement After Frenotomy for Posterior Tongue-Tie: A Prospective Randomized Trial. Otolaryngology–Head and Neck Surgery. September 2021.doi:10.1177/01945998211039784
Ferrés-Amat, E., Rodriguez-Alessi, P., Pastor-Vera, T., & Mareque-Bueno, J. (2017, April). The prevalence of ankyloglossia in 302 newborns with breastfeeding problems and sucking difficulties in Barcelona: a descriptive study.
Luisruiz. (2023, May). Ankyloglossia prevalence: A previous cuestion. elfrenillolingual.com.
Think your baby may have a tongue tie and need guidance? Book a visit with Wisco Lactation! We offer home & office visit in Southern Wisconsin and NE Illinois. We also offer virtual visits worldwide.