Some days ago, an opinion article with the striking headline, “Inside the Booming Business of Cutting Babies’ Tongues,” was published in the prestigious New York Times. In this article, personal cases, situations, and first-person experiences about the process of performing a tongue-tie release (or frenotomy) are reported.

We wanted to take this opportunity to share with you our clinical team’s opinion and how we think about certain points of view in the management of lingual ankyloglossia or tongue-tie.

Stomatognathic functions and short lingual frenulum

First of all, we need to remember what ankyloglossia (or tongue-tie) is and which stomatognathic functions can be affected by an excessively restrictive frenulum.

The tongue has to perform different movements during sucking and swallowing: protrusion, grooving, elevation, and peristalsis. When the infant starts solids, lateralization movements must be added to move the food ball from one side to the other. Therefore, the first functions that may be affected by a short lingual frenulum are sucking, swallowing, and chewing.

Later, around the age of 4, children should be able to make all speech sounds. When a frenulum is too short, it can compromise the realization of alveolar consonant sounds such as [r], [R], and [d], so this short frenulum would be affecting another stomatognathic function: speech.

In addition to this, respiratory function can also be affected as the low elevation of the tongue causes the infant to breathe through the mouth.

Likewise, when an infant sleeps or does not eat, the mouth should be closed at rest, as this plays a vital role in the prevention of malocclusions and proper growth of the orofacial structures.

When the mouth remains closed, this reduces the likelihood of interference in dental growth, avoiding deviations in the position of the permanent teeth. Breathing through the nose, made easier by a closed mouth, contributes to the development of the palate, promoting the formation of an adequate palatal vault.

When breathing occurs through the mouth, there will be a series of changes at the structural level that will affect the infant’s well-being and may also cause changes in the body. The tongue must rest on the palate to exert its influence on the development of the jaw and maxilla.

This positioning not only promotes proper dental alignment but also stimulates the harmonious growth of facial structures.

Keeping the mouth closed and breathing through the nose contribute significantly to proper airway development. Mouth breathing, which can result from improper oral posture, is associated with malocclusions and respiratory problems, such as sleep apnea. Ensuring proper resting oral posture from infancy can prevent mouth breathing, thereby improving respiratory health and reducing the risk of associated disorders.

To summarize, restricted tongue mobility is related to alterations at the functional level of the infant’s stomatognathic structures with implications in several developmental and functional areas. In addition to those mentioned above, breastfeeding can also be affected by ankyloglossia of the infant, with consequences for both the infant and the breastfeeding mother.

There are other ties in the mouth, and they don’t need intervention

As mentioned in the NYT article, there are other types of frenulum in the mouth besides the lingual frenulum. In medical literature, there has been much controversy about their effect on breastfeeding.

In fact, in some countries, babies’ dental frenulum is still corrected. This dental frenulum is located between the upper lip and gum and there is literature that relates it difficulties of curling out of the upper lip during the feed at the breast, which would cause the infant to have a poor latch onto the breast and swallow air.

However, the evidence is scarce and highly contradictory. Moreover, clinical practice shows that the presence of a labial frenulum does not usually hinder the establishment and maintenance of breastfeeding. Similarly, there are other frenulae located from the cheeks to the gums that have also been routinely sectioned and have not been associated with difficulties in breastfeeding.

Who should assess a tongue-tie?

Knowledge of the implications of an infant’s ankyloglossia in breastfeeding is not new. Even so, for many years, it has been ignored due to the widespread use of commercial formula feeding.

In recent decades, thanks to a pickup in breastfeeding rates and breastfeeding support policies, measures for the evaluation and treatment if tongue-tie have been considered, ranging from clinical practice recommendations to governmental legislation.

As in many other fields, when breastfeeding difficulties were then again related to ankyloglossia, the approach to breastfeeding care was often reduced and simplistic. When a woman expressed pain during the feed and it was observed that the infant had ankyloglossia due to a restrictive lingual frenulum, frenotomy was performed without evaluating any other potential situations that could also be the cause of pain, such as breastfeeding positioning or inadequate latch onto the breast.

When difficulties in breastfeeding occur, we need to take a broader view. Comprehensive care of the dyad is necessary. From the first assessment during the first hours of the baby’s life by the midwife to a referral when necessary to specialized expert professionals such as lactation consultants, physiotherapists, speech therapists, and so on.

Follow-up exercises: yes or no?

What is the best method of intervention? Is it better to use an electric scalpel or to have a cold cut, and should massage exercises be performed after frenotomy, and if so, which one, how often, and for how long? As there is little published medical literature, controversy is rife. Each professional approaches ankyloglossia differently, and this means that the information that reaches families is contradictory.

One of the most delicate points is the need or not to massage the wound. The scarce published literature is contradictory. But in the clinical experience of the LactApp team, we can affirm that in infants with whom no exercises have been performed, adhesions are observed after a few weeks and then again the presence of limitations in the movement of the tongue.

When post-surgical exercises are recommended, we should bear in mind that these are exercises that will be performed on the wound and that they will have to be performed several times a day. This is undoubtedly a challenge for families who may not be fully informed or fully aware of what this may entail.

This generates discomfort and extra stress when families have not received the information about this requirement with time to think about whether or not they want to face the implied challenges.

Furthermore, it is essential to inform families that from 3-4 months of age carrying out these exercises inside the baby’s mouth can be very complex, as the little ones are likely to refuse to have this done and may put up resistance that prevents parents from performing them.

However, we would like to point out that the healing process in the mouth is usually fast and that it is relatively easy for the wound to close earlier than indicated, no matter how many exercises are performed. Sometimes, families are blamed for this fact, which we never find to be correct, as it places all the responsibility for the process on families.

Let’s talk about tongue-tie release and pain

It is known that during the first months of life, the frenulum is poorly innervated and vascularized, which is why cutting the frenulum of an infant of a few months is usually a procedure that we could think of as being little painful, but still annoying.

However, the intervention process experience can mark the infant’s subsequent reaction. We must remember that the little ones know the world around them through their mouths and that for some of them the process can lead to a rejection of the breast, that is usually temporary. This fact is also important for families to be aware of so that they are able to act in the event of this happening.

In relation to pain, a topical anesthetic has been used for some time prior to the intervention to reduce the discomfort that may be caused. What we now know is that this topical application is not effective because in order to work, the baby’s mouth has to be dry so that the product can be absorbed, and if the mouth is wet, the effect will be minimal.

Major downside: breast rejection

There is no evidence as to how many percent of infants refuse the breast following frenotomy. Clinical experience shows that some infants may have a longer or shorter duration of refusal following the procedure.

When the frenulum is cut, the infant is immediately put to the breast or offered a bottle. This first feed can be complex in some cases, as babies do not want to suck immediately, and of those who do, a small percentage are likely to refuse subsequent feeds.

This refusal usually lasts for a few days, but can sometimes last for weeks, with a high risk to the entire breastfeeding experience. Therefore, it is essential for families to know before the intervention that the risk of breast rejection exists, and this is the most serious complication that can occur.

And finally, let’s talk about business

If a public health service performs the intervention, such as is the case in most European countries, there is no cost to the families. The only drawback is usually the difficulties of referral and the time it can take to schedule the intervention.

This causes many families to seek care in private health care services in order to have the intervention performed. More and more health insurance companies are now covering the surgery, which is an outpatient procedure lasting only a few minutes; but if this is not the case, the cost of the procedure in Spain ranges from 50 to 700 Euros and can increase to 1,000-1,500 Euros if it is performed in the operating room with sedation.

And yes, there are certainly professionals who are dedicated exclusively, or almost exclusively, to performing tongue-tie releases, which is the downside of being highly specialized.

The financial implications for families are significant. If frenotomy is correctly indicated, informed, and performed, with comprehensive support for breastfeeding, it is likely to be the ideal treatment. But doubts arise when this procedure is an isolated event, without good support or assessment of other factors that may be affecting this vital stage.