A growing chorus of medical experts is questioning the widespread use of surgery to treat tongue-tie — a condition in infants that can affect breastfeeding — with the American Academy of Pediatrics (AAP) raising concerns about potential over-diagnosis and unnecessary procedures.
Last month, the AAP warned about the rising practice of using scissors or lasers to address tongue tissue in infants who have difficulty breastfeeding.
The report, published on July 29 in Pediatrics, encourages pediatricians and other medical professionals to consider nonsurgical options to address breastfeeding problems. The report cites a study that suggested that less than half of the children with tongue-tie characteristics have difficulty breastfeeding.
The study also highlights the lack of research into the effectiveness of tongue-tie surgery for improving breastfeeding outcomes.
“All of us have a little piece of tissue under our tongue and for some people, it’s a little tighter. For infants, it’s important because if it’s really tight it’s hard to extend the tongue beyond the gums. Babies need to move their tongues beyond their gums to be able to get the milk out of the breast,” explained the lead author of the report, Dr. Maya Bunik, who is also a professor of pediatrics at the University of Colorado Denver School of Medicine.
“It also causes some pain in moms when they’re breastfeeding and also makes the baby less efficient. But in general, it usually doesn’t cause too many problems and it also will stretch with time. And, unfortunately, it has become the catchall solution if there’s any breastfeeding problems.”
Tongue-tie, or ankyloglossia, is a condition present at birth where the tissue connecting a newborn’s tongue to the floor of their mouth is too short, restricting the tongue’s movement, according to HealthLink BC.
The cause of tongue-tie isn’t widely known, but the provincial health authority said it can run in families or may occur in babies who have other problems that affect the mouth or face, such as cleft palate.
While the exact prevalence of tongue-tie is unknown, the Canadian Paediatric Society (CPS) estimates that between 4.2 per cent and 10.7 per cent of infants are born with the condition.
Even though it is a common birth anomaly, the medical community remains divided on its link to lactation problems, speech disorders and other oral motor issues, according to CPS, adding that the procedure is an “ongoing source of controversy.”
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Diagnoses have also been increasing in Canada and worldwide, the AAP report said, attributing this trend to the lack of uniform diagnostic criteria for the condition and the absence of a consensus on how to treat it.
The condition known as tongue-tie can make it hard for the infant to extend and lift their tongue to grasp a nipple and draw milk — which in turn can be painful for the mother, the AAP reports.
Although cutting the tissue is a minor procedure, the AAP report noted that it can cause complications such as bleeding, infection or injury. However, these incidents of minor complications appear to be rare.
There are two types of procedures known as frenotomy. The most common involves making a simple incision or snipping the tongue-tie, which is the tissue connecting the tongue to the floor of the mouth, CPS said.
Specialized private clinics are now offering frenotomy using laser ablation, which uses a laser to release the tongue-tie. However, CPS noted that there is limited data available on the safety and effectiveness of the laser technique compared to the conventional method.
Is the procedure necessary?
An ineffective latch and poor weight gain are the main considerations for a pediatrician considering a diagnosis of tongue-tie, AAP said.
With a renewed emphasis on the benefits of breastfeeding, CPS said, “There is more pressure to diagnose ankyloglossia as a barrier to successful breastfeeding, thus increasing the demand for frenotomy.”
Dr. Jack Newman, a Toronto-based pediatrician, believes that tongue-tie in infants should be corrected immediately to facilitate breastfeeding and potentially prevent future speech difficulties.
“Breastfeeding should not cause significant pain,” he told Global News. “And the most common cause of significant pain is the baby is not latching on properly. One of the main causes of the baby not latching on properly is that the baby has a tongue-tie.”
“It’s such an easy procedure. It takes one second,” he said. “And I would say that it’s rare that a mother doesn’t get relief.”
He mentioned that he has seen mothers come in four months after their baby is born, still struggling with breastfeeding issues, and after the tongue-tie procedure is performed, the mothers experience immediate improvement.
Another potential problem with tongue-tie is what Newman calls “late-onset decreased milk supply.”
“So the baby is exclusively breastfeeding for two or three months, but then the mother starts to notice the baby is fussier and baby doesn’t drink as long as the baby is upset. And that late onset decreased milk supply, the cause is tongue-tie. So it’s not just pain, it can affect the supply.”
Bunik acknowledges that tongue-tie surgery may be necessary for some infants, but she still considers it a “quick fix” for an underlying issue that might not be related to tongue-tie at all.
Breastfeeding can be challenging for new families and painful in the first few days, but she noted that this doesn’t always mean it’s due to tongue-tie; other issues may be at play.
This leads to over-diagnosis, she said.
“It’s become a popular sort of thing to throw out there,” Bunik said. “It could be that the mom has unusually large nipples or the baby is premature or is really sleepy … but we blame it on the tongue-tie. And then time is lost and you can’t bring the milk back. You often delay what is really going on.”
In the report, Bunik and the other authors encourage dentists, lactation specialists, primary care doctors and pediatricians to work together to determine the best method to treat breastfeeding challenges in each case.
“I think the family really should be making decisions about this type of surgery, whether it be laser or with a scissor, with their doctor before they jump into it. There’s just so much on the internet, and unfortunately, most people don’t have dental insurance for their babies, so they’re paying out-of-pocket costs,” she said.
— with files from the Associated Press