When you are breastfeeding a baby who struggles to latch because of tongue tie, it’s very common to find yourself considering tongue tie release surgery (frenotomy). This surgery, however, can be a huge decision and isn’t always an easy choice to make. Many parents have concerns about the cost and if it will be worth the results... will the surgery actually improve breastfeeding or not? Some doctors will recommend tongue tie release without hesitation while others feel it’s only beneficial in rare cases. I’ve seen many parents and professionals disagree about whether or not tongue tie release surgery should be considered a solution for breastfeeding challenges. Today we are going to dig into some of the research on this topic and compare that with what practitioners and parents experience in the real world.
"Tongue Tie Release Surgery does not improve breastfeeding outcomes" - but what does this mean?
One study looked at multiple studies on frenotomy to determine if there is enough evidence to recommend tongue tie release surgery for the purpose of improving breastfeeding outcomes. The results were very interesting. The researchers came to the conclusion that tongue tie release did reliably reduce mother’s nipple pain during breastfeeding in the short term, but longer term breastfeeding outcomes did not reliably show improvement. This is one of the big reasons why many parents and providers are hesitant to consider tongue tie release surgery as the solution for breastfeeding challenges. As a mother of 5 who had each child released young, as someone who had her own lingual frenulum released at 4 years old, and as a lactation consultant who has worked with many families who have had tongue tie releases, my opinion on this conclusion is complex. Let’s dive in some...
Tongue Tie Release Surgery Reduces Nipple Pain in Breastfeeding Mothers
One of the most common maternal symptoms of tongue tie in a breastfed baby is nipple pain and nipple damage. The research showed that this symptom is reliably improved as a result of tongue tie release surgery. Antecdotally, I can say that in my experience and in my practice most mothers do notice a marked improvement in comfort during feeding after tongue tie release. However, nipple pain (or lack thereof) isn’t usually the only factor in achieving breastfeeding goals. Often, release providers, parents, and even some lactation consultants will conclude that because the nipple pain has resolved, there is nothing else to do and breastfeeding will continue to work perfectly. Then, after some time has gone by parents may realize that weight gain has not resolved, milk supply issues are not improving, and presume that they’ve done everything possible and the surgery “didn’t work” so they give up on breastfeeding and begin exclusive pumping, supplementing with formula, or weaning all together.
The issue here is that in the majority of tongue tie releases I’ve experienced, the release was performed too soon and with inadequate post-op management.
The problem with tongue tie release surgery as a solution to breastfeeding issues
Most of the studies that were included in the review that concluded tongue tie release doesn’t improve breastfeeding outcomes looked at frenotomy in a vacuum. Most of them did not consider that the best approach to improved breastfeeding out comes after tongue tie release might require a longer term interdisciplinary approach to care. These studies did not evaluate if the families were seeking ongoing lactation support with an IBCLC trained in oral habilitation both before and after release. These studies did not evaluate if these families were performing consistent post-op care, including exercises to improve range of motion. These studies did not evaluate the emotional and lifestyle needs and challenges families may be facing that directly impact breastfeeding success.
So should you even be considering tongue tie release surgery if it isn’t a reliable solution?
My conclusion from this data is not that frenotomy doesn’t improve breastfeeding outcomes, but rather frenotomy alone does not improve breastfeeding outcomes. My experience has shown that most parents and professionals alike expect tongue tie release to be the magic bullet that fixes breastfeeding issues. Many providers and parents see tongue tie release as something that will bring immediate relief to breastfeeding issues, without necessary preparation work and proper on-going follow up care and lactation support. Frequently, I have clients contact me weeks after a “failed tongue tie release” because breastfeeding still isn’t getting better. Many times we realize the issue was not that the release didn’t work, but rather that the previous LC they saw recommended release without guidance on how to best prepare, and without ensuring follow up. The release provider did not stress the importance of continuing to work with Lactation post-op. And the parents didn’t know that there were possibly other factors at play impacting feeding beyond the tongue tie because everyone was so focused on tongue tie release being THE solution. Ultimately, I believe the biggest indicator of frenotomy success is appropriate expectation management from the first contact with the Lactation Consultant all the way through the process with solid communication between providers and parents. If your baby has a tongue tie and you are considering scheduling a tongue tie release, make sure you give yourself and your baby the best shot by starting the process with a lactation consultant who can help you truly understand if your baby needs a release, why they need a release, and how to increase likelihood of the release being successful.
Understanding Limitations in Tongue Tie Release Surgery and Breastfeeding Research
Some providers state they are hesitant to recommend frenotomy, even in cases where they have no other explanation for breastfeeding challenges, or solutions to offer, because they feel that there is "not enough high quality evidence to prove this procedure works" .
I always find this to be an interesting point, as, in my personal and professional experience, many of the same providers support other procedures with poor quality evidence, like circumcision. In fact, most don't even question the evidence on circumcision and promote it as essential care when the science and social analysis shows otherwise (but that's a conversation for another day).
An important reality to acknowledge is that properly developing a high quality study on frenotomy is highly unethical as it would require with-holding procedures from babies who need them and providing procedures to babies who don't need them. It's also impossible to blind parents or providers to the treatment. So while our quality evidence is limited, there is evidence to show success. Many providers dedicated to helping parents are working hard to create more information, research, and data on this procedure within the context of breastfeeding. Just because the currently published data is limited, does not mean that there is "no evidence" of success. One survey showed that parents who experienced frenotomy with the goal of improving breastfeeding were happy with their experiences and would do it again. Another study performed by Dr. Gahreri, a leading frenotomy researcher and provider, shows similar results, that families who experienced frenotomy had improved breastfeeding confidence and experiences, with objective improvements using a specialized bottle feeding system to measure functional improvement during feedings. Another study performed on infants diagnosed with ankyloglossia supports the belief that there are measurable improvements in oral function after frenotomy.
Also of note, is that the majority of the studies published, including those showing lack of positive outcomes, completely exclude input from lactation consultants (IBCLCs). Studies that reference breastfeeding-- but only from a medical provider perspective, and not the perspective of trained and experienced lactation consultants, are lacking in both authority and perspective. It is also worth noting that while some studies do conclude there is no consistent improvement in breastfeeding outcomes after frenotomy, the majority of these studies are not concluding that there are negative outcomes. Very few, if any, studies demonstrate that there is a common experience of reduced breastfeeding after frenotomy.
What does all of this mean for parents of tongue tied babies who want to breastfeed?
If you are a mother breastfeeding a tongue tied baby and you do not know if frenotomy is the right choice for you, here are my recommendations:
Consult your healthcare provider on their opinion. If they assert frentotomy is not the answer, engage in dialogue over the alternatives. What other options do they have for you? If their only other option is "bottle feeding" or stating "some breastfeeding issues are just unable to be addressed" this would be a sign that they may not be well educated in breastfeeding, breastfeeding support, or lingual restrictions.
Consult a lactation consultant experienced in working with oral restrictions. Your lactation consultant should neither dismiss your concerns (as described above), nor send you directly for frenotomy without a comprehensive feeding exam and measures to improve function before surgical intervention.
Consult a trusted frenotomy provider who works well with your lactation consultant. Providing a release (or not) without consulting the findings of a comprehensive feeding examination is not providing whole-baby care.
Take your time! You should never feel the need to rush into a procedure. It's okay to get an evaluation and schedule the surgery for another day so you have time to consider the pros and cons. Sometimes taking extra time can show you that your baby will either improve with time or is not improving with time and intervention may be successful.
Here at Little Bear Lactation, when a parent suspects tongue tie in their newborn, listening to their experience and improving their experience is a priority. Little Bear Lactation is dedicated to ensuring that parents make decisions they feel confident in by being provided information, are supported in consulting their intuition, and given space to freely decide what is right for their family. Parents seeking guidance on managing breastfeeding challenges can book an in person or virtual lactation consultation here.