By Robert Preidt
These minor "tether release" or frenotomy surgeries involve a snip, using either sterile scissors or a laser, to loosen the frenulum. That's the thin band of tissue that connects a baby's tongue to the bottom of the mouth, or the upper lip to the gum.
Frenotomy has gone in and out of fashion over the past century, and its popularity seems to be on the upswing again, said study lead author Dr. Christopher Hartnick.
"We have seen the number of tongue-tie and upper lip tether release surgeries increase dramatically nationwide, without any real strong data to show these are effective for breastfeeding," said Hartnick. He directs pediatric otolaryngology at the Pediatric Airway, Voice, and Swallowing Center, part of Massachusetts Eye and Ear, in Boston.
In fact, there was a 10-fold increase in such surgeries in the United States between 1997 (1,279 surgeries) and 2012 (12,406 surgeries), Hartnick's group noted in a hospital news release.
In some cases, movement restrictions caused by tongue-tie and lip tether can result in difficulty with breastfeeding. In rarer cases, they may affect dental health or speech later in childhood.
But is the "snip" now overused? To help find out, the researchers examined 115 newborns who had already been referred by other doctors to undergo a tongue-tie surgery.
But instead of going straight to surgery, this time each mother-newborn pair underwent a thorough breastfeeding and speech-language evaluation, conducted by a multidisciplinary team of clinicians.
Following evaluation, nearly 63% of the newborns did not end up having the surgeries. As for the rest of the babies, 10 (about 9%) underwent lip surgery alone and 32 (28%) underwent both lip and tongue-tie surgery, according to the report.
"We don't have a crystal ball that can tell us which infants might benefit most from the tongue-tie or upper lip release," Hartnick said in the news release. But the new findings suggest that the wider use of a comprehensive clinical evaluation may prevent infants from having the surgery when they don't need it.
The study authors noted that the outpatient procedure can have real downsides for parents and baby. Risks include pain and infection, and there can be significant out-of-pocket costs for the procedure.
Two pediatricians agreed that the procedure may be overused, although some newborns may still benefit.
Dr. Michael Grosso is chair of pediatrics at Northwell Health's Huntington Hospital in Huntington, N.Y. He said the popularity of tether release surgeries has waxed and waned over subsequent generations, and when he began his practice it was hardly ever used.
But, "come the 1990s and the tide had changed again," Grosso said. "Breastfeeding medicine was now a specialty and this procedure was seen as a previously 'underutilized' intervention that vastly improved the experience and success rate of breastfeeding mothers and their babies."
But the new study suggests the pendulum has swung too far in that direction, and moderation is required.
"It's very likely that frenotomy helps some babies," Grosso said, but he agreed that a thorough evaluation by breastfeeding and speech-language experts should come first. Following such examinations, however, it may be that "a large fraction of babies referred for the procedure need either a different procedure or none at all," he added.
Dr. David Fagan, vice chair of pediatrics at Cohen Children's Medical Center in New Hyde Park, N.Y., agreed.
"The take-home message that the study supports, in my opinion, is the importance of a comprehensive feeding evaluation by a certified lactation consultant or speech and language pathologist prior to consenting to a tongue-tie release procedure," he said.
Fagan's only remaining concern is that such resources may not be available to parents in all areas of the United States. "Hopefully, more health care providers will become certified lactation consultants to meet this demand," he said.
The study was published July 11 in the journal JAMA Otolaryngology--Head & Neck Surgery.