Infant Tongue Tie – To Release or Not To Release

Some babies are born with a band of tissue that tethers the bottom of the tongue down to the floor of the mouth.  This band of tissue is called the lingual frenulum.

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In some cases, the frenulum restricts the baby’s ability to move the tongue and in so doing makes breastfeeding difficult for baby, mother, or both.  These problems can include ineffective latch, maternal pain, insufficient milk flow, inadequate milk supply, and inadequate baby weight gain. If the frenulum is causing breastfeeding problems then the baby is considered ‘tongue-tied’.  For these babies, a ‘release’ – cutting the frenulum to enable better movement of the tongue – can help to improve the breastfeeding.  This is usually a minor surgical procedure carried out in the outpatient setting.

Deciding whether or not to release an infant’s tongue-tie can be challenging. Parents of tongue-tied babies often receive differing, even conflicting advice from healthcare providers as they struggle through treatment options.  This can be particularly disconcerting for mother-baby dyads who are struggling severely with breastfeeding.

I have developed the algorithm below to help simplify the treatment decision-making process.  Although this algorithm may seem to over-simplify the problem, I find it to be very helpful, nonetheless, in guiding treatment, both for myself and for the mother-baby dyads struggling with this problem.

Follow the algorithm by simply answering ‘yes’ or ‘no’ to the four questions below:

1. Is there tissue under the tongue that can be cut?

There cannot be a tongue tie without tissue tethering down the tongue.  Although not typically the case, there are babies who do not have any lingual frenulum.  Doing the release procedure on these babies would be impossible because there would be no tissue to cut.

It is worth mentioning that in some cases, although present and causing breastfeeding problems, a frenulum may not be easily seen or may require skilled examination for diagnose. These are called posterior and/or submucosal tongue-ties and are sometimes missed or overlooked by health care practitioners.  If there is any doubt, it is important to have baby assessed by a health professional who is adequately trained and experienced in this field.

2. Are there breastfeeding difficulties?

If the answer to number 1 is yes, then it is important to determine whether or not the dyad is struggling to breastfeed.  If mother and infant are breastfeeding without any difficulty then there is no compelling reason to subject the baby to the pain and risk of the release procedure. On the other hand, if a tongue-tied baby is struggling to breastfeed, it is important to consider that the struggle may be due to the tie and a release may help to correct the problem.

3. Is continued breastfeeding an important goal for the family?

There are families who are not particularly keen on breastfeeding. For these families, offering the baby formula or expressed/pumped milk in addition to or as an alternative to breastfeeding may make the most sense.  For these families, I can understand why they would choose to avoid the pain and risks of the procedure.  If successful breastfeeding is important to the family and the baby is tongue-tied, then the release should be seriously considered. There are also some babies for whom a tongue tie interferes with their ability to drink from a bottle.  For those babies, a tongue-tie release may help as well.

4. Do the anticipated benefits of the procedure outweigh the risks?

Finally, making the decision to release one’s baby’s tongue tie must ultimately come down to weighing the risks and benefits of the procedure.  The anticipated benefits would be that the breastfeeding improves.  The risks include pain (usually lasting for seconds), bleeding (usually lasting for minutes), infection (virtually never happens), and the possibility that the procedure will not help (we still do not know what percentage of tongue-tied babies benefit from the procedure). I am not aware of any long-term risks of a tongue-tie release. In my experience, when the answer to questions 1 through 3 are ‘yes’, then the vast majority of families choose to proceed with the release.

It is important to keep in mind that a tongue-tie release is not a substitute for competent care from a qualified and experienced lactation consultant. To maximize the success of breastfeeding after a tongue-tie release, support and guidance from a lactation consultant can be invaluable.

Ultimately, it is important that parents feel well-informed, supported, and not rushed when making this decision.  When this is the case, the vast majority of families feel happy and satisfied with their choice regardless of the breastfeeding outcome.