SAN DIEGO (FRONTLINE MEDICAL NEWS)Pediatricians should perform frenotomy to release tongue-tie if an affected baby is struggling to nurse and the mother reports breast pain and trauma as a result, according to Dr. Anthony Magit.

“There are so few problems with this procedure, and it works so well that there is really no excuse for not doing it when it’s indicated,” added Dr. James Murphy, a pediatrician and certified lactation consultant based in San Diego.

About 4% of babies are born with tongue-tie (or ankyloglossia), an anatomic variation in the frenulum that restricts the tongue’s movement. The condition impedes nursing and can later cause problems with speech articulation, particularly for languages such as Spanish that require a relatively high amount of tongue movement, said Dr. Magit, professor of surgery at the University of California, San Diego.

Babies with tongue-tie may latch poorly, chomp at the breast, fuss, or fall asleep while nursing, and fail to gain weight normally, Dr. Magit added. Their mothers tend to develop painful, engorged breasts, which increases their risk for mastitis and is a reason to perform frenotomy promptly, he said. “If frenotomy is performed early – at 1 or 2 days of age – you will see more rapid improvement, whereas if it’s done at 2-3 weeks old, the mom is less likely to have problems completely resolve,” Dr. Magit emphasized at the annual meeting of the American Academy of Pediatrics.

If tongue-tie is suspected, a tongue depressor can be used to elevate the tongue and visualize the frenulum, said Dr. Magit. Tongue-tie appears as an unusually short, long, tight, or thickened frenulum (or frenum) that may be pyramidal, triangular, vertical, or even bumplike, Dr. Murphy added. The lateral edge of the tongue may form the shape of a W, V, or heart, and the baby’s lips may appear cobblestoned as a result of trauma during attempts to nurse, he said.

When Dr. Murphy suspects tongue-tie, he said he lays the baby on its back on an examining table with the shoulders slightly elevated on a blanket. Then he pulls the lower jaw gently down with both thumbs while using his palms to restrain the baby’s arms by the sides. This approach enables him to best see the frenulum and to observe the extent to which it is restricting the tongue’s movement, he added. An assistant uses the same hold technique when he performs frenotomies, Dr. Murphy added.

Frenotomy in newborns requires no anesthesia and can be performed in a nursery or office, said Dr. Magit. The infant is swaddled, a grooved retractor is used to direct the tongue toward the palate, the frenulum is clamped to create crush injury and direct the line of incision, and scissors are used to clip the frenulum within 1-2 mm of the junction of Wharton’s ducts, he said. After the procedure, the tongue is swept with a gloved finger and stretched to ensure complete release of the frenulum, Dr. Magit added. Most mothers report an immediate improvement in breastfeeding, including better latch, suction, and milk flow, he said.

Frenotomy in older infants and young children requires general anesthetic in the operating room, while children older than 5 years can undergo the procedure under local anesthetic in an office setting, Dr. Magit said. Complications after frenotomy are “extremely rare,” and include scarring or recurrent ankyloglossia and trauma to Wharton’s ducts, he added. Parents should be told that it is normal for yellow transitional tissue to develop at the wound site during healing, said Dr. Murphy.

Adults with tongue-tie also can benefit from frenotomy because the condition causes chronic tightness of muscles surrounding the tongue, said Dr. Murphy. “When you snip that fibrous band, the surrounding muscles relax, the hyoid bone goes down, and the larynx goes down,” he said. He has released frenula in adults and has had them report a dramatic improvement in sleep afterward, he noted.

Dr. Murphy and Dr. Magit declared no relevant financial conflicts.


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