To Cut or Not to Cut
Why frenectomy, or tongue tie release, may not always be the best choice
Social media is rife with stories about how tongue ties and tethered oral tissues (TOTs) are the reason for almost all breast and bottle-feeding difficulties and that a simple “release” (frenectomy or frenotomy) will immediately result in the resolution of all such problems. Don't worry, I am not here to argue the merits, or lack thereof, of tethered oral tissue release. That is not my intent with this blog. Instead, I want to share some recent cases where a ”simple” tongue tie release resulted in greater complications as a result of simplistic, “one size fits all” thinking as applied to TOTs. In these cases, and others that I have seen, no one took the time to truly assess the unique situation of the specific child nor took note of any underlying diseases or conditions that may, put the child at risk and be contraindicated for tethered oral tissue release.
I can almost hear the tongue clicks in the background as people read this and say, “How could a tongue tie release possibly put a child at risk? It's a simple procedure that is currently being completed by dentists, ENT's, pediatricians, and self proclaimed specialists, after all!”
In order to thoroughly answer this question, I need to give you the reader, a better understanding of anatomy and physiology, and in order to do so, I'm going to go a little bit sideways and talk about a subject with which most people are more familiar – obstructive sleep apnea (OSA). For those of you with friends, spouses, or even perhaps, yourself, who sleep with a c-pap machine, you know all about OSA and how it impacts the quality of your sleep and the quality of the sleep of those who happen to sleep with you. According to the Mayo Clinic website, OSA …occurs when the throat muscles (emphasis mine) relax and block the airway (Obstructive Sleep Apnea - Symptoms and Causes - Mayo Clinic, 2023). This relaxation of the muscles on the throat can result in the jaw dropping backwards as well as the tongue falling back towards the throat for back sleepers. One of the names for this condition is temporary “upper airway collapse” and it can result in people struggling to breathe when they are sleeping.
Now, I want you to think back to those infants who are having their tongues released. Why are we releasing the tongue? In order to release it partially from the floor of the mouth, in order to make it more mobile so as to aid in elevation and protrusion (sticking it out), right? But this release can also result in that same tongue now falling back towards the airway when the baby sleeps. For most children, this is not a problem, but in 2 different children I evaluated recently, this ability for the tongue to fall backwards towards the throat was actually a very bad thing…
The following cases sited here have been altered in order to remove any identifiable information.
Case 1: Ever heard of laryngomalacia? According to the Boston’s Children’s Hospital website, laryngomalacia is a condition that results from a birth defect in your child’s voice box (larynx). The soft tissues of the larynx fall over the airway opening and partially block it. This can result in stridor — a high-pitched sound that is heard when your child inhales (Laryngomalacia (Laryngealmalacia) | Boston Children’s Hospital, n.d.) I recently had a consultation with a mom of a newborn with very noisy breathing. The baby also had significant difficulty feeding at both the breast and the bottle because they had a very difficult time breathing while eating. Unfortunately, lactation only saw a “poor latch” and did not take into consideration that this child was working very hard to breathe. Recommendation? Tongue-tie release. The pediatrician, someone who has little to no training in infant feeding or feeding disorders, agreed with the hospital lactation consultant and did a tongue-tie release in the office when the baby was still only days old.
The result? The baby had more problems at the breast and when feeding with a bottle. Her breathing became noisier and often sounded so wet that it sounded like she was breathing through a pool of liquid. When respiration sounds wet like this, it is strongly suggestive of aspiration (when food or fluid is misdirected to the lungs).The mom contacted me because she was extremely worried about her baby and the baby's breathing. She said he sounded like he was drowning and sent me a film to watch and listen to him. The poor thing! All I did was listen for less than a minute and I knew that this baby's first and foremost concern was BREATHING!
Interestingly enough, while both the lactation counselor and the pediatrician were quick to diagnose a tongue tie, no one had ever stopped and listened closely to this infant and suggested that he needed to be seen first and foremost by an ENT for evaluation for and possible treatment of suspected laryngomalacia. Anyone who is involved in feeding of any kind should be looking at airway stability first. Why? Because in order to live, you have to breathe, and babies will always choose breathing over feeding, even when very, very hungry.
Once this little one got to the right specialists, he was diagnosed with laryngomalacia along with aspiration. Did the aspiration occur as a result of the frenectomy? Since no one did any before and after x-ray imaging there is no way to know. However, this child had baseline upper airway collapse as a result of his congenital (at birth) laryngomalacia. Releasing the tongue, which allows it to fall backward into an already compromised airway, is contra intuitive and puts that baby’s airway further at risk for obstruction. A thorough evaluation of the whole child, rather than just looking at the latch at the breast, would have informed both the lactation consultant and the pediatrician that for this child a frenectomy was likely to be an unsafe choice. This is a case of a very narrow focus by the medical professionals involved in this infants’ care, a one-size-fits-all approach, and a lack of understanding of how tongue attachment to the jaw may impact the function of the upper airway.
Case 2: Micrognathia. According to Boston’s Children’s Hospital, micrognathia is an underdeveloped or abnormally small lower jaw (mandible) that is much shorter than the rest of the face and as a result of the smaller jaw this can result in Glossoptosis: A tongue that is positioned further back in the mouth than normal. Because of the small mandible, the tongue is too large for the airway (Philadelphia, n.d.) As you may expect, these conditions can result in feeding difficulties both at the breast and with a bottle. Why? The actions of feeding for an infant are a combination of both sucking and compression. In a baby with a small jaw, compression is difficult because of the decreased jaw size and the ability to create a good seal for suction is difficult because bottles aren’t generally shaped to fit slightly differently shaped and angled mouth openings. However, when the tongue is solidly anchored to the mandible it is able to help the jaw to achieve better compression by aiding the muscles that elevate the jaw, while also filling the spaces around the nipple thus aiding in improved suction.
Unfortunately for this little one, one of the first things that was done when mom found that she was having difficulties with breastfeeding was to head to a clinic that specializes in TOTs where the baby’s lingual frenulum was cut as well as the baby’s “lip tie”. Was there any improvement in breastfeeding? No. So this little one was seen multiple times by a lactation professional, a pediatric chiropractor, as well as receiving craniosacral work, none of which relieved the difficulties mom was having with sore breasts nor with the baby falling off the nipple throughout the feeding.
Interestingly, breastfeeding is typically easier with these babies with smaller jaws, because the breast tissue is more malleable and able to fill the oral space. However, because the jaw is smaller and/or is placed a little further back in alignment, an attached tongue is necessary in order to help move the jaw forward as it works to naturally cup the breast.
When I evaluated this baby, what I was observed was that a now frenum-less tongue was pulling back and humping up at the back of the mouth, rather than coming forward under the breast. Additionally, because of the smaller jaw size and its placement, the baby would naturally work herself off of the nipple while feeding because her jaw, without the aid of her tongue, was unable to really get under the breast tissue for compression. With each suck, the jaw slowly moved the baby’s head back and away from the breast.
This baby’s mom has breastfed older siblings so once she understood why the baby was coming off the nipple, we were able to work on positioning of both mom and baby, allowing the baby to be above/on top of the breast in order for gravity to help the jaw moved forward. Paired with mom watching her child closely to help readjust the latch as baby moved back and away, mom was able to successfully continue breastfeeding. But that tongue tie release was not helpful for this child and likely exacerbated already difficult latching issues that resulted from physiological differences.
A few final thoughts…
Social media at its best, brings people together and helps people share ideas as well as acting to educate and inform. It also, by its very “social” nature, can quickly become a forum for hyperbolic claims regarding miracle cures and unknown conditions that are proliferating throughout our communities without our knowledge. Trends, may they be in fashion, music, childcare, or health quickly become monetized and we all must be careful that we don’t just gobble up the beautiful pictures and perfect life headlines without scrutinizing who is doing the posts and why.
My suggestion. For every headline or media post that seems "to good to be true" take a moment and ask yourself "What's in it for the person posting?" Of put on your nerd hat and pull up Google scholar and look for articles on things like TOT's. That's where I read a 2021 study regarding the usefulness of frenectomy that found while 70% of lactation consultants surveyed believed that tongue ties result in feeding problems, 90% of pediatricians believe that this is rarely the case.(my emphasis) (Geneeskd,2021). And another report from 2017 in the Journal for the American Academy of Otolaryngology- Head and Neck surgery that indicated that tongue tie releases have increased from 3934 annually in 1997 to 32,837 in 2012. That’s greater than an increase of 8x over 15 years!
Be inquisitive, especially when it comes to the health and wellbeing of your precious children.
And if you want to learn more, reach out. I'd love to chat!