Surgical procedures to assist newborns in breastfeeding are not always necessary

Surgical procedures to assist newborns in breastfeeding are not always necessary

It is estimated that between 4 and 10% of babies are born with ankyloglossia1, commonly referred to as a 'tongue-tie’' The condition appears to be more common in boys than girls and occurs when the piece of tissue that connects the bottom of the mouth and the tongue (the lingual frenulum) is ubnormally short, thick or tight. This may give the appearance of a heart-shaped tongue.

Tongue-tie (ankyloglossia)
Left: Tongue-tie (ankyloglossia), Right: Tongue-tie causing heart-shaped tongue

In some cases, the terms 'ankyloglossia' or 'lip-tie' may also be used to refer to the piece of skin that connects the upper lip to the gum (the labial frenulum) being too short, thick or tight.

Lip tie (labial frenulum)
Lip-tie (labial frenulum)

Both a lip- and tongue-ties can be corrected with a simple procedure known as a frenotomy (also referred to as frenulotomy, frenulectomy or 'tether release' surgery). In recent years this type of surgery has experienced a notable upswing but the findings of recent research call into question whether too many infants are undergoing this procedure to improve breastfeeding despite limited medical evidence of its effectiveness2

How does ankyloglossia affect breastfeeding?

Ankyloglossia restricts the tongue and lip’s range of motion. While this may not always cause a problem, in some cases it can interfere with breastfeeding. Later in life a tongue-tie may cause issues with eating, swallowing and speech3.

When it comes to breastfeeding, issues may arise in babies with a tongue-tie as the tongue is used to latch on to the breast. To latch onto the breast and seal the latch in order to drink milk, the baby’s tongue is extended, taking the nipple and some of the surrounding areola into the mouth.

When the tongue and/or upper lip’s range of motion is restricted this can not only make latching and sealing difficult but also prevent the baby from performing the movements required to squeeze the milk ducts under the nipple during breastfeeding. This often results in painful breastfeeding for the mother and poor extraction of milk from the breast for the infant, both of which are reasons why some women stop breastfeeding early.

The early termination of breastfeeding is less than ideal. It is well established that breastfeeding affords the breastfeeding mother and infant both short- and long-term health benefits4,5.

What does tongue-tie and lip-tie surgery (frenotomy) involve?

A frenotomy (aka frenulotomy) is a simple release or ‘clipping’ of the frenulum that is performed with or without local anaesthesia6.

In instances where local anaesthesia is used, it will be administered, followed by a waiting period for the medication to take effect. The newborn is then held in a swaddling pose and his/her head is gently held by the surgeon’s assistant. The tongue or lip is lifted and held in place either by two gloved fingers or with the help of forceps and a retractor. The frenulum is then snipped taking care to avoid injury to the nearby structures.

Frenotomy for tongue-tie
Left: Tongue-tie (ankyloglossia), Right: Post frenotomy

The procedure rarely causes any serious bleeding and any bleeding that does occurs is controlled by applying gentle pressure to the area using a gauze sponge.

Some surgeons may suggest using a laser to perform the incision as this allows for a bloodless cut, but this does make the procedure more expensive and has not proven to offer any added advantage in achieving the results.

Once the procedure is complete and infant may breastfeed immediately.

While most studies report little discomfort and few adverse effects, the possible adverse effects of a frenotomy may include6:

  • Bleeding
  • Infection
  • Pain
  • Ulceration
  • Possible damage to the tongue and submandibular ducts

Why this surgery may not be necessary in the majority of cases

Emerging evidence from a new study, published in JAMA Otolaryngology - Head & Neck Surgery this week indicates that the majority of infants referred for tongue-tie and/or upper lip tether surgery did not require the procedure. In fact, less invasive methods can assist in achieving successful breastfeeding2.

This was demonstrated in an observational quality improvement study that took place between March and December 2018. It involved 115 newborns ranging from 19 to 56 days of age who were referred to a tertiary care centre for difficulty with breastfeeding with the recommendation of undergoing a frenotomy.

A comprehensive feeding evaluation was conducted by a multidisciplinary team of doctors including a speech and language pathologist. Each infant’s oral structures and function as well as their ability to breastfeed were examined. The mothers were taught techniques that addressed the specifically identified difficulties being experienced prior to considering surgical intervention.

Following these interventions 72 of the 115 infants (62.6%) found success in feeding, gained weight and did not require surgical intervention. It was established that the remainder of the referred cases did, in fact, require the procedure.

The study’s authors conclude that the majority of infants referred for surgery to address ankyloglossia may instead benefit from alternative interventions after a comprehensive feeding evaluation. They note that a close collaboration of multidisciplinary teams is imperative for treating babies with breastfeeding difficulties.

Lactation specialist for breastfeeding difficulties

Action plan for mothers whose babies have difficulty breastfeeding

It is common to think that breastfeeding is a natural instinct and that any difficulty experience with this must be the result of some kind of physical issue. This, however, is not always the case.

Likewise, while some breastfeeding issues related to ankyloglossia may require surgery, this should not be the first option. Instead of spending endless days and nights fretting over your baby’s feeding (or lack thereof) and any issues you may be experiencing as a result, ask for a referral to a speech and language pathologist as well as a lactation consultant. These specialists are specifically trained to assist you in determining the root cause of the issue and to give advice on how to correct it with minimally invasive techniques.

Only once all of these attempts fail, is it time to consider an alternative approach such as surgery.


1. Hong P. Ankyloglossia (tongue-tie). Can Med Assoc J. 2012;185(2):E128-E128. doi:10.1503/cmaj.120785
2. Caloway C, Hersh C, Baars R, Sally S, Diercks G, Hartnick C. Association of Feeding Evaluation With Frenotomy Rates in Infants With Breastfeeding Difficulties. JAMA Otolaryngology–Head & Neck Surgery. 2019. doi:10.1001/jamaoto.2019.1696
3. Chinnadurai S, Francis D, Epstein R, Morad A, Kohanim S, McPheeters M. Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review. American Academy of Pediatrics. Published 2015. Accessed July 12, 2019.
4. Victora C, Bahl R, Barros A et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475-490. doi:10.1016/s0140-6736(15)01024-7
5. Ip S, Chung M, Raman G et al. Breastfeeding and Maternal and Infant Health Outcomes In Developed Countries. AAP Grand Rounds. 2007;18(2):15-16. doi:10.1542/gr.18-2-15
6. Isaacson G. Ankyloglossia (tongue-tie) in infants and children. Published 2019. Accessed July 12, 2019.