Why didn’t the frenectomy procedure help with my baby’s tongue-tie? A guide for families

Ankyloglossia, commonly referred to as tongue-tie, frequently caused by a short and/or thick lingual frenulum, usually restricts the tongue from extending beyond the gum line and also from lifting and reaching the palate, which is the tongue’s normal resting position in the mouth.  This tongue restriction, along with lip ties and sometimes buccal ties, very often interferes with breastfeeding, forcing babies to compensate which typically presents as a shallow, painful latch causing nipple damage and reduces the likelihood that breastfeeding will continue for two years as recommended by the World Health Organization. More importantly, this issue can take a toll on mothers’ health, both physically and emotionally, and mothers are not reaching their personal breastfeeding goals. Complicating matters further, even when these tethered oral tissues are recognized and released early in the life of the baby, oral restrictions may continue to interfere with breastfeeding, giving the procedure a bad name, when families feel like it “did not help” or perhaps even worsened breastfeeding symptoms. Some symptoms may continue as the baby grows, negatively influencing, feeding, sleep, growth and development. Some may even struggle with related issues their entire lives.

This simple, non-invasive and very effective procedure is failing families more often than anyone wants to admit and there are several reasons this is occurring, many of which may be avoided.

Although there are many healthcare providers whose scope of practice includes performing the frenectomy procedure, with at least as many tools and methods to perform it, the current evidence base is minimal and standards of care non-existent. No protocols or anything beyond proclaimed current best practices state how frenectomies should be performed. An Internet search for guidance quickly reveals how much the information varies, and sometimes quite drastically between providers of this procedure.

Frenectomy providers found in North America include, Dentists, ENTs, Surgeons, Physicians, Pediatricians and Family Nurse Practitioners, each with their own education and training, which can be extremely minimal when pertaining to this procedure. Currently in the US none of these specialties have any formal frenectomy education or training in place.

Some of the popular methods currently practiced to release (and revise) ties include scissors, scalpel, a variety of lasers, electro surge and other electrocautery tools, with some of these claiming to be lasers. The competency and experience of the provider with their tool of choice obviously also varies. Additionally, laser companies are unregulated and so again, without any current standards in place, this can quite literally mean someone can purchase a laser and begin performing procedures without any training on the laser just purchased. This is especially frightening when taking into consideration the many different possible setting options available with each laser.

Inexperienced and perhaps undereducated frenectomy providers, although well-meaning, may not actually release the entire restriction, sometimes admitting to ‘a conservative approach’. Others may believe they are providing a full release, which can be very difficult or impossible with certain tools like scissors, often due to bleeding and inability to see or access remaining frenulum. With these kinds of procedures it is common to use silver nitrate to cauterize and stop bleeding which can lead to suboptimal healing and restrictive scarring of the delicate tissues beneath the tongue.

When providers use hot-tipped tools to release ties, even when performed really well, there’s a very good chance that the wound will heal with significant scar tissue that can result in the return of or continued restriction.  Scar tissue is also inelastic, and has the potential for reducing tongue mobility. Use of these tools that heat up tissues also cause greater discomfort than a tool that never comes into contact with tissues, like Co2 lasers. This pain risks infant oral aversion.

Sometimes no pain management instructions are provided which can actually worsen feeding issues temporarily. Also, very often no wound management instructions are provided or even recommended for encouraging ‘healing by secondary intention’, meaning purposefully encouraging very slow, gradual healing, which is known to minimize any future restriction in tongue movement. The only exception for when active wound management exercises would not be recommended would be cases of partial release where frenulum remains and there is no diamond wound area beneath the tongue to work with.

Few providers know of or understand the necessity of physical therapy before, during and/or after the procedure and therefore may not be recommended at all. Physical therapy after any procedure is routine in order to achieve optimal outcomes. Benefits of the frenectomy procedure may be drastically reduced without this necessary component.

The timing of release also needs careful consideration especially in certain circumstances as with birth trauma and releasing tethered oral tissues in an older baby.

In cases of suboptimal healing, commonly referred to as reattachment, mothers feel the setback of returning symptoms. Providers may not see or agree with the severity in restriction or may discover other possible reasons that may seem to explain the symptoms as something else unrelated to oral restrictions. Once again, mothers and babies will continue to struggle. Sometimes a mother may insist on a second procedure while others will believe the procedure did not work to help their situation. Adding to frustration, providers may refuse to revise or redo another provider’s procedure leaving the breast feeding dyad to continue to persevere through returning or continued symptoms after initial release. For too many mothers, difficulties that resurface and cannot seem to be overcome might result in discontinuing breastfeeding or early weaning.

In some parts of the country, and with more seasoned release providers with many years of experience, second and even third procedures are not uncommon and breastfeeding ultimately succeeds. Still for many release providers, second and third revisions are often viewed negatively as reflecting poorly on adequacy of procedures being performed. Another reason may be that repeated procedures will interfere with data collected and overall success rates in their practices, which is a commonly asked question amongst release providers.

The comparing of “success rates” among peer frenectomy providers may serve no purpose. There are numerous variables to consider that make comparison impossible, inaccurate and with no validity. The sharing of unedited testimonials from families, especially those who’ve gone through the frenectomy experience more than once, however, can be very helpful and something everyone can continue to learn from.

It’s important to note that even in situations where an initial release was unsuccessful for any of the reasons previously mentioned, the revision carried out by the knowledgeable, experienced release provider is known to further reduce or resolve symptoms and supports successful breast feeding outcomes. So while a repeated procedure cannot guarantee success, as there are no guarantees in life, when a frenectomy is performed properly and adequately by well-educated and experienced release providers, and includes continued support of the family by the highly skilled interdisciplinary, breastfeeding supportive team, it is highly successful in the vast majority. Poor outcomes are virtually unheard of in situations with experienced professional provider teams.

Many well established providers of the frenectomy procedure have a deeply moving story, often stemming from their own personal experiences, that first compelled them to learn how to perform this procedure. This passion to help others to avoid the struggles they themselves may have endured, continues to drive them to learn more, share their knowledge and time freely, and collaborate with other healthcare professionals in their own communities and beyond. These few providers often have long term high breastfeeding success rates that demonstrate their passion for optimal health, proving over and over again that they care and are truly making a difference in the world of tethered oral tissues. We can be thankful for these professionals who listen to parents, nursing mothers and the symptoms they experience or continue to experience, and are willing to support them to reach their goals, whatever it takes, putting the mother and breastfeeding above all else.

American Breastfeeding Foundation is dedicated to providing access to education and lactation care to ALL vulnerable breastfeeding families. If you are struggling with breastfeeding or have questions, American Breast Feeding Foundation is here to help.

René Moore is a registered IBCLC in private practice in Phoenix Arizona.  Her interest and passion for breastfeeding began in 1996 upon becoming a mother.  In 2000 she became a La Leche League Leader and still leads local meetings for groups she started in her area, then also became an International Board Certified Lactation Consultant to be able to help more mothers, babies and families.  She’s been performing in-home lactation consultation visits for well over a decade and regularly attends procedures when requested by parents and welcomed by providers.

American Breast Feeding Foundation Copyright © 2020 – All Rights Reserved / May be used with permission: rene.moore@americanbreastfeedingfoundation.com