In the JournalsPerspective

Tongue-tie surgery unnecessary for about 60% of infants

More than half of infants referred to an otolaryngology center for tongue-tie surgery did not need to undergo the procedure after consultation with a speech-language pathologist, according to recent findings.

Tongue-tie, or ankyloglossia, is characterized by the lingual frenulum attaching close to the tip of the tongue. Researchers suggest that between 4% and 11% of all newborns have this condition, which can cause problems breastfeeding. An analysis of the Kids’ Inpatient Database showed that tongue-tie surgeries increased 10-fold in the United States between 1997 and 2012, but inadequate evidence supports that this surgery improves the ease of breastfeeding.

“We have seen the number of tongue-tie and upper lip tether release surgeries increase dramatically nationwide without any real strong data to show these are effective for breastfeeding,” study author Christopher J. Hartnick, MD, MS, director of the division of pediatric otolaryngology and the Pediatric Airway, Voice and Swallowing Center at Massachusetts Eye and Ear Infirmary, said in a press release. “We don’t have a crystal ball that can tell us which infants might benefit most from the tongue tie or upper lip release, but this preliminary study provides concrete evidence that this pathway of a multidisciplinary feeding evaluation is helping prevent babies from getting this procedure.”

Photo of mother breastfeeding her infant 
Source: Adobe Stock

The researchers conducted an observational quality improvement study that included 115 infants and their mothers. All infant-mother pairs were referred for feeding evaluation between March and December 2018 because of difficulties with breastfeeding. The evaluation was led by speech-language pathologists.

Surgery was unneeded for 62.6% of referred infants after consultation with a speech-language pathologist. When surgery was needed, 8.7% required labial frenotomy only, and 27.8% had both labial and lingual frenotomy.

“We’ve learned that an interdisciplinary collaboration is key to a thorough feeding evaluation,” Cheryl Hersh, MS, CCC-SLP, a pediatric speech-language pathologist at MassGeneral Hospital for Children, said in the release. “This is still a work in progress, but we have learned a great deal about what we can do differently to help our patients and their families. In doing so, we have been able to identify many babies who are having breastfeeding problems that are not related to their lip and tongue anatomy.” – by Katherine Bortz

References:

Caloway C, et al. JAMA Otolaryngol Head Neck Surg. 2019;doi:10.1001/jamaoto.2019.1696.

O’Shea JE, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD011065.pub2.

Walsh J, et al. Otolaryngol Head Neck Surg. 2017;doi:10.1177/0194599817690135.

Disclosures: Hersh reports receiving a salary from the Massachusetts General Hospital. All other authors report no relevant financial disclosures.

More than half of infants referred to an otolaryngology center for tongue-tie surgery did not need to undergo the procedure after consultation with a speech-language pathologist, according to recent findings.

Tongue-tie, or ankyloglossia, is characterized by the lingual frenulum attaching close to the tip of the tongue. Researchers suggest that between 4% and 11% of all newborns have this condition, which can cause problems breastfeeding. An analysis of the Kids’ Inpatient Database showed that tongue-tie surgeries increased 10-fold in the United States between 1997 and 2012, but inadequate evidence supports that this surgery improves the ease of breastfeeding.

“We have seen the number of tongue-tie and upper lip tether release surgeries increase dramatically nationwide without any real strong data to show these are effective for breastfeeding,” study author Christopher J. Hartnick, MD, MS, director of the division of pediatric otolaryngology and the Pediatric Airway, Voice and Swallowing Center at Massachusetts Eye and Ear Infirmary, said in a press release. “We don’t have a crystal ball that can tell us which infants might benefit most from the tongue tie or upper lip release, but this preliminary study provides concrete evidence that this pathway of a multidisciplinary feeding evaluation is helping prevent babies from getting this procedure.”

Photo of mother breastfeeding her infant 
Source: Adobe Stock

The researchers conducted an observational quality improvement study that included 115 infants and their mothers. All infant-mother pairs were referred for feeding evaluation between March and December 2018 because of difficulties with breastfeeding. The evaluation was led by speech-language pathologists.

Surgery was unneeded for 62.6% of referred infants after consultation with a speech-language pathologist. When surgery was needed, 8.7% required labial frenotomy only, and 27.8% had both labial and lingual frenotomy.

“We’ve learned that an interdisciplinary collaboration is key to a thorough feeding evaluation,” Cheryl Hersh, MS, CCC-SLP, a pediatric speech-language pathologist at MassGeneral Hospital for Children, said in the release. “This is still a work in progress, but we have learned a great deal about what we can do differently to help our patients and their families. In doing so, we have been able to identify many babies who are having breastfeeding problems that are not related to their lip and tongue anatomy.” – by Katherine Bortz

References:

Caloway C, et al. JAMA Otolaryngol Head Neck Surg. 2019;doi:10.1001/jamaoto.2019.1696.

O’Shea JE, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD011065.pub2.

Walsh J, et al. Otolaryngol Head Neck Surg. 2017;doi:10.1177/0194599817690135.

Disclosures: Hersh reports receiving a salary from the Massachusetts General Hospital. All other authors report no relevant financial disclosures.

    Perspective
    Adva Buzi

    Adva Buzi

    Considering the significant increase in frenotomies over the past several decades, this study is an important addition to the current literature addressing the relationship of ankyloglossia and lip tie to infant breastfeeding.

    Literature examining the effectiveness of frenotomy and lip release for breastfeeding difficulty is lacking. A Cochrane review of current studies showed sufficient evidence that lingual frenotomy led to temporary relief of nipple pain in breastfeeding mothers but did not result in measurable improvements in infants’ feeding. The effect of lip tie on newborn breastfeeding has been even less well studied. It is logical that appropriate patient selection through comprehensive evaluation would improve outcomes of frenotomy.

    In this study, Calloway and colleagues have demonstrated that a multidisciplinary feeding evaluation may mitigate the need for surgical intervention in many babies referred for breastfeeding difficulty associated with ankyloglossia. The researchers’ conclusions have far-reaching implications. They suggest that the large increase in the incidence of frenotomy has outpaced measures of evaluation to determine the etiology of newborns’ feeding difficulty, even among referral sources with expertise in breastfeeding. Therefore, many frenotomies may be offered and performed on inappropriately selected patients. Their results also imply that, through thorough evaluation, many babies who are candidates for lingual frenotomy may also benefit from concomitant lip release.

    Importantly, the authors have not demonstrated that speech evaluation and a conservative treatment pathway results in superior outcomes to frenotomy because they did not compare the two or provide post-treatment efficacy data for either approach. Their analysis does provide design for an entire treatment arm of such an important study. The authors also mention the high cost of frenotomy but do not detail the cost of speech evaluation and subsequent intervention.

    Infants with ankyloglossia should undergo a comprehensive history and exam before undergoing a procedure. A multidisciplinary approach, as outlined by the researchers, or development of better tools to evaluate infants who present for frenotomy would likely decrease unnecessary procedures. There is great need to determine the efficacy of frenotomy and lip release, and this study significantly increases knowledge regarding this important question. 

    • Adva Buzi, MD
    • Attending physician
      Division of otolaryngology
      Balance and Vestibular Program
      Children’s Hospital of Philadelphia

    Disclosures: Buzi reports no relevant financial disclosures.