Frenotomy

What is a Frenotomy?

A frenotomy is a surgical procedure that releases a tight sublingual frenulum by clipping the frenulum by use of surgical scissors or by use of a directed laser. ENT (ear, nose, and throat) specialists and pediatric dentists are the primary providers who perform frenotomies although some nurse practitioners and midwives who are lactation consultants have special training to perform the procedure as well. The type of frenotomy performed by laser or clipping by surgical scissors solely depends on the preference/training of the provider.

What is the Risk?

As of today, there are no randomized controlled studies comparing the two procedures to determine which has better outcomes or less adverse effects. Although there are publications touting less pain, improved healing, and less bleeding with laser frenotomies, in my almost 24yrs experience evaluating infants after a frenotomy, I have not seen any difference in bleeding risks between either procedure. Anecdotally, I had noted more episodes of delayed healing upwards of 7 days in the infants with laser frenotomies versus simple surgical clipping where healing occurred by day 3 at the latest. However, did this difference cause any significant negative outcomes or of any clinical significance? Maybe not. As far as laser frenotomies resulting in less pain versus surgical clipping, that claim is dubious at best.

A risk factor of frenotomy that I don’t see acknowledged much is oral aversion with breast refusal which occurred in 3 infants in my practice- all three of them were post frenotomy by laser. I know this is a small number but something to be aware of and I wonder if it was related to accessory tissue damage, provider with poor technique or limited training, disturbance of nearby nerves causing tongue numbness, or excessive pain. These are all questions that cannot be answered in the current body of literature. This is not meant to deter one from choosing frenotomy by laser as it is a viable option, but I just present food for thought. Again, the need for better studies to sort out these kinds of issues are necessary to guide our decision making.

There is no denying unfortunately that performing frenotomies has become big business, and I personally have seen pediatric dentists charge anywhere from $500-$1000 for laser frenotomies as many dental plans do not cover this procedure. According to Dr. Marty Makary from his book Blind Spots: When Medicine Gets It Wrong and What It Means for Our Health, recent Medicaid data revealed frenotomy has become the primary procedure performed by some dentists. On top of that, a Cochrane Review of literature in 2017 only found 5 randomized controlled trials from a body of publications spanning 20 years which concluded there were no improvements in breastfeeding outcomes after frenotomy. Albeit the studies themselves had poor designs, poor definition of tongue-tie, poor standardization of tongue-tie diagnosis, small sample sizes and different endpoints.

All of this should be taken under advisement to ensure not only an accurate diagnosis of tongue-tie, but whether that is the primary reason for any breastfeeding difficulties and thoroughly understanding the risks/benefits of frenotomy. Second opinions related to the diagnosis of tongue-tie are encouraged to avoid unnecessary procedures, cost, and potential adverse outcomes.

So what’s a mom to do?

As with most things in medicine, when there seems to be confusion surrounding a diagnosis or treatment usually common sense prevails and the answer usually lies somewhere in the middle of the two opposing narratives. My professional opinion is that there is a place for frenotomy in addressing latch issues and improving breastfeeding outcomes. However it is to be applied judiciously, and there are babies for whom I have not recommended frenotomy. It’s my ethical responsibility as a Nurse Practitioner and Lactation Consultant to provide full informed consent and inform parents of what is known and most importantly what we don’t know.

If you have been told your baby has a tongue-tie and would like a second opinion or are unsure if your baby has a tongue-tie, please schedule a Lactation Consultation. Go to www.milkwagon.net for more information about location, services, pricing. You can book an appointment on-line or call 307-212-8283