Ilana Shapiro* describes breastfeeding her first baby as a nightmare. Not only did her nipples hurt while nursing, but the pain lasted for two hours afterward, due to vasospasms—when the blood vessels in the nipple tighten and spasm. “The pain was so bad that I couldn’t sleep. Then, just as the pain started to go away, she wanted to be fed again,” says the mother of two, who lives in Toronto.
Six weeks postpartum, Shapiro found herself, at the advice of friends, at the Newman Breastfeeding Clinic in Toronto. A lactation consultant diagnosed her infant with a tongue-tie—an unusually short or thick frenulum, the piece of tissue connecting the bottom of the tongue to the floor of the mouth. The lactation consultant's theory was that the tongue-tie was the culprit behind a bad latch, which was causing her vasospasms. With her permission, Newman, the paediatrician who runs the clinic, cut the piece of tissue under her infant’s frenulum using medical scissors.
“My daughter screamed right away. She’s crying, I was crying. My mom was crying. It was awful,” recalls Shapiro. “I felt so guilty. She looked at me as if she were thinking, ‘Why did he do that to me?’”
All the tears would have been worth it had the tongue-tie procedure, called a frenectomy, helped with the breastfeeding pain. But it didn’t. A couple of weeks later, Shapiro started exclusively pumping.
There is little doubt among health providers that cutting a frenulum can help with breastfeeding. That’s because for breastfeeding to work well, the tongue needs to move forward and upward, both to help create a seal and also to put enough pressure on the breast to stimulate the release of milk. A tight frenulum can keep the tongue back in the mouth, causing a poor seal and a shallow latch.
But while all the experts agree tongue-ties can cause a problem, some worry the procedures to fix them are done too often and sometimes aren’t necessary. It seems like an obvious quick fix: Cut the frenulum with scissors or vaporize it with a laser to improve mobility in the tongue. But the scientific evidence that it helps with breastfeeding is weak. And in rare cases, tongue-ties can cause complications, like bleeding or infection. So why do so many new mothers swear by it?
Canadian data shows that tongue-tie surgery across the country (excluding Quebec) almost quadrupled from 2002 to 2014, but the number varies greatly by province. For example, in 2014, Alberta and Saskatchewan both had rates of the procedure four times higher than British Columbia. This suggests that healthcare providers’ attitudes about frenectomies are far from consistent. “How a tongue-tie is diagnosed and managed also differs according to the provider you see,” says Anne Rowan-Legg, an Ottawa-based paediatrician who wrote the Canadian Paediatric Society’s position statement on tongue-ties and breastfeeding.
Rowan-Legg is worried about the meteoric rise in the procedure, given the evidence it works is pretty weak. Sure, a frenectomy is a relatively simple surgical procedure and “the risks are small,” Rowan-Legg says, but, “if it’s done through the provincial insurance system, that has a cost to all of us, and if it’s done in private dental offices, the out-of-pocket cost can be significant.” Many dentists, who aren’t covered by provincial health insurance plans, charge $500 for the procedure. A mom might go to a dentist because the wait time to see a doctor who diagnoses the condition is too long, or because her physician disagreed that tongue-tie is the issue making breastfeeding difficult. And, as Rowan-Legg points out, it’s still a surgical procedure, which should never be taken lightly.
But Newman, who estimates his clinic does three to five tongue-tie releases a day, isn’t concerned with the skyrocketing rates of tongue-tie surgeries. “I don’t think tongue-tie is overdiagnosed. On the contrary, it’s underdiagnosed,” Newman said in an email. In his opinion, too many women face obstacles in getting the surgery. “Mothers are in pain, the baby has a tongue-tie and the physician believes that sore nipples are a normal part of breastfeeding,” he explains. Newman thinks the number of women getting the procedure is on the rise simply because more mothers are determined to breastfeed today, compared to two decades ago. According to Statistics Canada, in 2003, 17 percent of moms breastfed exclusively for six months or more. In 2018, 33 percent of moms aged 18 to 34 and 42 percent of those above 35 exclusively breastfed for the same duration. (These statistics only include the provinces, not territories.)
Newman also points to the increased awareness of how tongue-tie interferes with breastfeeding among health providers, especially lactation consultants, who frequently diagnose the issue.
One of the reasons there is so much debate about tongue-tie surgery is that there is not a universal standard for identifying the condition (and when it’s a problem) in the first place. There’s widespread agreement that a frenulum should only be cut if it's limiting the tongue’s mobility to the point that it negatively affects the baby’s ability to breastfeed. That’s because a lot of infants have noticeably short or thick frenulums, but they nurse perfectly well. But for tongue-tied babies who aren’t breastfeeding well, it’s not always easy to tell if the tongue-tie is causing the breastfeeding issues, or whether it's something else.
Leanne Rzepa, an international board-certified lactation consultant (IBCLC) and registered nurse in Calgary, says she diagnoses a tongue-tie based on the IBCLC standard screening tool method. First, she puts a gloved finger in the baby’s mouth “to see how the tongue looks and how it is moving.” Then she’ll ask questions about how feeding is going. “Sore nipples is a pretty classic, telltale sign,” she explains, that a frenectomy might help because it suggests a latch that’s too shallow. Then, she’ll observe a nursing session. “I'm watching for a quivering jaw and a chompy-type suck,” she says. The jaw muscles have to work harder to create a seal around the nipple if the tongue isn’t doing its part, which explains the chompy suck. But they get tired, which can cause quivering. Clicking, from a poor latch, is another clue.
She’s seen great success from tongue-tie surgery. “Almost every mom I work with notices some degree of improvement. It might not fix every issue right away. But typically, there is a noticeable improvement,” she says.
That’s the experience of many moms who talk about breastfeeding and tongue-tie in online chat groups. When I asked a popular parent’s group on Facebook about their experiences with tongue-tie surgery, the responses are overwhelmingly positive, with almost all moms convinced it helped, and some saying it saved their relationship to nursing.
Kristina Huber had the procedure done by a nurse practitioner at a clinic in Montreal after what she calls, “two and a half months of excruciating pain” while breastfeeding. The frenulum snip wasn’t too bad for her son. “After it was snipped, they put him directly to my breast, so the pain was soothed by the breast,” she says. Over the next couple of weeks, nursing got better and better, as her infant learned to breastfeed properly by using his tongue muscles. Before the procedure he was using other means to get the milk, like relying on the movement in his lips and jaw, she explains. Huber continued breastfeeding until her son was two.
The published evidence on tongue-ties is less conclusive. A Cochrane review from 2017 pooled the results from five of the highest-quality frenectomy studies that the researchers could find and concluded that only one of those trials proved the procedure improved breastfeeding in a measurable way, with infants who had the procedure demonstrating a better latch and suck compared to the infants whose parents were told they had the procedure, but actually hadn't. But that study only had around 30 infants in each group. Two of the five trials found that while the infants who had their frenulum clipped didn’t noticeably feed any better, the moms reported less nipple pain.
That is not to say that there haven’t been studies showing frenectomies to be wildly successful. In fact, one of the studies in the Cochrane review showed that 96 percent of the tongue-tied infants who got the frenectomy immediately improved their nursing, compared to 3 percent of the tongue-tied babies who got intensive support from a lactation consultant. But this study wasn’t included in the final results because it relied solely on interviews with mothers instead of independent observations. If you’ve been told by a doctor that a frenectomy is likely going to help, and you want to believe it helped (and that the pain of your helpless babe wasn’t for nothing), you’ll likely look for signs that it worked.
That same bias of “self-report” applies to all the extremely positive reviews of frenectomies on social media. (People are so convinced on the merits of the surgery that those who question it report being kicked out of Facebook groups discussing tongue-ties.) There’s no reason to doubt a mom who says nursing got better after the procedure, but it’s hard to say there weren’t other factors that contributed—like the baby’s mouth getting bigger and the facial muscles getting stronger, or the mom trying other methods to improve nursing around the same time.
A little snip might seem like no big deal, but about five percent of babies have bleeding or three percent have infection-caused ulcers a day or two after the procedure. (In the studies, the complications went away on their own but could have interfered with nursing in the meantime).
The other issue is that something could be missed if a mom and provider are too focused on a tongue-tie. “There are many reasons that kids may have problems feeding in the early days, and not all the health professionals that have a stake in the tongue-tie piece are able to assess for those other issues,” says Rowan-Legg. Complications from the delivery, a mother’s mood, swallowing conditions and a host of other issues can interfere with breastfeeding. A study published this past July looked at 115 babies who had been referred to an ear, nose and throat surgeon to have a frenectomy to improve breastfeeding. Rather than going straight to the surgery, a comprehensive assessment was done by a multi-disciplinary team, including a speech and language pathologist (experts on tongue movement and swallowing disorders), a lactation consultant, and an ear, nose and throat specialist. They observed feedings and considered a range of possibilities for the issues, not just tongue-tie, but also conditions like parental anxiety, too-fast milk flow, and reflux. Before surgery, other things, like advice on how to ensure a good latch, different nursing techniques, and medication (in the case of gastroesophageal reflux) were tried first. In the end, 38 percent went forward with the surgery and 62 percent didn’t. For that latter group, “they were able to breastfeed, and the amount that they were able to breastfeed was sufficient that the children were able to get enough calories to avoid the procedure,” explains Christopher Hartnick, director of the division of pediatric otolaryngology at Massachusetts Eye and Ear, a hospital in Boston.
According to Hartnick, the study suggests that before getting a frenectomy, parents should make sure other issues have been ruled out and may want to get a second opinion if a tongue-tie surgery is recommended. When there are breastfeeding difficulties, parents often feel desperate and vulnerable, Hartnick acknowledges. “But if it’s suggested to them to their child undergo a procedure, they really need to feel empowered to ask the questions, ‘Why? Is there anything else I could do before I do that procedure?'” he says.
Rowan-Legg recommends patients be wary of a practitioner who seems too quick to jump to tongue-tie, without comprehensively examining the baby, observing nursing and asking questions to rule out other possibilities. Of course, when you’re desperately trying to keep alive an infant who’s not feeding great, a strongly internet-endorsed quick snip can sound much more attractive than driving around to different providers for assessments.
As for Shapiro, she’s not sure exactly why she wasn’t able to breastfeed her first baby, something she desperately wanted to do. “I thought, ‘Maybe I just have really sensitive breasts, maybe there’s something wrong with me,'” she says. But her second baby, despite some pain at first, is now latching fine.
*NAMES HAVE BEEN CHANGED
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