Behind the headlines: Exploring the complex world of tongue tie releases and pediatric feeding disorder

Published by Feeding Matters on Jan 29, 2024

A tongue tie release procedure (frenectomy or frenotomy) is increasingly prevalent among children with pediatric feeding disorder (PFD) that the majority of them have had it, or their parents at least considered it.

That’s because difficulty breastfeeding is common among children with PFD. A frenectomy is often considered an early treatment to improve latching while breastfeeding.

Breastfeeding is a complicated process that doesn’t come naturally to all mothers and babies. It takes multiple muscles, the ability to coordinate sucking and breathing and the strength to stay awake through strenuous exercise. Releasing a tongue tie can seem like an easy fix.

But for kids with PFD, a frenectomy doesn’t necessarily fix feeding problems and is instead one step along a journey of treatment when the frenulum is not the sole cause for feeding dysfunction. For some babies, a frenectomy can be helpful. For others, it’s not necessary. And in some rare cases, the elective procedure causes harm. While generally safe and often performed by dentists, the procedure maintains the potential to do harm, without a significant assurance of benefit. The procedure is sometimes not covered by insurance and can cost hundreds of dollars.

The debate about releasing tongue ties recently was brought to the forefront in The New York Times article, Inside the Booming Business of Cutting Babies’ Tongues. Showcasing many cases where the procedure was unnecessary or went wrong, the article paints a picture of a procedure as controversial as it is common.

Tongue tie releases for children with pediatric feeding disorder

What’s clear from working with countless families of children with PFD is the benefits of a frenectomy vary on a case-by-case basis. Most importantly, it should never be a result of a self-referral to a clinician who advertises the procedure as the obvious answer for breastfeeding difficulties. Instead, the decision should be shared by the family and a qualified clinician.

Nikhila Raol, MD, MPH, pediatric ENT and an associate professor at Emory University School of Medicine who researches ankyloglossia, or tongue ties, says getting the procedure is a multifactorial decision, meaning it

takes careful consideration with advice from multiple clinicians working together. “Even when the tongue tie is physically obvious, I’m still a proponent of having a functional evaluation with a feeding therapist or lactation consultant with real expertise in evaluating feeding and latch before a procedure. What I’m finding in my ongoing research is that even if a baby has a tongue tie, if the mother’s breast shape is favorable, it may not cause as much issue as we think,” she says.

Breastfeeding often takes some time for babies and moms to adjust. Dr. Raol recommends most parents wait at least two weeks to a month of trying ways to adjust to breastfeeding before getting a frenectomy on a newborn, assuming that the weight gain is acceptable. “Sometimes, you just have to give the baby time to figure it out and the mom’s body to adjust to breastfeeding. Figuring out how to latch and how to get a strong suck sometimes just get better with time,” she says.

Jaclyn Pederson, CEO of Feeding Matters, sees many parents consider the benefits of a frenectomy when breastfeeding or picky eating is challenging. As a parent, she did the same and released the tongue tie on one of her sons. She says that while a tethered tongue is a concern, what can get lost is the nuance that it’s one concern of many –– especially when a child is diagnosed with PFD. “What we know about PFD is that it’s incredibly complex. One of the first things that we share with families is helping them understand that there’s not just going to be a switch that’s flipped to make their feeding journey easier. It’s a series of small milestones that build over time,” she says.

The challenge of considering a frenectomy as a quick fix to difficulty breastfeeding is not just disappointment when it doesn’t work. It can mean overlooking the actual root of the problem, such as some other problem with feeding or swallowing. “Assuming that the surgery is the solution, even as minimal of a procedure as it is, still leaves out a lot of other feeding components,” says Pederson.

One family’s tongue tie release story
When Emily Garlinsky’s son, Landon, had trouble breastfeeding, she was at first confident a tongue tie wasn’t the issue. Clinicians in the hospital when he was born, as well as her pediatrician, assured her his tongue looked normal.

But as Landon continued to struggle and Emily shared her feeding frustration in Facebook groups, she kept hearing people recommend a tongue tie evaluation. By the time Landon was four months old and still struggling to feed, Emily thought it was time to revisit the issue. Landon was already in feeding therapy at that point, and his therapist agreed the procedure might help.

Emily went to a pediatric dentist who told her Landon had a lip tie and a tongue tie. Landon underwent the procedure, but his feeding didn’t improve. He did well with the surgery, though, and Emily is glad they did the release. “There’s a lot of back and forth on Facebook groups from people who regret it. It didn’t help with feeding for us, but other aspects of the release are helpful for speech,” says Emily.

True or false? Tongue tie myths

Dr. Raol warns against peddling fear to encourage parents to act for their babies or overpromising treatment results. “You must be careful because breastfeeding mothers are a vulnerable population. A new mother just wants to do her best,” she says.

Following are some common assumptions around tongue tie release procedures. Some have no research evidence to support them, and others have emerging research.

Tongue ties cause swallowing difficulties: Maybe
Dr. Raol is rigorously studying this in her research. She says, “When you swallow, your tongue starts the pharyngeal squeezing process. When a child can’t squeeze hard, we think this could cause food or liquid to spill into the airway as it is trying to enter the esophagus.”

Tongue ties cause reflux: Unknown
Reflux is normal in babies due to low tone of the sphincter muscle that separates the stomach from the esophagus. Dr. Raol explains that it has never been objectively demonstrated that a tongue tie is responsible for this through aerophagia, or swallowing air, which is the proposed mechanism. However, some studies have shown that reflux symptoms improve after frenectomy. What we do not know is if the symptoms would have just gotten better with time.

Tongue ties cause problems with craniofacial development: Maybe
There’s not a lot of existing research evidence to support this. More research is needed.

A laser is better than clipping for a tongue tie release: Maybe
Many parents hear on social media advice to go to a pediatric dentist instead of an ENT for a tongue tie release because dentists use a laser.

More research is needed, but a review of the existing research found the laser procedure resulted in a shorter surgery, without suturing, and less postoperative pain.

Tongue ties cause speech issues: Maybe for some
The jury is still out on this because Dr. Raol explains there is a deficiency in the literature. Most of the research comes from English-speaking countries, but there’s a difference in how the tongue works in other languages. “In Indian languages, we use the tongue a lot more with certain sounds where you put your tongue far back on the palate. In India, the primary reason kids get a frenectomy is for speech.”

For serious speech issues, though, says Dr. Raol, a tongue tie release is not a quick fix. “In the case of expressive aphasia or something like that, we should not be telling families that clipping a tongue tie will solve that problem,” she says.

You should go to a pediatric dentist for a frenectomy: Only with a diagnosis or consultation from an ENT, lactation consultant, feeding skill specialist, or pediatrician first –– and in that case, the ENT or a pediatric dentist could do the procedure
Breastfeeding is complicated, and any issues should be evaluated by an expert who considers both the baby’s and the mother’s anatomy. Misdiagnosing a tongue tie as the issue can mask other underlying problems, such as PFD.

While it’s true that a frenectomy is a minor surgery and a trained clinician can safely manage the procedure, it still requires careful consideration.

Be wary of a clinician who promises the procedure as a quick fix in exchange for out-of-pocket payment.

Signs your child might need an evaluation from a feeding therapist or lactation consultant

While some children’s tongue ties are apparent even to the untrained eye, it’s still important to get a thorough evaluation before scheduling a frenectomy. Under no scenario should you self-refer or decide based on advice from a friend or a clinician on social media. While this may seem obvious, many people are doing just that and then paying cash for the elective procedure. “We’ve seen this become the number one thing families are thinking about when they have trouble breastfeeding because they hear their friends talk about it and see it online,” says Pederson.

Following are some signs your child might be a good candidate for a frenectomy:

  • Your child is not steadily gaining weight from breastfeeding.
  • There is some tongue tethering.
  • Pain while breastfeeding goes beyond the initial adjustment period.
  • You’ve tried various positions and breastfeeding techniques.
  • The number of times your child feeds per day remains the same over time. Your baby should become more efficient at feeding as she grows.

When seeking the right clinician, Pederson recommends starting with your pediatrician and an ENT, who will conduct a thorough evaluation. “Look for a professional who shares the pros and cons of a scenario versus one who pushes a treatment as the answer to everything. Explaining the nuance is how you know that a professional really understands how complicated tongue ties are and the issue of feeding is in general,” she says.

Like any treatment or therapy for children with PFD, managing feeding requires a degree of personalized medicine. “Some kids really do need a frenectomy. But if all I have is a hammer, everything is a nail. The tongue is just one piece of the puzzle,” says Dr. Raol.

In the end, getting even a minor tongue tie release surgery is a decision parents should make based on clinical advice, says Dr. Raol. “If you’ve tried everything, and there does seem to be some tethering, and you’re fully aware that this may or may not help, then I don’t think the procedure is unreasonable.”

Feeding Matters blog posts are written by the communications team at Feeding Matters and designed to continue the conversation and awareness around pediatric feeding disorder based on expert opinion interviews.