Frenotomy procedure can help babies to breastfeed effectively

Doctors advise new mothers to breastfeed for at least the first six months of a baby's life, but a simple yet often untreated problem can sabotage their efforts, University of Florida researchers say.

Called a tongue tie, the problem occurs when the connective tissue under the tongue is too tight. A tongue tie can hinder some newborns from being able to breastfeed properly and painlessly, and this struggle can lead many new mothers to give up breastfeeding.

A simple snip can fix the problem, but many doctors still do not perform the procedure despite the effects a tongue tie can have on breastfeeding, writes UF neonatologist Sandra Sullivan, M.D., in an article published online this month in the journal Pediatrics.

"It is called a frenotomy, and it is far simpler than a circumcision, which we do fairly routinely," said Sullivan, an assistant professor of pediatrics and the lead author of the report. "It literally takes longer to fill out the consent form for the procedure than to do the actual procedure itself."

The problem is many practicing doctors were taught that the procedure is not medically necessary, Sullivan says.

But for babies to breastfeed effectively, their tiny tongues have to be able to perform a more complex type of sucking than what it takes to drink from a bottle. A tongue tie can hinder baby's efforts to move his tongue up, down and out, which he would need to do in order to nurse.

"If you take a bottle with an artificial nipple, there is not a lot a baby has to do to get milk," Sullivan said. "To get milk out of the breast, they have to make a vacuum and if they cannot get their tongue to the roof of their mouth, they cannot do this. They also need to use their jaw and tongue to move the milk along through the milk ducts in the breast.

"If they just bite on the nipple (like a bottle), first, it hurts (the baby's mother) a lot and second, it blocks off all those little tubes, which keeps the milk stuck in the breast."

Studies show about 2 percent to 5 percent of babies have constrictive tissue under the tongue and about half of those babies have problems with breastfeeding, said Isabella Knox, M.D., Ed.M, an associate professor of pediatrics at the University of Washington. About 4 million babies are born in the United States annually, meaning that between 40,000 and 100,000 babies are born each year with a tongue tie problem.

"That's a lot of babies," Knox said. "I don't think general pediatrics training gives us a lot of skills in supporting breastfeeding. A lot of pediatricians have lactation consultants, but we don't really know how to help somebody and for some people it is not always a priority."

In Sullivan's report in Pediatrics, she describes a patient who ended up in the hospital with feeding and growth problems, which could have been avoided if his tongue tie had been corrected as a newborn.

The baby's mother was following expert advice and exclusively breastfeeding. She had noticed the problem when her child was born, but doctors told her not to worry about it. Eventually, she was referred to an oral surgeon, but was told no one would operate on the baby until he was at least 6 months old.

To his parents, whose eldest child had been premature and small, the baby seemed to be growing. But by the time he was 6 months old, he weighed less than he did at birth, Sullivan says. "He gained about 2 pounds in a matter of 36 hours in the hospital, and all we really did was fix his tongue," Sullivan said. "This is just one example, an extreme example, of what happens when you do not fix this problem."

According to the American Academy of Pediatrics, breast milk is considered the optimal food for babies. Studies have shown that exclusive breastfeeding offers infants some protection against diseases and common childhood illnesses, such as ear infections.

"Breastfeeding is best for babies, and we want to encourage mothers to breastfeed and do it successfully for as long as they would like," said Jerry Isaac, M.D., a pediatrician and past president of the Florida chapter of the American Academy of Pediatrics. "This (paper) is an important piece of information adding to the body of knowledge that this may be a significant problem in some babies."

Sullivan is part of an international organization focused on issues related to tongue ties. She and other members of the group's screening committee are working to develop a screening tool that would help nurses quickly screen for a tongue tie while assessing the baby after birth.

"There is not a lot of literature about frenotomy, and there are still a lot of doctors who say, 'Is this really necessary?'" Sullivan said. "Whether or not there is an epidemic or whether we ignored tongue ties and are looking for them now, this is something that is coming up more often in nurseries."