Tongue Tie

In-Office Frenotomy

At Breastfeeding Medicine of Northeast Ohio, Dr. Ann Witt and Lauren Lasko, APRN, IBCLC are able to evaluate for tongue-tie(ankyloglossia) and if needed treat in the office by performing a frenotomy. Additionally Dr. Witt has received training in cranial osteopathic manipulative medicine to help identify and begin bodywork treatment of other functional limitations (like torticollis or neck tightness) that may contribute to difficulties in tongue function.

Ankyloglossia, also often referred to as tongue-tie, can limit your infant’s tongue movement, affect latch, cause pain and impact maternal milk supply. As there can be many causes for latching difficulties, pain and low milk supply, it is important that any tongue-tie concerns be evaluated in the context of a full breastfeeding evaluation. During your visit, we will evaluate all aspects of breastfeeding and collaborate with you to decide if a frenotomy is appropriate. Following the procedure, our team will address any remaining breastfeeding difficulties.

We recognize that ankyloglossia and the decision to perform a frenotomy elicits many different options. Dr. Witt speaks on this topic to medical providers and is current on the available research. See below, for discussion of common questions.

If you are experiencing breast or nipple pain, or are concerned about your baby’s latch, please call 216-291-9210 to schedule a consultation. If this procedure is an option, we will discuss the details during your visit.

  1. What breastfeeding difficulties can tongue-tie cause?
      Ankyloglossia can affect breastfeeding by impacting latch, causing pain with feeding, or limiting milk removal and thereby lowering milk supply. For this reason, we evaluate for a frenulum and restricted tongue movement in all infants. Frenotomy is a procedure that can be performed in our office to release the frenulum, improve tongue movement and improve breastfeeding difficulties. Randomized controlled studies have confirmed the effectiveness of frenotomy in reducing maternal pain with feedings. While some studies have shown improvement in latch and milk removal, these factors have not been as rigorously studied so clinical experience becomes an important factor for evaluating if a frenulum is contributing to your babies breastfeeding difficulties.
  2. What is a frenulum?
    The frenulum is a thin piece of tissue that attaches the tongue to the floor of the mouth. Ankyloglossia or tongue-tie describes a condition where the frenulum restricts tongue movement. When evaluating for tongue-tie it is important to look at both tongue appearance and function.
    Two 2019 studies by Mills et al in Clinical Anatomy (infant study) and ( adult study) describe the frenulum not just as a mucosal layer but also as a layer of fascia. Fascia is a layer of connective tissue that connects and support muscles, bones, ligaments and other parts of the body. Identifying the role of fascia in tongue function helps explain why some babies with feeding difficulties may benefit from cranial sacral, myofascial, chiropractor and/or osteopathic manipulative medicine treatment modalities. When evaluating tongue anatomy and function it is important to also evaluate head, mouth, and neck anatomy, muscle tone and function as there may be other factors impacting the appearance and function of the tongue.

  3. How do you describe my baby’s frenulum? What is the difference between anterior and posterior tongue-tie?
      There is no consensus on the best system for evaluating and describing ankyloglossia. Since the early 2000’s the Coryllos rating system has been used to describe appearance. It identifies frenulums as type 1, 2, 3 and 4 depending on where the frenulum attaches to the tongue with type 1’s attaching to the tip and type 4’s attaching toward the base of the tongue where the tongue connects to the floor of the mouth (imagine the web space of the thumb and index finger). Type 3 and 4’s are sometimes referred to as posterior frenulum. Type 1 and 2 frenulum, which are closer to the tip of the tongue, are commonly referred to as anterior frenulum.

      A 2014 study by Haham et al identified that over 95% of infants will have a frenulum as defined using the Coryllos scoring system. Yet, not all infants who have a frenulum on appearance will need a frenotomy. In Haham’s study, 11% of the 179 infants weaned because of breastfeeding difficulties and 4% needed frenotomies within the first two weeks. A limitation of this study is that infants were not followed past 2 weeks to identify if frenotomies were needed later. Further research is needed to better answer the question of which Coryllos frenulums need a frenotomy.

      Given the Coryllos system and the distinction of anterior versus posterior frenulum only looks at appearance, it is important to look at tongue function when deciding to perform a frenotomy. When breastfeeding, an infant’s tongue needs to establish appropriate suction to enable milk removal and extend past the infant’s gums. Their tongue needs to have enough movement to avoid biting and pain while feeding. After evaluation, your baby’s tongue movement will be discussed, along with appearance, at your visit. We will then collaborate with you on how to proceed.

  4. How do you decide if a baby needs a frenotomy?
      Given there are multiple reasons for breastfeeding difficulties. Our general approach is to focus on good lactation support in the first couple of weeks and determine the need for a frenotomy based on how breastfeeding is going. For those infant’s with clinically restricted tongue movement and feeding difficulties such as pain with feeding or poor weight gain we will recommend a frenotomy earlier. For those infants doing well but a posterior frenulum is noted, we will discuss the available research and then decide with your input to monitor over time versus perform a frenotomy. If deciding to wait and watch, know that if there is persistent pain with feeding, difficulty with weight gain or frequent feeds then a frenotomy should be reconsidered.
  5. Why am I getting different opinions?
      Interest in ankyloglossia has increased dramatically in the last 10 to 20 years. One study found that in the United States between 1997 and 2012 there was an 834% increase in diagnosis of tongue-tie and 866% increase in the rate of frenotomy. In the 1990’s there were approximately 10 articles per year on this topic and in the 2000’s approximately 40 articles per year. With this increase in information there are bound to be different opinions. While there is a consensus that ankyloglossia is a condition of limited tongue mobility caused by a restrictive frenulum, there is no consensus on the best system to describe both appearance and function. Given the variability in definition, it is harder for research studies to answer questions definitively.

      We recognize there is a lot of information on the internet regarding tongue and lip ties with some people very strongly believing they cause most breastfeeding difficulties and others dismissing the significance. The varied opinions is a reflection of the need for further research, especially prospective and long-term studies. Until these studies are done, we will continue to evaluate tongue anatomy, function and breastfeeding and then tailor the decision to your breastfeeding needs. Please talk to us if any questions.