What is frenotomy, what's the best method, and when might frenotomy help you and your baby breastfeed?

What is a frenotomy?

A frenotomy is a cut into the mucosa and connective tissue under your baby's tongue, performed with the aim of improving your baby's tongue mobility.

When is a frenotomy helpful?

Classic tongue-tie is not defined, and may never be defined through measurements. None of the tools that are commonly used by health professionals to screen for the diagnosis of tongue-tie or ankyloglossia have been shown to reliably help make the diagnosis.

I suspect, like many other diagnoses in medicine, the decision to diagnose tongue-tie or ankyloglossia will always be a clinical judgement, made by a clinician who integrates dozens or even hundreds of pieces of small information to weight up the potential benefits versus risks of frenotomy. The clinician does this through careful history taking, examination, and breastfeeding assessment.

It is important, however, to remember that many babies have visible anterior membranes running along the undersurfaces of their tongues. This is a normal anatomic variant which mostly doesn't affect breastfeeding, once you've got the fit and hold right.

A classic tongue-tie, in which the tip of the tongue is visibly tethered down tightly to the floor of the mouth, may require a scissors frenotomy. If this is severe, your breastfeeding support professional may recommend that this occurs very early, even before you do much breastfeeding. Usually with breastfeeding the first step is to apply the gestalt method of fit and hold as soon as problems arise (if you're not already using it preventatively).

It's important to know, in summary, that

• There is no reason to proceed with deep scissors or laser frenotomy. This is because there is no scientific basis to the diagnosis of posterior tongue-tie, and it should not be used. You can find out about this here.

• There is no reason to perform a frenotomy under baby's upper lip or for buccal connective tissue. This is because the frenula under baby's lip and upper cheeks are highly variable, and always normal. You can find out about this here.

• A simple scissors frenotomy may be helpful if your baby has a true or classic tongue-tie. You can find out about this here.

• When all the existing evidence concerning the effects of frenotomy or bodywork therapy on breastfeeding to date is carefully analysed, the research is unable prove there are positive benefits of frenotomy or bodywork on breastfeeding. You can hear more about analysis of research on this topic here. I predicted this back in 2013, when I first began to publish papers on this topic, arguing that we were focussing on the wrong questions, and that breastfeeding was not that simplistic.

Do you need a multi-disciplinary team if your baby has a tongue-tie?

If you have breastfeeding problems, your breastfeeding support professional might examine your baby including her mouth and suggest that she has oral connective tissues restrictions. You might be advised to go straight to a frenotomy, or to trial exercises first. I hope you will feel empowered to avoid unnecessary interventions as you work your way through Possums Breastfeeding and Lactation.

You might also hear that if you don't do something about this, your little one is at risk of developing a number of problems down the track caused by the connective tissue restriction, including speech and articulation impairments, less than ideal development of the face structures, and even sleep and behavioural problems. This is not true, and often frightens parents into having their baby receive an unnecessary frenotomy or course of bodywork therapy.

You might be referred to a multi-disciplinary team, which might include a speech pathologist, a dentist or dental technician, and a bodywork therapist (whether osteopath, chiropracter, craniosacral therapist, or oral myofunctional therapist). Although you might be told that the multi-disciplinary team approach offers you and your breastfeeding baby the best, most thorough and most scientific kind of care possible, in fact these multi-disciplinary teams are engaged in serious overservicing.

What is the best kind of frenotomy to give your baby?

The frenotomy, if you have it, may be performed either by scissors or by laser, often by a dentist but also by other medical or midwife practitioners.

• Simple scissors frenotomy is a small snip combined with pressure by the clinician's forefinger to release the mucosal tissues that make up the visible frenulum. This is low risk, and is the only kind of frenotomy that babies should receive (unless your baby has a serious medical syndrome at birth, which also incudes fusion of the tongue with the floor of mouth or severe syndromic tongue-tie). Often, it happens so quickly that baby doesn't really cry.

• Many babies receive a deep scissors frenotomy, which cuts down deeply through the connective tissue and floor of mouth fascia. This is unnecessary, once you understand the anatomy of baby's frenulum and floor of mouth fascia, and increases the risk of bleeding and other side-effects.

• Laser frenotomy cuts even deeper again. I have not uncommonly seen laser frenotomies in baby's mouths over the years that went into the genioglossus muscle. Laser frenotomy controls bleeding, but increases risks of other side-effects. Again, despite what you hear and read, there is actually no justification for laser frenotomy in the mouths of babies with breastfeeding problems.

Wound stretching exercises after the frenotomy don't change the way the frenulum and oral tissue heals

If you were advised to have a laser frenotomy performed on your baby, you are likely to be advised to follow up with wound stretching exercises a number of times a day, and also bodywork exercises and stretches in or around the baby's mouth and body. You might even be advised to do these exercises if your baby has scissors frenotomy, too.

But wound stretching exercises don't stop the mucosa re-forming the shape of the frenulum prior to the frenotomy. The belief that wound stretching exercises alters the way wounds in the mouth heals misunderstands the nature of oral mucosa and wound-healing.

Wound-stretching exercises can, however, result in baby having a conditioned dialling up when something is brought to her little mouth.

Although it does seem likely that the baby in the photograph at the top of this page has an ankyloglossia or tongue-tie and may benefit from a simple scissors frenotomy, it would be irresponsible of me to make a diagnosis from this single photograph. Ankyloglossia is a poorly defined category at the functionally more constrained end of the spectrum of oral connective tissue variations. A clinician can only make the diagnosis of ankyloglossia responsibly by performing a thorough oromotor assessment and watching baby breastfeed or feed. The diagnosis is a clinical judgement which arises out of complex contexts, requiring the collation and synthesis of many dozens of pieces of information, working in collaboration with the parents.

Selected references

Knight M, Ramakrishnan R, Ratushnyak S. Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT. Health Technology Assessment. 2023;27(11):https://doi.org/10.3310/WBBW2302.

Kummer AW. Ankyloglossia: misinformation vs. evidence regarding its effects on feeding, speech, and other functions. Journal of Otolaryngology - ENT research. 2024:DOI: 10.15406/joentr.12024.15416.00552.

Thomas J, Bunik M, Holmes A. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605.