What are possible side-effects of frenotomy?

On rare occasions babies suffer catastrophic blood loss after deep scissors or laser frenotomy

One of the confusing aspects of this topic is that some clincians mix up the risks of simple scissors frenotomy with the risks of deep scissors and laser frenotomy when they talk with parents.

For instance, it is often claimed that frenotomy is low risk, and that is definitely true of simple scissors frenotomy. But deep scissors and laser frenotomy do come with more substantial risks, which are documented in the research.

• A simple scissors frenotomy has a low risk of bleeding, with just a few drops of blood visible after the procedure. It is very rare (although possible) for more serious bleeding to occur after a simple scissors frenotomy.

• Deep scissors frenotomy comes with the highest risk of bleeding, because there is a greater risk that more vascular tissue is accidentally (or purposefully) cut into.

• Laser frenotomy cuts deeply, but also cauterises blood vessels, which decreases bleeding risk.

An Australian case that attracted social media attention

One day a woman with a reasonably high social media profile, who lived in New South Wales across the border from me, took her seven-week-old baby in for a frenotomy. Shortly afterwards, in a rushed, heartbreaking Instagram post, she announced to her followers that her baby was being ventilated. She posted that a blood vessel had been cut during the frenotomy, her baby was rushed by ambulance to an Emergency Department for resuscitation, and they were now on their way to an intensive care unit. Colleagues forwarded her post to me.

My heart went out to that baby and to the family. How terrible. How terrifying! But my thoughts also turned to the dentist who performed that frenotomy because he will be, surely, in a state of great distress. A health professional’s whole life can be defined by an event like this.

Mistakes are inevitable in medical or dental practice. This is why ‘human factors science’ addresses health system problems in order to both minimise error, and prepare for it.(1)

Rare catastrophic outcomes like this after frenotomy are not necessarily due to incompetence, but just to a numbers game: if large numbers of frenotomies are being performed, it's much more likely that eventually, for reasons that are not always clear, a little one will have an unusual but life-threatening bleed. This is just one reason why, as health professionals, it is our responsibility to avoid overdiagnosis and overtreatment. Yet overdiagnosis and overtreatment is on the rise internationally across many areas of health care, including in the care of children.(2,3)

The risk of side-effects rises as the numbers of frenotomies being performed rise

That Instagram post was forwarded to me by health professionals who had already been worrying a lot about the frenotomy industry. These colleagues had been worrying because they knew that we were seeing an exponential rise in rates of frenotomy. For example, my team found a 420% increase in Medicare-rebated frenotomies in Australian 0-4 year-olds between 2006-2016, and we couldn’t track frenotomies by dentists, who we believed were performing the majority of them.(4)

This is an epidemiological pattern characteristic of serious overtreatment, and it mirrors the findings overseas studies.(5-8) My colleagues have been worrying because when there is an exponential increase in the number of times a surgical procedure is performed, the risk of mishap rises dramatically.

This exponential increase in frenotomy rates doesn't reflect a global increase in breastfeeding rates, as is claimed by health professionals who identify as ankylofrenula specialists.(9)

What are the possible side-effects of frenotomy?

My colleagues who forwarded me the Instagram post on the day the Australian seven-week-old nearly died after a frenotomy had already been worrying about the side-effects we were seeing after frenotomies. My colleagues were worrying about the risk of

• Oral aversion which we were regularly seeing after a frenotomy. This is documented in the research as a reasonably common outcome after frenotomy. In the Possums programs, we refer to this as conditioned dialling up with the breast (or bottle). You can find out about this here.

• Infection. You can see an image of this at the bottom of the page.

• Damage to branches of the lingual nerves under the tongue, which can't be visualised in an outpatient frenotomy but which are responsible for sensation of the front part of the tongue, most especially with laser frenotomies.(10) How would we know if a baby lost sensation to the top part of his little tongue? Does this help explain why so many little ones develop a conditioned dialling up at the breast after laser frenotomy?

• Baby pain. Patients regularly report to me their own distress because of the way their baby screamed from pain during the laser or deep scissors frenotomy. In 2022, 211 breastfeeding medicine physicians reported that in their practice use of laser for a 'posterior' frenotomy increases parental report of baby pain experiences.(11)

• Systematic reviews and reports have since confirmed other unexpected outcomes after a frenotomy, such as a cyst under the tongue, and cuts to the baby's salivary ducts.(11-16)

Since that baby nearly died across the border from me, another two case reports have been published of potentially catastrophic blood loss, one in a six-week-old Canadian baby, five days after a laser frenotomy; the other in a neonate after tongue and upper lip-tie frenotomies.(17,18) This is likely to be the tip of an iceberg, as the majority of Emergency Department presentations are not written up and published in the research literature.

Every now and then, through international networks of colleagues, I hear of another case of catastrophic bleeding, sometimes quite delayed, in a baby after frenotomy. Blood loss in babies can be deceptive for health professionals who are not medical practitioners, because it doesn't take much blood loss for our babies to go into life-threatening cardiovascular shock.

A Canadian baby who had the catastrophic bleeding had been referred for frenotomy because of shallow latch, pain with breastfeeding, fussiness, possets after feeds, and open mouth rest posture.

• You can find out about fussiness with breastfeeding here.

• You can find out about reflux after feeds here.

• You can find out about pain with breastfeeding here.

• You can find out about shallow latch and what to do about it here.

A true or classic tongue-tie requires low-risk, simple scissors frentomy

Parents dealing with the distress of breastfeeding problems and related unsettled infant behaviour do not need to take their babies to dentists who perform frenotomy. A true or classic tongue-tie requires simple scissors frenotomy (not a deep scissors frenotomy, which substantially increases the risk of bleeding). A simple scissors frenotomy can be performed by a GP or doctor or trained midwife.

Before going ahead, the clinician who plans to perform your baby's frenotomy will ask you to sign a consent form ensuring that

• You've been properly informed of the risks

• Your baby has had a vitamin K injection, and

• Your baby has no family history of bleeding tendencies.

If a baby is born with a congenital syndrome which causes a severe oral connective tissue problem such as a webbing connection between the tongue and floor of mouth, referral to a paediatric ENT surgeon is required.

The baby in this image below has a nasty infection at the site of a laser frenotomy which also is affected the sublingual salivary glands. This could lead to scarring of the glands long-term, or the development of a mucocoele under the tongue.

References

1. Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Quality and Safety. 2013;22(802-808).

2. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390:156–168.

3. Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1-11.

4. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018;208(2):88-89.

5. Wei E, Tunkel D, Boss E, Walsh J. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology - Head and Neck Surgery. 2020: https://doi.org/10.1177%1172F0194599820925415.

6. Lisonek M, Shiliang L, Dzakpasu S, Moore AM, Joseph KS. Changes in the incidence and surgical treatment of ankyloglossia in Canada. Paedaitrics and Child Health. 2017;22(7):382-386.

7. Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40

8. Ellehauge E, Schmidt Jensen J, Gronhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.

9. Smart S, Todd D, Hogan M. Debate over tongue tie procedures in babies continues. Here's why it can be beneficial for some infants. The Conversation. 2024: https://theconversation.com/debate-over-tongue-tie-procedures-in-babies-continues-heres-why-it-can-be-beneficial-for-some-infants-230008.

10. Mills N, Keough N, Geddes DT, Pransky S. Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy. 2019;32:824-835.

11. O'Connor ME, Gilliland AM, LeFort Y. Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey. internatioanl Breastfeeding Journal. 2022;17(39):https://doi.org/10.1186/s13006-13022-00481-w.

12. 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.

13. Solis-Pazmino P, Kim GS, Lincango-Naranjo E. Major complications after tongue-tie release: a case report and systematic review. International Journal of Pediatric Otorhinolaryngology. 2021;1(138):110356.

14. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D, et al. Complications following frenotomy for ankyloglossia: a 24-month prospective New Zealand Paediatric Surveillance Unit study. Journal of Paediatrics and Child Health. 2019:doi:10.1111/jpc.14682.

15. Heaton PJ. Posterior tongue tie and lip tie - division of tongue-tie: surgical complications. BMJ. 2021;372:n8.

16. Van Biervliet S, Van Winckel M, Velde SV, De Bruyne R, D'Hondt M. Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted. European Journal of Pediatrics. 2020;https://doi.org/10.1007/s00431-020-03705-5.

17. Hendriks AM, Van der Meulen GN, Van Leeuwen JC. Haemorrhagic shock after frenotomy of the lingual and maxillary labial frenula in a neonate. Ned Tijdschr Geneeskd. 2023;167:D7285.

18. Kim DH, Dickie A, Shih ACH, Graham ME. Delayed hemorrhage following laser frenotomy leading to hypovolemic shock. Breastfeeding Medicine. 2021;16(4):346-348.