Should I clip my baby’s tongue tie?
What does the research show?
Tongue tie (ankyloglossia) is one of these hot button infant-related topics that generates a lot of strong (and emotional) responses. Opinions range from “never ever clip them” to “your baby will have long-term harm if you don’t clip them” — and of course, parents are left unsure what to do.
This week, the AAP released a strong statement about tongue ties and frenotomies. It pointed out that over the past decade more and more tongue ties are being diagnosed and treated. This is unlikely to be because there is “something increasing the rates of tongue ties” and more likely to be a result of increased awareness.
The AAP cautioned against jumping into doing surgical procedures unless they are needed. But if you look online (which, let’s admit it, most of us do), there are countless articles about the dire consequences of leaving them untouched. It’s hard to figure out what information is based in fact, and how much is predatory.
As a pediatrician and a mother whose baby needed a frenotomy, here’s my take—from both sides of the stethoscope.
Our story
My youngest (now 3 years) had a frenotomy a few months after he was born. It was absolutely the right choice for us, and it made a difference quickly.
But choosing to move forward with the frenotomy was not a decision we made lightly. We consulted with multiple experts and took into account many factors including his poor weight gain, poor milk transfer (and inability to latch well even onto a bottle), his comfort, my comfort, and my feeding goals. The procedure was done by an experienced ENT. And we have zero regrets.
Our story isn’t unique. But it is also an anecdote, and there are many, many patients for whom the frenotomy either wasn’t indicated or did not help.
Unfortunately, social media and the internet have a way of highlighting only extreme, black-and-white responses — which is not helpful if you’re a parent. So let’s take a more nuanced, balanced approach and review what the AAP statement said.
A summary
As a whole, I think the AAP statement is thorough and thoughtful. It is well-researched and does not shy away from pointing out that:
The mere existence of a tongue tie does not mean a baby needs a frenotomy. Just as with other anatomical features (noses, ears), anatomic variations of the lingual frenulum are normal. We all have adenoids and tonsils. Some are larger than others. Some are obstructive and cause symptoms, and in those cases, we might choose to remove them. But jumping into a surgical procedure for everyone does not make sense, and since we have some data that other measures (such as steroid nasal spray) can shrink them, we should try that first. It is not a perfect metaphor but it’s a helpful way to think about it.
Less than 50% of babies with ankyloglossia have difficulty breastfeeding.
Frenotomies should be considered only if a tongue tie is causing symptoms. What is tough is that many of the early symptoms (feeding difficulty, poor weight gain, latch challenges) are vague - and could be due to lots of different factors. We need to make sure the tongue tie is the problem before we clip it.
The procedure can be expensive and carries risk. I have seen severe bleeding after a frenotomy. Other risks include infection, damage to the tongue or salivary glands, or nerve injury. (Note: this is why you want it done by an expert who is able to handle a complication quickly… it’s why we chose an ENT).
Leaving the tongue tie alone does not mean your child is doomed to a life of trouble with speech, sleep apnea, behavior, or will have other “devastating effects on growth and development” (yes, I’ve seen this claim made). Ties are common, but these complications are simply … not. Of course, there are certainly cases where a tie might have longer-term implications, but we have created a situation where we are over-correcting and over-intervening without any real data backing up those interventions.
We are probably jumping to this surgical intervention prematurely in many babies... without adequately exploring the many factors at play when it comes to feeding and weight gain.
Are there still some babies who do benefit from frenotomy? YES.
But is there value in trying conservative interventions before jumping to surgical ones? ALSO YES.
So what should you do if you’re concerned?
Talk with your pediatrician.
If you have a baby who is struggling to feed, your ped should be able to trouble shoot with you and if not (or if you simply want a second opinion, which is reasonable), ask for a referral to an IBCLC or an SLP. Remember, your goal is to identify and work on functional issues.
Your pediatrician will also make sure that there are no other reasons that your baby is struggling. I have seen babies diagnosed with “missed tongue ties” who have underlying genetic issues, hypotonia, thyroid issues, heart disease, and more. The tongue-tie is often not the problem in these situations (even if it is present). Decisions to proceed with frenotomy should be based on evidence and clinical experience, with an eye towards minimizing unnecessary intervention.
If your child is older, and you’re concerned about speech development, dentition, or other functional issues, start with a consultation with an experienced SLP. The majority of people with ties do not have issues, but it can happen. I have seen one patient who needed a tongue-tie release at an older age for articulation issues. But let me reassure you: this is not as common as the internet would have you believe.
What does the AAP statement overlook?
While I agree with the AAP statement, it is worth reflecting on how we ended up where we are. Postpartum & pediatrician experiences are what lead many patients down the path of searching out alternative support.
Not every pediatrician has expertise in breastfeeding education. It is not a standard part of pediatric training (although it should be).
Our current healthcare system doesn’t always leave space for parents to bring up concerns or have nuanced conversations, which is why they turn to the internet. There are too many stories from parents who have felt dismissed or rushed (or have been told to “just switch to formula”) when bringing up concerns about weight, feeding, or tongue ties during their brief pediatrician visits. (To be clear: Many pediatricians are amazing and wouldn’t do this. But it happens). After my baby’s frenotomy, one pediatric healthcare provider mocked our choice to proceed - even as I was describing how much of a difference it made. I was able to shrug it off… but experiences like this in the pediatric office leave a lasting impression.
The way we listen - and the words we use - matter.
Experiences like this also leave an opening for misinformation & unfounded fearmongering that targets a vulnerable population: desperate parents who want to do the right thing for their baby.
To be able to turn the tide on overdiagnosis and overintervention - the goal of the AAP statement - we need to make real changes to the postpartum & pediatric experience. This starts with:
Making sure parents who are struggling feel heard and supported. Some of this involves addressing pediatrician burnout. Some involves addressing postpartum support.
Finding ways to give pediatricians the time they need with patients. This is tough in a world where insurance reimbursement is dictating how we care for our patients. It is a systemic issue, and I know most pediatricians wish things were different, but not all have the flexibility to make it happen. Practices like mine, where appointments are as long as they need to be, are not common — but I believe the quality of care is higher.
Better pediatric education around breast-feeding and oral assessment. Right now, most education and training is done by a pediatrician’s choice, on their own time, (and on their own dime, too).
Involving a multidisciplinary team when needed. Which brings me to my third point: Trust amongst teammates matters, too.
We need to change our conversations
Far too often, I see non-pediatrician providers who work with these families disparage the pediatrician’s role (just look at the vitriol in the comment section of the AAP post). It is disheartening and unhelpful.
There is a lot of rhetoric about “missing” tongue ties. I’m sure that is true sometimes. But sometimes, the truth is actually that these issues are complex, and figuring them out takes time and patience. You don’t want a pediatrician who is trigger-happy about surgical procedures. Having someone thoughtful & methodical is crucial when it comes to your child’s health.
Telling families to “skip the pediatrician” does them a disservice.
Lactation Consultants, ENTs, Dentists, SLPs all have important expertise. Their knowledge base is complementary to that of the pediatrician. They should be part of the team - especially if a pediatrician does not feel comfortable with the assessment. Telling families to “skip the pediatrician” does them a disservice. Referrals and teamwork are what is best for the patient, but they require mutual trust and respect
So, what is the bottom line? To clip or not to clip?
There is no single “right” answer.
We talk a lot about nuance at The Pediatrician Mom. Parenting is full of nuanced decisions and grey areas. Overly black-and-white thinking fails to acknowledge the complexity of this topic.
As with so many things in maternal, postpartum, and infant health, there is not enough research. This is a hard topic to study because RCTs are challenging and outcomes are often based on subjective measures (eg self-report). But, until we have more data, we (as providers AND as parents) can only make decisions based on the knowledge we have.
Science is about evolving our recommendations based on what we learn. If you’re a parent who has already chosen to do a frenotomy (like me), I want to reassure you that we also don’t have evidence of long-term harm from having intervened.
