Midwives performed neonatal frenotomies in the 19th century. In the 1960’s, frenotomies decreased due to the rise of bottle feeding. With the increased popularity of breastfeeding, especially since the 1990’s, there was a resurgence of interest in ankyloglossia [1, 4, 6–8, 10, 13–15, 20]. Nowadays, approximately 80% of mothers in our area initiate breastfeeding. However, breastfeeding problems are common, keeping rates of breastfeeding lower than they should be [3, 8, 9, 18, 31, 32]. Causes of early weaning include apparent breast refusal, inadequate milk intake, introduction of formula supplementation with a subsequent decrease in milk production, and breast and nipple pain [6–9, 13, 15, 18].
Lingual function is more important than appearance of the frenulum, and must be carefully evaluated as well. One of the most widely used tools to assess lingual function is HATLFF (Hazelbaker’s Assessment Tool for Lingual Frenulum Function) score , which we used to evaluate our patients. Some tongue-ties restrict extension of the tongue beyond the lower gum and force the infant to use its jaw to keep the breast in the mouth and form a proper seal, making breastfeeding difficult [1–6, 12–14, 16–18, 20, 25, 32]. Research has shown that between 25 and 80% of tongue-tied infants have difficulty breastfeeding [13, 25, 33]. Even though most studies have not found any effects on bottle feeding, given the more passive efforts involved with it, a few authors have observed that tongue-tied infants may have trouble sucking from a bottle as well [1, 2, 10–12, 20]. We believe that all the newborns should be explored to rule out the presence of a lingual frenulum and should be offered a frenotomy as soon as possible in case of ankyloglossia given the risk of breastfeeding cessation [4, 6–8, 11–13, 16, 17, 20, 25]. Frenotomy has shown to reduce maternal nipple pain in the short term, although improvement varies individually. Further randomized controlled trials of high methodological quality are warranted to determine longer term effects of frenotomy in terms of breastfeeding effectiveness, decrease in breast/nipple pain and feeding problems, increased duration of breastfeeding, and infants’ growth [9, 16, 17]. Like Ballard and Hogan, we observed an improvement in 95.2% of cases. Sometimes improvement is not immediate because sore or traumatized nipples may take 24 to 72 hours to heal, and the infant may need time to re-learn suckling . Ghaheri’s prospective cohort study found an immediate improvement following frenotomy but also that breastfeeding continued to improve over the first month post-procedure . Schlatter evaluated breastfeeding at the age of 2.5 weeks and found that only 13% of frenotomized neonates had breastfeeding problems following the procedure [6, 25]. Messner found that 83% of infants with ankyloglossia were breastfed for at least two months, compared with 92% of control infants . In our case, 415 of 451 (92.0%) neonates with ankyloglossia were exclusively breastfed at discharge, and the percentage was higher in frenotomized infants, probably because mothers who accept a frenotomy are more prone to breastfeeding. We found that the rate of exclusive breastfeeding at discharge was higher among tongue-tied infants than non-tongue-tied infants (Table 1). When comparing treated and untreated infants, the rates of exclusive breastfeeding at discharge were significantly higher in favor of frenotomy (Table 2). These results could indicate that performing a frenotomy in tongue-tied infants may help establish breastfeeding. However, they must be cautiously interpreted because we did not have a formal control group.
The main limitation of our study is the lack of a formal control group. We offered the frenotomy to all tongue-tied patients and most parents consented to it. Due to the low risk of frenotomy and the risks of early weaning, we did not find it ethical to have a control group. Another limitation is that the group of mothers with tongue-tied neonates, despite being homogeneous with non-tongue-tied infants in regard to the variables we measured, may not be homogeneous in terms of motivation to breastfeed. This could justify the higher breastfeeding rate among the ankyloglossia group. Motivation for breastfeeding may be even more relevant among mothers who refused a frenotomy, for which comparisons with the 29 untreated infants must be interpreted cautiously. Parents who refused a frenotomy could be less motivated for breastfeeding, for which they preferred not to do any interventions. We measured short-term improvement in terms of maternal nipple pain by asking the mothers if they felt less pain after the procedure, but we did not use quantitative measures of pain. We used no quantitative measures of infant latch onto the breast but relied on lactation consultants’ observation of the feeds according to the LATCH scale. Neither the observer nor the mother were blinded, because the objective of our study was to describe our current practice, not to demonstrate the effectiveness of the frenotomy. The mother was confident that thefrenotomy would solve her breastfeeding problems, and witnessing the procedure may have conditioned her immediate perception of the feed. All the parents were informed of the presence of ankyloglossia, which could have influenced them to believe that there would be problems breastfeeding. We took into account whether the mother had previously breastfed a baby; however, we did not analyze for how long or if exclusively. The intervention took place prior to the establishment of breastfeeding, and since sucking improves during the first days and weeks, the improvement could have been erroneously attributed to the intervention . Our study has strengths as well. This is, as far as we know, the largest study published to date, which took place at one single center and was carried out by a small team of neonatologists. We need to analyze our group to look for the duration of breastfeeding.