Last updated February 15, 2018 at 11:05 am
A 10-year review of Medicare data has demonstrated a 420% increase in the incidence of frenotomy, or tongue-tie surgery in children.
The rate of surgery to treat tongue-tie has jumped from 1.22 per 1,000 in 2006 to 6.35 per 1,000 in 2016. That’s an increase from 1,580 in 2006 to 9,947 surgeries in 2016 across Australia.
So what is a frenulum and why do we have one?
The frenulum is the little bit of tissue under your tongue that attaches to the bottom of your mouth. As well as under the tongue, they can also be present under the upper lip, in the cheeks or near the back molars.
In the developing embryo, the frenulum helps guide the growth of the tongue. In most cases, the tongue grows past the frenulum, which allows for normal movement of the tongue. In tongue-tie, the frenulum is too short and restricts the tongue moving freely. The medical term for a tongue-tie is ankyloglossia. Estimates vary on how prevalent it is, with estimates of around 2-3 per cent. A baby born with a tongue tie may not necessarily have it forever, as the shape of the mouth changes so dramatically during the first few years children often grow out of it.
Do tongue-ties lead to difficulty breastfeeding?
There are disagreements as to just how much of a problem tongue-ties are. While there is conflicting evidence about the role that tongue-ties cause in speech, the drive in the increased rates of tongue-tie surgery are being driven by a belief that it is the cause of a lot of breastfeeding issues.
“There is very limited research about tongue tie surgery with low quality evidence regarding benefits in newborns,” says Dr Vishal Kapoor, lecturer in Children’s Health at The University of Queensland and lead author of the new study.
“The benefit is likely to occur only in a small proportion of infants with significant tongue tie.”
“There is both under-diagnosis and over-diagnosis” says Assoc Prof Lisa Amir of LaTrobe University, who was not involved in the study but is a medical practitioner with a research interest in breastfeeding.
“Infants need to use their tongue to attach to the breast deeply and feed well. If their tongue is restricted this can be difficult for both mother (nipple pain and damage) and the infant (poor weight gain).”
“There is evidence that, for a simple scissors release of anterior tongue-tie, where the where the frenulum extends to the tip of the tongue, or near the tip, and restricts the infant being able to attach to the breast – there is evidence that this procedure is useful in helping mothers continue to breastfeed.”
Dr Amir believes that the rise of blaming “posterior tongue-tie”, where the frenulum attaches further back under the tongue, is more concerning.
“Posterior tongue-tie is being blamed for a wide range of issues (eg. gassy baby, noisy feeding, potential problems in the future) without any evidence.”
“And the current concern about lip-tie is completely unwarranted, the frenulum under the lip, usually changes over time and does not play a large part in breastfeeding.”
To snip or not to snip?
Tongue-ties are treated by releasing the tongue to move freely by cutting the frenulum. This can happen with scissors, or with laser surgery.
“It is a very minor procedure for a simple snip with scissors, but more invasive procedures could potentially have a risk” says Assoc Prof Amir.
“There have been reports of significant bleeding with tongue tie surgeries, so the tongue tie surgery is not entirely without risks although the major side effects are uncommon.” Says Dr Kapoor.
Worringly, some parents are being instructed to massage the area around the wound site after tongue tie surgery, which can be painful for babies and cause even more issues through oral aversion.
Dr Kapoor believes the massive increase of surgeries is concerning and an indication of overdiagnosis. The figure calculated in the study uses medicare item numbers, and so the actual incidence of frenotomy is probably much higher.
“In practice, most tongue-ties are released by GPs in the community and they are probably not including a Medicare item number for this” agrees Dr Amir.
So why has the rate for tongue-tie surgery rocketed in the last decade?
The pressure on new mothers to breastfeed is enormous. It’s not something that comes easily for a lot of people, and it can be an excruciating process for some. While tongue-tie can cause nipple pain for breastfeeding mums, a recent review found that around half of babies with tongue-tie won’t have any issues at all.
Dr Vishal Kapoor says that as well as a lack of proper support for mothers breastfeeding, and the influence of social media and parenting blogs and forums on the internet, there is a mushrooming industry around providing tongue-tie surgeries.
“Anecdotally, the paediatric health professionals in the public hospitals tend to snip a tongue-tie or recommend tongue-tie surgery on far fewer occasions (only if tongue-tie is clinically significant),” says Dr Kapoor
“It is likely that a majority of tongue-tie surgeries are being recommended and performed in the private sector.”
Assoc Prof Amir agrees that there are many potential causes of breastfeeding problems, and that people shouldn’t rush to blame something like tongue-tie.
“In particular, be wary of clinicians who are charging hundreds of dollars for procedures.”