RATES OF TONGUE-TIE OPERATION ARE INCREASING
Tongue-tie (ankyloglossia) in babies is common and characterised by a short lingual frenulum that may restrict tongue tip mobility (Figure 1).1 Reported incidence varies from around 4%–11%, and is thought to be increasing because of widening definitions of tongue-tie.2 With over 680 000 live births in the UK each year, around 60 000 babies may have tongue-tie, some of whose mothers will have difficulty breastfeeding and seek support from a health professional.2,3 However, most infants (75%) with tongue-tie are asymptomatic and do not have feeding problems.1
Figure 1. Typical appearance in infant suspected of having tongue-tie. Credit: SCIENCE PHOTO LIBRARY.
In high-income countries, rates of tongue-tie operations (frenotomy/frenulectomy — the surgical division of the lingual frenulum) have more than quadrupled over 10 years.4,5 Operation rates are higher in babies of first-time mothers who are more affluent and/or have private health insurance.5 Although frenotomy may reduce nipple pain in mothers, a Cochrane Review found no robust evidence that it improves long-term successful breastfeeding.4,5
LACK OF CONSENSUS ON MANAGEMENT OF TONGUE-TIE
There is a lack of agreement about diagnosis and treatment of tongue-tie both around the world and among different health professions, and guidance is also changing over time.4 Internationally this is reflected in variable guidance regarding tongue-tie operations: Japan, Canada, and the Netherlands advise against routine frenulectomy; Ireland is neutral; and UNICEF and the US mostly support operation if tongue-tie is causing feeding problems.6 UK-based National Institute for Health and Care Excellence (NICE) guidance published 18 years ago supported frenulectomy, but reported that evidence was limited.7 At the time, however, some NICE specialist advisers stated that ‘It is difficult to be certain whether any perceived improvement in breastfeeding is due to division of the tongue-tie.’7
HOW CAN GPs SUPPORT A BREASTFEEDING MOTHER WORRIED ABOUT TONGUE-TIE?
Most GPs will not be confident about diagnosing tongue-tie. They should consider encouraging the mother to see a good breastfeeding counsellor as soon as possible and not to rush into a tongue-tie operation.8 They can reassure the mother that many mothers who successfully breastfeed have problems initially.8 Breastfeeding difficulties often get better with time and persistence: a tight (unsplit) lingual frenulum may physically adapt and stretch with age, and breastfeeding quality may improve without intervention.9 For mothers worried about tongue-tie affecting speech development, they should be reassured that the vast majority of infants with a tongue-tie do not have speech or language issues.10
A GP consultation about breastfeeding and possible tongue-tie should usually cover:
The mother may complain of nipple pain, poor latch, prolonged feed duration, poor breast drainage, a crying baby, and inadequate infant satiety post-feed.1 They may be expressing milk and giving it via a bottle. They may be exhausted, not sleeping, and feeling low. They are likely to be anxious if the baby is not gaining weight. Their midwife or other health professional may have suggested that the baby may need a tongue-tie operation.2,11
The GP should explore any concerns the mother has about breastfeeding and tongue-tie, and ask about her mental health. It is important to discuss previous experience of breastfeeding in multiparous mothers, as this can influence success with breastfeeding in subsequent infants.8 The GP will need to examine the mother’s breasts and the infant’s mouth to rule out any other cause of difficulty in breastfeeding besides tongue-tie, such as mastitis, breast abscess, or oral thrush.10 The GP could also arrange review in a few days to monitor breastfeeding and the baby’s weight gain, and provide safety-netting advice.
ADVICE FROM A LACTATION EXPERT
After checking there is nothing seriously wrong with the baby, the mother, or their interaction, the GP should usually signpost the mother to a lactation expert. This could be an experienced midwife or health visitor, a breastfeeding support worker, or a private lactation consultant. The appointment or home visit should be done as soon as possible to minimise the risk of the mother giving up breastfeeding altogether. It usually involves observation of a feed and advice about latching backed by immediate support and review within 1 or 2 days. There is also useful information for breastfeeding mothers at: https://www.breastfeedingnetwork.org.uk/help-and-support-on-tongue-tie.
TONGUE-TIE OPERATION
For mothers who are interested in exploring frenulectomy, GPs can explain that, although it may reduce nipple pain, there is not much reliable evidence for benefits for the baby.10 However, many mothers find it helpful. Possible risks of tongue-tie operations to the baby include discomfort, bleeding, anaemia, infection, and recurrence in around 13%.5 It is important to know that many breastfeeding/tongue-tie problems resolve spontaneously within a few weeks without intervention.4,9
CONCLUSION
GPs can support mothers concerned about breastfeeding problems and tongue-tie by explaining the limited evidence for the benefit of tongue-tie operations, and signposting to lactation experts. Engaging struggling breastfeeding mothers early will empower them to make an informed decision about the best care for them and their baby. For key messages for GPs see Box 1.
Tongue-tie (ankyloglossia) in babies is common (prevalence 4%–11%) and characterised by a short lingual frenulum that may restrict tongue tip mobility. Most infants (75%) with tongue-tie are asymptomatic and do not have feeding problems. In high-income countries, rates of frenotomy have quadrupled, and are higher in babies of first-time mothers and mothers who are more affluent. Frenotomy may reduce nipple pain but there is no robust evidence that it improves long-term successful breastfeeding. Mothers with problems breastfeeding need urgent assessment and advice from a lactation expert and/or paediatric review before considering frenotomy.
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Box 1. Key messages for GPs
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
We are a team of five authors. Two are foundation doctors working on the general practice Specialised Foundation Programme (formerly known as the Academic Foundation Programme). The other three authors are female GPs who have successfully breastfed and offered advice to mothers with breastfeeding problems. Komal Chadha is also the patient representative. She had two babies with tongue-tie but only the first baby had a tongue-tie operation. All three have recent experience of first-time, professional, breastfeeding mothers whose babies have undergone (repeated) tongue-tie operations.
- © British Journal of General Practice 2023
