More cautiousness for lingual frenotomy in newborns and infants!
Press release of the French National Academy of Medicine (*)
April 26, 2022
Section (frenotomy) or excision (frenectomy) of the tongue frenulum in newborns or infants involves surgically cutting (with scissors or laser) a short and/or thick tongue frenulum to restore the amplitude of movement of the mobile tongue, in particular its protraction.
This surgical procedure, which was rare until recently, is indicated in the case of ankyloglossia* with significant functional impact.
One can only wonder before the spectacular increase, in France and throughout the world, of lingual frenotomy which, performed very soon after the stay in maternity, would then facilitate breastfeeding that is both effective for the newborn and the infant, and make it painless for the mother: more than 420% in Australia in about ten years [1,2,3]. This increase is all the more surprising since three recent national and international recommendations [1,2,3], as well as a Cochrane  review, have concluded that scientific studies regarding this practice are of poor quality.
These recommendations highlight:
– the lack of a clear and consensual anatomical definition of restrictive tongue brakes and ankyloglossia,
– the need to clarify the diagnostic criteria, as it is actually a functional rather than anatomical diagnosis. Although a restrictive tongue-tie is sometimes recognized as one of the causes of nipple pain and early cessation of breastfeeding, it is far from being the most common cause. Thus, a very anterior location of tongue-tie attached to the tip of the tongue and/or its thickness is not an indication for surgery if this does not interfere with sucking,
– the lack of scientific evidence, due to a lack of rigorous methodology, as to:
– the usefulness of surgically cutting the tongue frenulum to improve milk transfer and/or relieve nipple pain,
– the assessment of the optimal age to indicate a frenotomy, the best surgical technique (laser or scissors), the value of manipulations or applications of substances on or near the incised area post-surgery, or the effectiveness and duration of breastfeeding over the post-operative long-term.
– the responsibility of ankyloglossia invoked in pathologies such as gastro-esophageal reflux, speech difficulties, sleep apnea, colic, oral difficulties at the time of the transition to solid food.
– despite the simplicity of the surgical procedure, the possible occurrence of complications of which the parents must be informed, even if they remain rare: hemorrhages, collateral tissue damage, obstruction of the respiratory tract, breastfeeding refusal, oral aversion, infection, increased post-surgery breastfeeding duration.
A collective call for vigilance!
Faced with the significant increase throughout the country of networks offering, at excessive prices, to treat nipple pain and early cessation of breastfeeding by frenotomy (or worse, to perform it as a preventive measure), the National Academy of Medicine joins several learned medical, surgical and paramedical societies, professional colleges and associations in expressing the greatest reservations about the interest and safety of this invasive procedure with the risk of side effects, and formulates the following recommendations :
- In the absence of breastfeeding difficulties, the presence of a short and/or thick tongue frenulum is not in itself an indication for frenotomy, which is an aggressive and potentially dangerous procedure for newborns or infants and should not be performed.
- In the presence of any breastfeeding difficulties, a rigorous diagnostic approach should be carried out by professionals with university training, or with officially accredited training in breastfeeding, respecting evidence-based medicine, considering the child’s overall general condition, complemented by a rigorous anatomical and above all functional evaluation of the child’s sucking/deglutition. Frenotomy, remaining exceptional, should be decided in connection with the attending physician or the pediatrician.
- A scissor frenotomy may be indicated after informing the parents of the benefit/risk ratio, provided that there is a short and/or thick anterior lingual frenulum and only after the failure of conventional non-surgical conservative measures. This procedure is performed with or without contact anesthesia, immediate return to the breastfeeding and prescription of an analgesic. After the frenotomy, no intraoral procedure is necessary in the following days.
- Methodologically rigorous studies targeting the indications, efficacy, and safety of frenotomy should be conducted without delay.
- Breastfeeding preparation and training of professionals should be improved in order to emphasize conservative and non-surgical care in case of difficulties.
* Ankyloglossia: term corresponding to a limitation of tongue movements caused by a very anterior and/or thick lingual frenulum. It is a congenital anomaly.
 Australian Dentist Association 2020. Ankyloglossia-and Oral-Frena-Consensus-Statement. First edition: Ankyloglossia-and-Oral-Frena-Consensus-Statement_J.aspx (ada.org.au)
 Messner AH, Walsh J, Rosenfeld RM, Schwartz SR, Ishman SL, Baldassari C, Brietzke SE, Darrow DH, Goldstein N, Levi J, Meyer AK, Parikh S, Simons JP, Wohl DL, Lambie E, Satterfield L. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020 May;162(5):597-611. doi: 10.1177/0194599820915457. Epub 2020 Apr 14. PMID: 32283998.
 LeFort Y, Evans A, Livingstone V, Douglas P, Dahlquist N, Donnelly B, Leeper K, Harley E, Lappin S. Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads. Breastfeed Med. 2021 Apr;16(4):278-281. doi: 10.1089/bfm.2021.29179.ylf. PMID: 33852342.
 O’Shea JE, Foster JP, O’Donnell CP, Breathnach D, Jacobs SE, Todd DA, Davis PG. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev. 2017 Mar 11;3(3):CD011065. doi:10.1002/14651858.CD011065.pub2. PMID: 28284020; PMCID: PMC6464654
 AFPA Press Release 17/01/2022. https://afpa.org/2022/01/17/section-de-freins-de-langue-chez-les-nourrissons-et-les-enfants-alerte-sur-des-pratiques-abusives/. Signatories of the AFPA press release of 17/01/2022: CIANE Association, Association des Lactariums de France (ADLF), Association Française d’ORL pédiatrique (AFOP), Association Française de Pédiatrie Ambulatoire (AFPA), Association I.P. A – Information Pour l’Allaitement, Centre de Référence Maladies Rares ” Syndromes de Pierre Robin et Troubles de Succion-Déglutition Congénitaux ” (SPRATON), Collège Français d’Orthophonie, Collège National des Infirmier(e)s puéricultrices(eurs) (IPDE), Collège National des Sages-femmes (CNSF), Conseil National de Pédiatrie Conseil National Professionnel de Stomatologie et Chirurgie maxillo-Faciale, Comité de Nutrition de la Société Française de Pédiatrie, Coordination Française pour l’Allaitement Maternel, DIU Lactation humaine et allaitement maternel (DULHAM), DU Allaitement maternel, Marseilles, Fédération Nationale des orthophonistes), Groupe de Pédiatrie Générale Sociale et Environnementale (GPGSE: group of the Société Française de Pédiatrie), Fédération des réseaux de Périnatalité Française, Société Française de Chirurgie Orale, Société Française de Médecine Périnatale, Société Française de Néonatalogie, Société Française d’Odontologie Pédiatrique (SFOP), Société Française de Pédiatrie (SFP), Société Française de Stomatologie, Chirurgie Maxillo-Faciale.
(*) Communiqué from the Academy’s Rapid Communication Unit validated by the members of the Board of Directors on April 25, 2022.