Should family physicians perform frenotomy for neonatal ankyloglossia?

Sir,

Ankyloglossia (tongue-tie) is a fairly common congenital anomaly in newborns that is often implicated in difficulty in breastfeeding. We present a case of successful frenotomy by our family medicine team in an infant with symptomatic ankyloglossia.

A 1-day-old term female was born via induced vaginal delivery to a 16-year-old gravida 1 by the inpatient family medicine service at an academic medical center. Moderate ankyloglossia was discovered on initial examination [Figure 1a]. Several hours after delivery, her nurses reported that the newborn was not feeding well. They were concerned about her latch and maternal nipple pain. Lactation specialty nurses were consulted. After approximately 12 h of various interventions and coaching, breastfeeding was still inadequate, so they switched to supplementation and breast pumping. With the family's consent, an anterior frenotomy of <3 mm incision through the frenulum was performed using a blunt pair of scissors [Figure 1b]. There was only a drop of blood, and the newborn tolerated the procedure well crying for a very short time. Following the procedure, LATCH (Latch, Audible swallowing, nipple type, comfort, and hold) scores improved and maternal self-report of nipple pain immediately reduced. Supplementation was no longer required and there was a safe amount of expected weight loss at 24 h. The incision healed in 24 h [Figure 1c].

Figure 1

(a) Ankyloglossia in a day old newborn, (b) immediate postfrenotomy, (c) 1 day postprocedure

Ankyloglossia affects about 2-5% of newborns.[123] In those who have breastfeeding difficulty, the condition is implicated in 12.8%.[2] Frenotomy seems to improve maternal nipple pain and sometimes infant breastfeeding. However, high quality randomized control trial studies are few.[456] In clinically significant ankyloglossia, frenotomy is recommended as soon as possible.[2] Neonatal frenotomy, especially when performed in the first 4 weeks of life, is a safe and simple procedure, which can be performed with or without local anesthesia.[1237] The procedure is easily taught using multimedia resources. Other than minor bleeding and discomfort, complications are rare.[1234567] In a review article, Brookes et al. described no complications in eleven studies with a total of 930 patients.[7]

Family physicians are often the first to identify ankyloglossia and therefore, could be first to intervene. Currently, there is no evidence to show that frenotomy performed by trained family physicians is any different from what is performed by specialists. The literature seems to support the view that primary care physicians should perform frenotomy when indicated and when the physician is confident in performing the procedure.[89] Toner et al. found that performing frenotomy in the office rather than the operating room on 25 patients saved more than $240,000 and eliminated risk of general anesthesia in the first few weeks of life.[10] The Academy of Breastfeeding Medicine recommends that frenotomy should be performed by an appropriately trained physician.[9]

Frenotomy performed by primary care providers has a low complication rate, can help some mothers to continue to make the effort of breastfeeding, and has a much lower cost compared to the same procedure performed by a specialist under general anesthesia in the operating room. Family physicians are perfectly able to make the diagnosis and safely intervene early to minimize the complications of ankyloglossia. There is a need for randomized controlled trials to study this further.

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Conflicts of interest

There are no conflicts of interest.