Warning Against Increased Lingual Frenotomy in Infants

France — On April 26, the French Academy of Medicine published an official statement calling for "more cautiousness for lingual frenotomy in newborns and infants." In January, several academic societies had already expressed concern about the abnormal increase, in France and worldwide, in lingual frenulum surgeries in children following their discharge from maternity clinics. André Chays, MD, member of the French National Academy of Medicine, and Michel Le Gall, MD, member of the French Federation of Orthodontics, have shed light on the practice for Medscape Medical News.

Dramatic and Unquantified Increases

"A lingual frenulum section (frenotomy) or excision (frenectomy) in newborns or infants involves surgically cutting (with scissors or a laser) a short and/or thick lingual frenulum to restore range of motion of the mobile tongue, in particular its protraction. Until recently, this rare surgical procedure has been indicated for ankyloglossia with a significant effect on function," the Academy of Medicine explained in an official statement published on April 26.

Ankyloglossia limits the tongue's range of motion due to a "restrictive" very anterior and/or thick lingual frenulum. It is a congenital anomaly.

"This is not a new procedure. It is old and well-known," said Chays, an ear, nose, and throat specialist and member of the French National Academy of Medicine. But what concerns the academy is "the dramatic increase, in France and worldwide, in lingual frenotomy, a procedure which, if performed very soon after discharge from the maternity clinic, supposedly then permits breastfeeding that is both effective for the newborn and infant and painless for the mother." Thus, in Australia, it found an increase of more than 420% in this procedure over a decade. "The increase has not been quantified in France,” said Chays.

In January 2021, several academic medical, surgical, and paramedical societies, such as the French Society of Oral Surgery, the French Association for Pediatric Otolaryngology, the French Society of Pediatric Dentistry, and the French Pediatric Society, were already troubled by the abnormal increase, in France and worldwide, in lingual frenulum surgeries in children after their discharge from maternity clinics. Thus, the academic societies pointed out that "lingual frenotomy has always been a standard, albeit quite rare, practice in the maternity clinic. They are performed to address sucking problems following a clinical evaluation and a lack of success in breastfeeding assistance measures. Their unjustified recent increase in the months following birth warrants alerting parents, early childhood experts, and institutional specialists."

Lack of Quality Studies

"This increase is all the more surprising because three recent national and international recommendations and a Cochrane Review concluded that there is a lack of quality scientific studies regarding this practice," the Academy of Medicine added.

There are no new studies demonstrating the benefit of this procedure in facilitating breastfeeding and eliminating nipple pain for breastfeeding mothers, according to Chays. He remarked that "there is no reported relationship between the anatomy of the lingual frenulum and the source of breastfeeding problems." Nevertheless, "on social networks and forums, when you search 'breastfeeding problems,' you find anything and everything from one comment to the next, with some people giving their advice without having any expertise," he said.

In his view, "breastfeeding is tricky and either succeeds or fails during the first 72 hours. If there are no staff members to coach and guide the mother, the easy course of action is to cut the baby’s lingual frenulum and send the mother home, telling her things will get better!" The risks of this procedure are very rare and benign in principle. "But in rare cases there can be complications, especially bleeding, which may be serious," he warned.

Therapeutic Good Sense

A frenotomy may be indicated "if the child has trouble breastfeeding and after all other causes have been ruled out," said Le Gall, professor at the Marseilles School of Dentistry, head of the Dento-Facial Orthopedics Department at Timone Hospital, and member of the French Federation of Orthodontics. "You need to use therapeutic good sense. It should not be the miracle solution for breastfeeding problems," he added.

For older children, after the age of 2 or 3 years, a frenotomy may solve difficulties pronouncing certain phonemes or resolve atypical swallowing that can have dental, alveolar, and skeletal repercussions on the child’s mouth.

Here, too, however, the clinician must make a diagnosis and differentiate between what requires therapy with a speech therapist and what requires surgery. "We mustn’t fall into the habit of routinely performing a frenotomy from a very young age," said Le Gall. The Academy of Medicine shares this opinion. It recommends, in particular, the following: "in the event of breastfeeding problems of any kind, a rigorous diagnostic process […] carried out by professionals with a university education or who have had officially accredited breastfeeding training that adheres to evidence-based medicine, taking into account the child’s overall general health, and is supplemented by a thorough anatomical and above all functional assessment of the child’s sucking/swallowing. A frenotomy should remain for exceptional cases and should be decided on in conjunction with the attending physician or pediatrician."

In addition, the academy calls for "methodologically rigorous studies targeting the indications, efficacy, and tolerability of frenotomy."

This article was translated from the Medscape French edition.

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Cite this: Warning Against Increased Lingual Frenotomy in Infants - Medscape - May 23, 2022.