Is a procedure aimed at fixing breastfeeding complications a medical necessity, or trendy diagnosis?
Ear, nose and throat surgeon Heather Nardone has one gloved finger, knuckle deep in baby Maxwell’s mouth.
His mom, Esmeralda Reza-Vasquez, is standing nearby. Maxwell’s grandmother Luz Maria Vallejo coos to the baby in Spanish while the doctor peers under his tongue.
Reza-Vasquez and her mom are a tag team taking turns quieting the baby.
Nardone tells the family that Maxwell has what is commonly known as a “tongue-tie.” A piece of tissue, his frenulum, is short and tightly tethering his tongue to the floor of his mouth.
The medical term is ankyloglossia, and Nardone says Maxwell has a severe tongue-tie. His frenulum is connected all the way to the tip of his tongue.
Because of this, he can’t lift his tongue very high or stick it out. Most importantly, he hasn’t been able to latch well onto his mother’s breast when it’s time eat.
At two weeks old, Maxwell is not yet seven pounds. His mom, Esmeralda Reza-Vasquez, says from day one, it was hard for him to nurse. He’d get tired after just three or four minutes.
“Everyone was saying he was really skinny,” Reza-Vasquez, 25, said.
Maxwell wasn’t gaining weight. So his pediatrician sent him to see Nardone, a specialist at Nemours Hospital for Children in Wilmington, Delaware.
Maxwell’s mom wants to breastfeed almost exclusively, so otolaryngologist Nardone recommended that they cut the frenulum—divide the tissue—to release his tongue and improve its motion.
Many babies with a tongue-tie don’t need any kind of procedure. There’s a wide spectrum of ‘connectedness’ to the floor of the mouth–thick tongue-ties, short ones, as well as frenula tethered in many different positions under the tongue. Medical experts don’t routinely ‘snip’ a tongue-tie, but the procedure is often recommended to improve breastfeeding.
Nardone takes out surgical scissors.
She isolated the frenulum, cut the cord, and then dabbed a bit of blood away with a gauze.
Maxwell was pretty unhappy. For a few seconds during the procedure, his baby grunts turned to high-pitched yells. Looking on, his mother looked pretty uncomfortable, too.
(Reza-Vasquez says she didn’t have Maxwell circumcised because that’s not medically necessary—the thought of her first born in pain makes her queasy. But she decided the tongue-tie procedure was necessary.)
It happened right in the doctor’s office, and was over in less than 45 seconds. Afterward, the surgeon dipped her finger in sugar water, Maxwell sucked and calmed down quickly.
Back in the days when most people were born at home, some midwives would keep one fingernail long and sharp. If she noticed a baby had trouble breastfeeding and that his or her tongue was ‘tied’ to the floor of the mouth, she’d sweep her nail under the baby’s tongue and snip the problem, right at the bedside.
Today, the procedure is a little more complicated and sanitary. And there’s some debate about whether ‘tongue-tie’ has become a trendy diagnosis to fix breastfeeding problems. In surveys of physicians and lactation consultants there’s disagreement about when—and if–a tongue-tie should be divided to help with breastfeeding.
Babies have trouble feeding for lots of different reasons, and newborns are often slow to gain weight in the first days of life. Help from a lactation consultant and a visit to the pediatrician can help parents figure out if there’s a problem—and if a frenulum procedure would help.
A laser ‘snip’
In Philadelphia, dentist Paul Bahn opened a business separate from his pediatric dental practice, where he consults with breastfeeding mothers and evaluates newborns with a possible frenulum problem.
At Infant Laser Dentistry, he can do as many as many as five tongue-tie ‘snip’ procedures a day.
Instead of surgical scissors, Bahn uses a medical laser, which cauterizes the wound while it cuts. The laser might not be what you’re imagining. It looks more like an electric toothbrush than a weapon from Star Trek.
“It’s a light beam that comes out of here, and it produces heat at the very tip of that. And that interacts with the tissue in a focalized spot,” Bahn explained as he demonstrated the tool. The mouth heals quickly and the risk of infection is very low, he said.
Bahn says a consultation with a newborn’s family can take as long as 45 minutes while he examines the baby and asks about the mother’s breastfeeding experience.
Sometimes the consultation includes a basic explainer about how nursing works.
“The tongue has to go out and grab the nipple and pull it into the mouth,” Bahn said.
“The tongue makes this wave motion, almost this peristaltic wave motion, so the tongue has to almost strip milk from the nipple.”
Getting milk from a bottle takes a little less work: because there’s a built-in, protruding nipple and holes at the tip for easy flow. Lots of children with a mild or moderate tongue-tie eat from a bottle just fine.
But breastfeeding is increasingly popular in the United States. Bahn says that renewed interest in nursing may spotlight a common difference in the structure of a baby’s mouth that goes unnoticed unless there’s a problem.
In the early 1990s, about 55 percent of moms in the United States attempted breastfeeding. Today, federal health surveys show that 80 percent of mothers at least try to nurse.
Six-month-old Ellis was about 3 and a half weeks old when he had the laser procedure to un-tether his frenulum.
His mother Katherine Gajewski says pain during nursing was a big problem.
“I would say day one, latch one, pretty immediately it started to hurt,” she said.
Ellis seemed to be chopping instead of teasing out her milk.
“It just feels like this beautiful, tiny being, is rubbing your nipple raw,” she said.
Early on, Gajewski had lots of help and encouragement to breastfeed. She had a doula, a midwife and frequent visits from a lactation consultant—and still she and Ellis struggled with nursing.
Today Ellis is a sturdy climber with ruddy cheeks and a fuzz of brown hair—not much fazes him. But in the first few weeks after he was born, he was fussy and Gajewski says it was stressful not being able to comfort him.
She’s now convinced that he was just really hungry.
She gave him a bottle with donor breast milk but worried her own milk supply would slow.
“I had all of these notions in my head about supplementing with formula and kind of equated that with failure and everything else,” she said.
She also worried Ellis would become a ‘lazy feeder.’
“Another concern when you are working through all of this and trying to get to successful breastfeeding is that your baby might start to prefer the bottle over the breast and you can never get them back to the boob,” Gajewski said.
After the laser procedure, dentist Paul Bahn prescribed some post-op exercises.
Gajewski had to roll her finger around in Ellis’ mouth to break up the scar tissue, and she says that was the worst part. The wound was still fresh and it was unnerving for her. After that, the baby had to re-learn how to use his tongue.
“It would kind of flop around for those first few weeks after the laser treatment, and then he figured it out, and about three weeks after the treatment, things clicked and we were off to the races,” she said.
It’s not clear that the tongue snip was the fix, but today, Ellis is a good eater, and he rotates between formula, breast milk and solid food.
In 2012, the American Academy of Pediatricians reviewed the evidence on the frenulum procedure and didn’t uncover a lot of good data. There are also no evidence-based guidelines on tongue-tie fixes.
One study of babies with significant tongue-ties, showed improvements in breastfeeding after the frenulum procedure—compared to a group of babies with a similar condition who did not have the procedure.
Katherine Gajewski said the consultation with the pediatric dentist plus the ‘snip’ surgery cost about $450. Dental insurance rejected the claim, but she’s re-submitting—and hopes Ellis’ medical insurance will pick up the bill.
Ear-nose-and-throat specialist Heather Nardone says she can’t predict for parents if a baby’s tongue-tie will cause trouble later in life. A lot of kids adjust as they grow. A mild tongue-tie sometimes stretches as a child becomes more vocal, she said.
Many parents and physicians simply monitor the child’s development and look out for speech problems, issues with dental hygiene and breathing trouble as the child sleeps.
A postscript report from Baby Maxwell’s mom, Esmeralda Reza-Vasquez:
“Maxwell has eaten a ton better since the surgery, my breasts are less swollen and it is less painful since he’s not gumming my nipples as hard to get milk out. He’s still healing slightly.”