Don’t be so quick to write off frenotomy

We are writing in response to the Clinical Inquiry, “Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?” by Cawse-Lucas et al (J Fam Pract. 2015;64:126-127).

We respectfully disagree with the authors’ conclusion that frenotomy probably isn’t helpful in overcoming breastfeeding difficulties and that “the evidence concerning improvements in maternal comfort is conflicting.” In addition, the authors cited only randomized controlled trials (RCTs). We believe they were remiss for not referencing systematic reviews that have found an association between frenotomy and improved breastfeeding.

In a systematic review of 5 RCTs and 9 case studies, Finigan and Long¹ found that frenotomy offered long-term improvement in more than half of cases. Edmunds et al² reviewed 25 papers and concluded that for most infants, frenotomy offers the best chance of improved and continued breastfeeding. In a review that included 4 RCTs and 12 observational studies, Ito³ found “moderate quality” evidence for the effectiveness of frenotomy in treating breastfeeding difficulties.

We also believe that qualitative data from breastfeeding mothers should be used to inform quantitative research. We need to explore—and offer—any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Sarah Oakley, BA (Hons), RN, RHV, IBCLC
Annabelle MacKenzie
Association of Tongue-tie Practitioners and Tongue-tie UK
Clapham, Beddford, England

Authors’ response:
Clinical Inquiries prioritizes the RCT as the best method to evaluate whether a treatment is valid and helpful because these trials can tell us whether treatment produces a significantly better outcome than expectant management.

We need to offer any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Other types of studies included in systematic reviews (eg, cohort, case series, observational) can only demonstrate an association between an intervention (frenotomy) and an outcome (subsequent improvement in breastfeeding). They cannot demonstrate whether the treatment produced the improvement or if the babies would have improved anyway without frenotomy.

Based on the highest quality evidence—the 4 RCTs we described in our article—it appears frenotomy produces a small and temporary reduction in maternal nipple pain in infants younger than 2 weeks, but no overall improvements in validated breastfeeding scores.

Frenotomy for tongue-tie in breastfeeding infants is understandably controversial, and will remain so as long as there is a paucity of high-quality research on this topic. We look forward to future RCTs, perhaps informed by the experiences of nursing mothers and using validated tools, that may further elucidate the question.

Jeanne Cawse-Lucas, MD
Shannon Waterman, MD
Leilani St. Anna, MLIS, AHIP
E. Chris Vincent, MD
Seattle, Wash