10 Reasons NOT to get your Baby "Revised" by Alison K. Hazelbaker, PhD, IBCLC, FILCA, CST-T, RCST, PPNE
For the record, there is such a condition as tongue-tie. (Formally known as ankyloglossia.) It is a congenital anomaly that occurs because of genetic coding. It is hereditary, and contrary to popular belief, it only affects 3-5% of babies at the most. Revision, a term that is misused to refer to frenotomy or frenectomy, actually means undergoing a second or subsequent procedure. Henceforth, I will use the appropriate term divided, clipped or frenotomy/frenectomy to refer to the initial surgery for tongue-tie and what is referred to as posterior, lip or buccal tie.
Division for truly tongue-tied babies is appropriate but only if proper management of breastfeeding fails to correct the feeding problems or if it is so severe that it will cause other issues down the road.
It takes training and skill to properly assess for and diagnose a true tongue-tie as many structural insults from fetal life, birth or neonatal handling of the baby can cause breastfeeding problems. The assessing practitioner must be able to differentiate between these insults and true tongue-tie. Many practitioners cannot or do not differentiate between these causes and so the assessment and treatment of “tethered oral tissues” has become a catch-all diagnosis regardless of harm, efficacy, evidence, or appropriateness.
Here are ten reasons for NOT getting your baby’s oral tissues divided:
1. Posterior tie does NOT exist. If a practitioner diagnoses your baby with a posterior tie, run as fast as you can in the opposite direction and find yourself a competent practitioner. Why?
a. Anatomically, posterior tie cannot exist. The lingual frenulum is a sheath of fascia that forms the roof of the mouth floor. There is no tight band, mast with a sail or a sub-mucosal posterior tie behind an anterior one. These are all gross misunderstandings of the anatomy of the mouth.5-8
b. The Watson Genna-Coryllos “assessment” is invalid. This is the most common assessment used for posterior tie. Any study that has used this (or some other invalid classification schema) to diagnose posterior tie belongs in the round bin. Its findings cannot be trusted. No valid screening tool, for what is dubbed posterior tie, exists and this is what has prompted the American Academy of Pediatrics to state: “Posterior ankyloglossia is a poorly defined term, lacking agreement from experts, and should not be used as a reason to perform surgical intervention on an infant.”15
c. Recent anatomical studies that have been dismissed by posterior tie proponents corroborate earlier findings and are corroborated by multiple fascial studies.5-8
d. Temporary tongue movement increases as a result of surgery does not prove the diagnosis correct. The only thing it proves is that cutting this tissue increases tongue movements temporarily.
2. “Lip-tie” does NOT exist. Why?
a. Over 93% of babies have a prominent labial frenum that is attached low on the gumline. A prominent labial frenum is NORMAL in infancy.4,9,13
b. The article presenting the notion that lip “tie” causes breastfeeding problems had no data included that proved a cause-and-effect relationship and was based on a few children aged 8 months to three years.
c. There is NO study that proves a cause-and-effect relationship between a prominent labial frenum and breastfeeding difficulties. This is a made-up diagnosis prompting the American Academy of Pediatrics to state: “Labial and buccal frenae are normal oral structures unrelated to breastfeeding mechanics and do not require surgical intervention to improve breastfeeding.”15
d. The labial frenum gets smaller and thinner as the infant grows. The attachment point appears to rise when the gum grows past it as the teeth erupt.2,9,13
e. What is the long-term consequence of revising a labial frenum when it is not needed? Nobody knows. It hasn’t been studied. Safety and efficacy studies must be done by those who are proposing the treatment. That is their duty.
3. Buccal tie is an extremely rare condition that accompanies severe genetic syndromes. Tight cheeks do not equal buccal “tie” but they may equal over-firing of the nerve that innervates them. It’s called tension and tension is not a congenital anomaly requiring surgery.
4. Aggressive aftercare exercises, also known as Active Wound Management or AVM, prescribed by many practitioners, cause harm and make no difference.1 Don’t believe me, believe the myriad of wound healing studies, especially those that demonstrate the harm in forcibly opening a closing wound.
a. Lasers, by their very nature, cause scar tissue.
b. Deep frenotomies and frenectomies create a wound that heals by second intention. Second intention means that the wound heals and closes by generating granulation tissue that then forms a scar. Scar tissue replaces the tissue cut away. Mother Nature and a complex cascade of biochemicals ensure this process happens quickly and well unless it is disturbed.
c. Rubbing, manipulating, or breaking open a healing wound causes the body to make even more scar tissue.3,16 A complex biochemical process mediates this reaction. Practitioners call this excessive scar tissue formation “reattachment” and yet it is caused by their use of lasers and their aggressive aftercare practices.
d. Oral aversion and ongoing feeding and swallowing difficulties have been attributed to these aggressive practices.10
e. There is no study to show efficacy or safety of these aggressive aftercare practices. Plenty of science, good science, supports the hands-off approach!3,15
5. There is no requirement for practitioners to get trained to use the two legitimate, evidence-based screening tools for infant tongue-tie. That means the diagnosis is subject to the whims of the practitioner. They see what they want to see.
6. There is no requirement for practitioners to be trained on lasers or to perform frenotomy/frenectomy. This leads to a lack of skill, a lack of best practice, and harm to the baby.15
7. The current practice of deep frenectomy or frenotomy may cut into tongue muscle, potentially damaging tongue movement, tongue coordination, swallowing difficulties, and decreased tongue sensation. There is mounting evidence that this is happening more than practitioners are willing to acknowledge. Parents have no recourse when this happens because there is no best practice standard of care.
8. We do not know what the long-term effects are of performing frenotomy/frenectomy on a baby who doesn’t need it. This constitutes putting the proverbial cart before the horse. One is supposed to prove safety and efficacy before proceeding with a treatment, especially when it involves vulnerable babies.
9. Here is a partial list of harms done by laser frenectomy and aggressive aftercare as reported by parents and in the scientific literature by professionals:1,11
Central nervous system instability, dysregulation, feeding difficulties, feeding refusal, poor weight gain, discoordination, poor swallowing coordination, refusal of solid foods, oral aversion, massive scarring, emotional trauma, tissue trauma, and excessive bleeding requiring hospitalization.
10. Bodywork First! Mounting evidence demonstrates that bodywork modalities can resolve or mitigate many of the issues that are at play with breastfeeding problems that are commonly claimed to be caused by posterior, lip and buccal “tie.” Bodywork modalities have been proven effective in thousands of good scientific studies. Bodywork modalities include PT, OT, chiropractic, craniosacral therapy, myofascial release, and osteopathy. No doubt you will be able to find at least one of these practitioners in your community to work with your baby.
If you have been pressured by any practitioner to put your baby through surgery the same day as an assessment is done, get out of there as fast as possible. Please get a second opinion by someone who is adequately trained to use the ATLFF™© or the Infant Frenulum Protocol. It is very likely that your baby does not have a posterior tie, a lip-tie or a buccal tie because these conditions do not exist.
By no means should you take advice from someone on social media or a practitioner who bills themselves as a Tongue-tie or Tethered Oral Tissues Practitioner. Social Media is rife with bad advice and tongue-tie practitioners will automatically over-diagnose, an unethical practice. Tongue-tie cannot be diagnosed by symptoms alone or by a picture. The baby must be seen in person.
Babies are not just their mouths. They can have difficulties feeding because of other affecting issues. In my very experienced professional opinion with 40 years of practice, who has done a lot of research on this subject and written a book about it, a practitioner who does not assess the baby’s whole body has no business diagnosing tongue, lip and buccal ties.
Before a clinical procedure becomes common, the case for performing that procedure must demonstrate, via well-performed scientific study, to have benefits that well-outweigh the risks. The proponents of “TOTs” have failed to do so.
I have pulled no punches in this post. No doubt proponents of “TOTs” are going to rant and rave, fuss and blather, and drag my reputation through the mud on social media as they have done before. I don’t care. I stand on science, I stand for innocent, vulnerable babies who have no say for themselves, and I stand for their confused and misled parents who just want their struggles to feed their babies to go away.
When will these “TOTs” practitioners do the same?
References
1. Bhandarkar, K.P., et al. (2022). Post Frenotomy Massage for Ankyloglossia in Infants—Does it Improve Breastfeeding and Reduce Recurrence? Maternal and Child Health Journal; 26:1727-1731.
2. Boutsi, E.A. (2014). The maxillary labial frenum. J Cranio Max Dis, 3:1-2.
3. Darby, I. A., Laverdet, B., Bonté, F., & Desmoulière, A. (2013). Fibroblasts and myofibroblasts in wound healing. Clinical, Cosmetic and Investigational Dermatology, 7, 301-311. https://doi.org/10.2147/CCID.S50046
4. Flinck, A., Paludan, A., Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr 4(2):67-73
5. Gartner, L.P., & Schein, D. (1991). The superior labial frenum: a histological observation. Quintessence Int. 22(6):443-5.
6. Mills, N., et al. (2019). Defining the anatomy of the neonatal lingual frenulum. Clinical Anatomy; doi.org/10.1002/ca.23410
7. Mills, N., et al. (2019). What is a Tongue Tie? Defining the Anatomy of the In-Situ Lingual Frenulum. Clinical Anatomy; DOI: 10.1002/ca.23343
8. Mills, N., et al. (2020). Understanding the lingual frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery. International Journal of Otolaryngology; Vol 2020. ID: 1820978. Https://doi.org.10.1155/2020/1820978
9. Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.
10. Nakhash, R., et al. (2019). Upper lip tie and breastfeeding: a systematic review. Breastfeeding Medicine; 14(2): 83-87.
11. O’Connor, M., et al. (2022). Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey. International Breastfeeding Journal; 17:39.
12. Placek, M., Skach, M. & Mrklas, L. (1974). Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol. 45:891–4.
13. Santa Maria, C., Aby, J., Thy Trong, M., Thakur, Y., Rea, S. & Messner, A. (2017). The superior labial frenulum in newborns: what is normal? Global Pediatric Health, 4:1-6.
14. Sewerin, I. (1971). Prevalence of variations and anomalies of upper labial frenum. Acta Odontol Scand, Oct; 29(4): 487-96.
15. Thomas, J., et al. (2024). Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report. Pediatrics, 154:2. E2024067605.
16. Wilkinson, H.N. & Hardman, M.J. (2020). Wound healing: cellular mechanisms and pathological outcomes. Open Biology, 10:9. https://doi.org/10.1098/rsob.200223