suggesting there is no correlation between what the tongue does during an oral exam and what it does during breastfeeding .

Using these tools as diagnostic decision makers is misguided , as the overall diagnosis needs to be more detailed . The assessment must include a thorough history of all breastfeeding problems ;

The anatomy of the sublingual frenulum was not described in medical literature until 2019 .

impact of a visible sublingual frenulum . These include involvement in other breastfeeding issues such as clicking , fussing at the breast , slow weight gain and reduced milk supply ; future dental or speech issues ; difficulty with bottle feeding and managing solids ; effects on sleep apnoea , snoring and reflux ; and more far-fetched problems including headaches ,

means possible . Most anterior sublingual frenula are thin , elastic and relatively avascular . Simple scissor frenotomy is a quick office procedure , requiring no anaesthetic , and done under direct vision . A sublingual frenulum that is thick or has clearly visible blood vessels should be referred to an ENT surgeon for an opinion on method of divi-

Procedural risks

There is a risk of harm when performing

releases of oral frenula . Risks need to be thoroughly discussed with the parent and should strongly guide the risk / benefit ratio ( especially considering the lack of evidence for some of these procedures ).

The risks include : bleeding ( including

examination of the baby ’ s oral anatomy ;

poor posture , dental malocclusion , plantar

sion , as the risk of complications are high

reports of near-fatal episodes and haemat-

examination of the maternal breast for

fasciitis , excessively unsettled infants , food

for an office-based procedure .

oma formation ); infection ; damage to sur-

milk stasis and nipple damage ; a close

allergies and even crying during car rides .

Laser release has become very popular

rounding tissues ( nerves , salivary ducts );

assessment of the dyad breastfeeding for

The majority of the above concerns have

in the dental community , mostly because

altered or damaged tongue function /

milk transfer ; and correcting any prob-

a correlation rather than causation basis , if

of the ability to control bleeding . The risks

movement due to nerve damage ; pain ;

lems with positioning and attachment . It

any basis at all . Fear of future problems is a

associated with use of laser include ther-

oral aversion leading to feed refusal ; air-

is likely this assessment may need review

major driver for parents seeking release of

mal burn to surrounding tissue ( that may

way compromise ; scar formation ( a scar

by more than one healthcare professional .

their baby ’ s lingual frenulum , but reassur-

involve nerves ), ocular injury secondary to

inherently constricts ); and no benefit to

Anterior sublingual frenulum release

This is only warranted in very specific sce-

ance can easily be given that causation has not been proven , there is no urgency in treatment , and if any of the listed issues eventuate , it is recommended to see an appropriate

laser exposure , inhalation of smoke / debris created by the laser , and aspiration of blood / coolant spray .

There are no published studies com-

the original breastfeeding problem .

In fact , if the oral frenula are not the cause of the breastfeeding problem , then procedure completion can lead to a delay

narios . Specifically , the only indication to release an anterior sublingual frenulum is for nipple pain in a breastfeeding mother which does not improve with changes to positioning and attachment , and when the baby clearly has a restricting anterior sublingual frenulum that extends to near the tip of the tongue and / or the gingival margins on the floor of the mouth .

The evidence does not support the

A sublingual frenulum that is thick or has clearly visible blood vessels should be referred to an ENT surgeon for an opinion on method of division .

paring the different methods of tongue tie division in humans ; although animal studies show scissor or scalpel incisions heal faster than laser ( possibly due to thermal damage with laser ).

Post-release stretches

There is no indication to recommend

stretches following anterior sublingual frenulum release . The proposed benefit of stretches

Conclusion

In summary , what currently appears to be a murky area of breastfeeding medicine and infant care can be made clearer by following best current evidence . While the evidence isn ’ t complete , hopefully

release of an anterior sublingual frenulum

is that it reduces “ reattachment ” of the frenu-

the two consensus statements discussed

for any other reason than maternal nipple

healthcare professional for a full assessment ,

lum . However , this has no evidence base .

above will guide further research . And

pain in breastfeeding ( and to a lesser extent ,

rather than assuming it is the fault of the lin-

In other scar management , stretching of a

for now , we can be confident that by fol-

poor milk transfer , although the quality of

gual frenulum .

wound has been shown to increase healing

lowing the recommendations of those two

evidence relating to this is not as robust ). If there is no functional impairment of breastfeeding , the presence of a sublingual frenu-

Scissor frenotomy

This procedure is currently the gold stand-

time , risk of scarring and even infection . Not to mention it is incredibly painful if a wound is manually stretched . This can lead to oral

publications , we can guide parents on current evidence as to how to best manage their baby ’ s oral frenula .

lum is a normal anatomical variant and does not require any treatment .

There are many hypotheses around the

ard approach for anterior tongue tie release , when indicated . The aim should be to release the tight tissue in the least invasive

aversion in an infant , worsening the initial feeding problem as the infant refuses to have anything in its mouth .

References on request from kate . kelso @ adg . com . au