Surgical frenotomy in infants with ankyloglossia

Clinical question

Does surgical frenotomy in infants with ankyloglossia improve mother or infant breastfeeding outcomes?

Bottom line

Surgical frenotomy in infants with ankyloglossia likely reduces maternal nipple pain by approximately 2 points on a 10-point scale, and improves breastfeeding outcomes in 78% to 96% of patients versus 3% to 47% control. Effects on infant weight gain and rates of breastfeeding are unknown due to large crossover in control groups. Common adverse events are bleeding (up to 5%) and repeat frenotomy (up to 4%).

Evidence

Results are statistically significant unless indicated. Six randomized controlled trials (RCTs) of infants aged 1 day to 10 weeks with ankyloglossia and breastfeeding difficulties (25 to 169 patients) were included.^1-6

• Nipple pain: A comparison of prefrenotomy to post-frenotomy, immediately after procedure and up to 2 weeks, found a 2-point improvement on 10-point visual analogue scale.^1-4 This was statistically different in 1 RCT,⁴ but was unreported in other trials.^1-3 In 1 RCT there was no statistical difference versus sham.² On a 50-point scale, there was a 12-point improvement in the frenotomy group (6-point improvement control).⁵ These changes are likely clinically relevant.

• Self-reported improvement in breastfeeding outcomes at 0 to 48 hours postfrenotomy:

  • -Frenotomy improved outcomes in 78% to 96% versus 3% to 47% control^2,6; number needed to treat (NNT) of 1 to 3.

  • -Infant Breastfeeding Assessment Tool (15-point scale) score improved 2.3 points in the frenotomy group (little change with control).⁵

• As-treated analysis of any breastfeeding at 3 months of age: 90% frenotomy versus 69% breastfeeding support alone.¹ Intention-to-treat analysis uninterpretable (73% to 85% patients underwent frenotomy in control groups).^1,3

• Adverse events were not statistically different: There was minor bleeding in 1% to 5%^1,2; repeat frenotomy in 4%³; salivary duct damage in 1%¹; and a small white patch at frenulum base in 64% (healed in about 7 days).³

• Limitations: Long-term outcomes (eg, infant weight gain, continued breastfeeding) uninterpretable due to many control groups undergoing procedure (73% to 100%).^1,3 Breastfeeding scores do not always include nipple pain. Largest RCT stopped early due to COVID-19 pandemic.¹ Systematic review unable to pool most results.⁷

Context

• The World Health Organization recommends exclusive breastfeeding for the first 6 months of life.⁸ Exclusive breastfeeding rates in Canada drop to 38% by 6 months of age⁹; difficulty with breastfeeding is the main reason for stopping before 1 month.⁹ Nipple pain and latching difficulty have a large differential diagnosis. The lingual frenulum is a normal structure; presence alone does not indicate functional impairment or necessitate intervention.¹⁰ Ankyloglossia is a functional diagnosis.

Implementation

A comprehensive assessment of breastfeeding and latch is recommended to diagnose ankyloglossia.⁹ Breastfeeding medicine physicians or international board-certified lactation consultants can assist with breastfeeding assessments. Frenotomy could improve nipple pain and latching difficulty if ankyloglossia is a potential cause.¹⁰ Surgical frenotomy (scissors) is considered standard of care over laser.¹⁰