What is lingual frenotomy, what's the best method, and when might frenotomy help you and your baby breastfeed?

When is a lingual frenotomy helpful?

A lingual frenotomy is a cut into the mucosa and connective tissue under your baby's tongue, performed with the aim of improving your baby's tongue mobility.

A classic tongue-tie, in which the tip of the tongue is visibly tethered down tightly to the floor of the mouth, may require a scissors frenotomy. If this is severe, your breastfeeding support professional may recommend that this occurs very early on. Usually with breastfeeding the first step is to apply the gestalt method of fit and hold as soon as problems arise (if you're not already using it preventatively).

What is the best kind of lingual frenotomy for your baby?

The frenotomy, if you have it, may be performed either by scissors or by laser, often by a dentist but also by other medical or midwife practitioners.

• Simple scissors frenotomy is a small snip combined with pressure by the clinician's forefinger to release the mucosal and perhaps connective tissues that make up the visible frenulum. This is low risk, and is in my view the only kind of frenotomy babies should receive (unless your baby has a serious medical syndrome at birth, which also incudes fusion of the tongue with the floor of mouth or severe syndromic tongue-tie). Often, a simple scissors frenotomy happens so quickly that baby doesn't really cry.

• Many babies receive a deep scissors frenotomy, which cuts down deeply through the connective tissue and floor of mouth fascia. This is unnecessary, once you understand the anatomy of baby's frenulum and floor of mouth fascia, and increases the risk of bleeding and other side-effects.

• Laser frenotomy cuts even deeper again. I have not uncommonly seen laser frenotomies in baby's mouths over the years that went into the genioglossus muscle. Laser frenotomy controls bleeding, but increases risks of other side-effects. Again, despite what you hear and read, there is in my view no scientific justification for laser frenotomy in the mouths of babies with breastfeeding problems.

Although it does seem likely that the baby in the photograph at the top of this page has an ankyloglossia or tongue-tie and may benefit from a simple scissors frenotomy, it would be irresponsible of me to make a diagnosis from this single photograph. Ankyloglossia is a poorly defined category at the functionally more constrained end of the spectrum of oral connective tissue variations. A clinician can only make the diagnosis of ankyloglossia responsibly by performing a thorough oromotor assessment and watching baby breastfeed or feed. The diagnosis is a clinical judgement which arises out of complex contexts, requiring the collation and synthesis of many dozens of pieces of information, working in collaboration with the parents.

Selected references

Knight M, Ramakrishnan R, Ratushnyak S. Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT. Health Technology Assessment. 2023;27(11):https://doi.org/10.3310/WBBW2302.

Kummer AW. Ankyloglossia: misinformation vs. evidence regarding its effects on feeding, speech, and other functions. Journal of Otolaryngology - ENT research. 2024:DOI: 10.15406/joentr.12024.15416.00552.

Thomas J, Bunik M, Holmes A. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605.