Should a tongue-tie be clipped?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Anita wrote in: “My little newborn has this bit of tissue under his tongue, so he can’t stick his tongue out. Should it be removed?”

I’m thinking Anita means, should the little bit of tissue be removed. Not the whole tongue. Probably.

That little bit of tissue is called a “lingual frenulum”, or a “sublingual frenulum.” What to do about these things is something that’s changed as years have gone by. When I was a baby, doctors would routinely just clip the things, right there in the nursery, as a matter of course. Probably without consent or any handwringing discussions.

Then, the pendulum swung away from clipping. By the 1990’s, the standard teaching was to leave the darn things alone. We figured that they didn’t do much harm, and seemed to go away on their own, so why mess with them?

Now, the pendulum may be swinging back towards at least considering clipping those frenula. Several small but good studies have shown that at least some mom-baby pairs have trouble nursing with a tight frenulum (sometimes called ankyloglossia, or a “tongue-tie.”) Clipping a tongue-tie in a baby who is nursing poorly can dramatically improve latching and milk transfer, and can really reduce the pain some women experience when trying to nurse a baby with a tight frenulum.

It’s less clear whether clipping has longer term benefits. Some feel that a tight frenulum can cause speech problems, or perhaps issues with eating or kissing.  Studies looking at the long-term effects of clipping on these issues haven’t been done.

Clipping one of these is a simple, safe, and quick procedure. However, few pediatricians who’ve been trained in the last 20 years have any experience with doing these. I did a CME training course that included videos and practicing on a dummy with a little pretend tongue, and it’s easy enough to learn. It is important that a good exam confirms that it’s a simple tongue-tie that can be easily clipped in the office. Some of these, if large or dense or located more towards the back of the tongue, would be better addressed by a surgeon in the operating room.

So, to answer Anita’s question: whether to clip a tongue-tie depends on what problems it’s causing. If there are nursing difficulties or pain, there’s very good evidence that clipping is a good idea. There’s not much evidence one way or the other to tell us if clipping should be done to prevent speech or language or other issues later in life. I try to judge that by how tight the frenulum appears, whether the tongue can be extended, and how much I think I can improve the tongue movement with a little snip, but that’s a call that has to be made individually for each baby.

If your pediatrician doesn’t have experience judging whether a tongue-tie needs to be clipped, ask for a referral to an ENT who can help decide if the procedure is needed, and how to do it safely.

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7 Comments on “Should a tongue-tie be clipped?”

  1. Nina Benaroch Says:

    I am a public school SLP, and I just was assigned a new client for articulation issues. She is 3 years old, but she will be out of preschool next week having her tongue-tie snipped, so I won’t see her until the week after. Will let you know if it makes a difference.

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  2. WWWAPedsDoc Says:

    Timely post! I just performed my third frenulectomy (or is it frenectomy?) TODAY after 10+ years in practice poo-pooing tied-tongues or referring out to ENT docs (many of whom also poo-pooed them, having received as much training in the science of breastfeeding as I did). Attended a CME by a general ENT who made a convincing case for the procedure using data, ultrasound images of tongue motion in nursing, and his own personal experience as a parent of a tongue-tied newborn. Less technically difficult than a circumcision and suspect a whole lot more potential for health benefit. Will be interesting to see if this trend continues enough to produce more evidence. Enjoy your posts and their subtle snarkiness!

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  3. Carina Says:

    What a great post!

    I have a girlfriend with 5 boys, 3 of whom were “diagnosed” as tongue-tied by a private SLP, who proceeded to clip their frenulums right then!

    Personally, I had a horrible time nursing my first – I asked the pediatrician if it could be because, “as you can see here,” (lifting his tongue in the Dr. office) “his tongue is connected to the bottom of his mouth all the way to his teeth.” The Dr’s response in 2004 was, “Hmmm…I don’t know…here’s the number for La Leche League.” We made it through, but years later, in a contest with his younger sister, he asked, “Hey, how come I can’t stick my tongue out like V?” And then, one night it hit me and I said to my husband, “Oh no! When he meets a girl, he won’t be able to kiss her!” Shortly followed by the dentist pointing it out! So, we have it on our list of things to address, at some point, but for now, we already made it through nursing successfully, regular speech, trilling our rrrr’s in Spanish – we’ll cross the kissing bridge soon enough I’m sure.

    For us, the Dentist actually said they can do it in their office too. I’ll bring it up to our Pediatrician (not the same one as his 1 month check-up – we’ve moved since then) and see what he thinks about it!

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  4. Joy Says:

    I think it’s great that more pediatricians are becoming aware of tongue and lip ties and are more open to addressing them. My daughter was born with tongue and lip ties. The first ped we saw (ours was on vacation) after coming home from the hospital didn’t even examine her mouth and immediately suggested supplementing. After I cried in his office, he said we could continue to try breastfeeding for 2 days. When we returned for the third weight check in a week, we saw another ped who spotted the tongue tie, but told us to call a lactation consultant to confirm it(!). A few days later, we had both ties clipped by a dentist using a laser. The results were dramatic. Within a few hours, my baby’s nursing had completely changed. She was noticeably more satisfied (milk drunk even), and my nipples healed quickly afterward. I was glad that we opted for the procedure so early and that I held my ground and didn’t give up on breastfeeding.

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  5. Dr. Roy Says:

    I’m glad that worked out, Joy. I have never actually actually heard of laser clipping, or of dentists doing it– maybe that’s a regional thing. Here in Atlanta, the ENTs do it, or a few pediatricians.

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  6. Sam Says:

    Where did you get your training. I’m a pediatrician trying to find a place.

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  7. Dr. Roy Says:

    I did at at the AAP NCE a few years ago. It was about a six hour thing, hosted by the section of breastfeeding medicine, with lectures and videos and practice on a little clay head. Fun!

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