PC2033: The Impact of Early Frenotomy on Breastfeeding Outcomes: A Systematic Review and Meta-analysis

Background: Ankyloglossia, or tongue-tie, occurs in approximately 8% of children aged one year or less. In the infant population, ankyloglossia is a recognized risk factor for breastfeeding cessation. Reasons for early cessation of breastfeeding related to ankyloglossia include pain with breastfeeding, sore/ cracked nipples, inadequate information on breastfeeding and infant difficulty latching/sucking. Following the diagnosis of ankyloglossia, the decision tree often includes immediate frenotomy (clipping of the tongue-tie), lactation support, or a “wait and see” approach. Though studies have been conducting examining the impact of frenotomy, the data regarding its benefit are mixed.

Methods: This systematic review and meta-analysis adhered to PRISMA guidelines. PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, and Google Scholar were searched for relevant studies. Controlled trials and cohort studies were eligible if they reported validated measures of the efficacy of surgical interventions to improve breastfeeding outcomes associated with pediatric ankyloglossia. Multiple reviewers performed screening, data extraction, and quality assessment. Inverse-variance-weighted meta-analyses were performed for each outcome measure with sufficient pooled data. Data were combined using fixed-effects or random-effects models according to heterogeneity tests. Meta-analyses determined the standardized mean difference (SMD; Hedges’ g effect size) between pre- and postoperative scores on the Breastfeeding Self-Efficacy Scale-Short Form, maternal nipple pain scales, and the Infant-Gastroesophageal Reflux Questionnaire-Revised.

Results: Of 1328 screened studies, 18 studies and 1861 infants with ankyloglossia were included. Maternal breastfeeding self-efficacy improved significantly after frenotomy. When self-efficacy was reassessed 5-10 days postoperatively, the SMD relative to baseline was 0.59 (95% CI: 0.47, 0.71; P < .001), representing a medium effect. When self-efficacy was reassessed at 1-month follow-up, the SMD relative to baseline was 0.91 (95% CI: 0.79, 1.04; P < .001), representing a large effect. Mothers also experienced significantly less nipple pain after their infants underwent frenotomy. Based on quantitative ratings, the effect on pain after 5-10 days was large (SMD -1.07 [95% CI: -1.58, -0.57; P = .002]), as was the effect at 1 month relative to baseline (SMD -1.07 [95% CI: -1.66, -0.47; P = .008]). Infant gastroesophageal reflux symptoms improved significantly after frenotomy. Frenotomy had a medium effect on symptom severity at 1-week follow-up (SMD -0.63 [95% CI: -0.95, -0.31; P = .008]). Symptom severity continued to decrease significantly, with a small-to-medium effect between 1-week and 1-month follow-up (SMD -0.41 [95% CI: -0.78, -0.05; P = .04]). Improvements in infant weight percentile and nutritional status were also observed.

Conclusion: Frenotomy is an effective in improving maternal comfort with breastfeeding, with a smaller but positive effect on infant feeding. Further studies are needed to compare alternative methods of non-surgical intervention to frenotomy, as well as studies identifying which infants are ideal candidates for surgical intervention.