14 February 2018

Soaring frenotomy rate smacks of overtreatment

Clinical Evidence Based

The evidence that frenotomy improves breastfeeding is scant, yet surgery rates have quadrupled over a decade in Australia.

An analysis of Medicare data published in the Medical Journal of Australia showed a sharp increase in the number of frenotomies performed on children aged zero to four years.

Since 2006, the frenotomy rate rose 420% across Australia, with around six children per 1000 undergoing the procedure in 2016.

The rate of surgery was highest in the ACT, and all states and territories reported significant increases, except for Tasmania, where frenotomy rates decreased slightly.

Surgical procedures to address tongue-tie or ankyloglossia include a quick snip of the lingual frenulum or upper lip frenulum using scissors or laser surgery, and more complicated operations performed under general anaesthetic.

The procedures are thought to reduce maternal breastfeeding pain, and make feeding easier for babies by removing tissue restricting mouth movement.

Over the past decade the popularity of frenotomy has grown, but the evidence showing benefit has not.

“High quality evidence that frenotomy improves breastfeeding is sparse,” US-based otolaryngologists Jonathan Walsh and David Tunkel said.

The rate of diagnosis and treatment of ankyloglossia in newborns was increasing in North America and around the globe, they said.

This might be a result of increased support services, changes in cultural expectations about breastfeeding, or increased clinical recognition of ankyloglossia.

“However, the overdiagnosis and unnecessary surgery by well-meaning clinicians may also play roles,” they said.

It was difficult to assess whether overdiagnosis was occurring in Australia without more data, Dr Anita Bearzatto, a Melbourne-based GP and lactation consultant, said.

“If procedures are being performed as an aid to breastfeeding significant improvements may be experienced post-frenotomy, so many of these procedures may be appropriate,” she said.

But in some circles clinicians were jumping straight to frenotomy without prior lactation assessment and support, which could indicate overdiagnosis, Dr Bearzatto said.

Underdiagnosis was also a problem when, for example, a frenotomy was not being recommended in the case of an anterior tongue tie contributing to breastfeeding problems, she said.

Dr Lisa Amir, a lactation consultant and researcher at La Trobe University, said tongue-tie had probably been underdiagnosed in the past.

“But now there are some babies having laser treatment by dentists, which is most likely unnecessary,” she said.

Dr Pamela Douglas, a GP and co-author on the MJA paper, said that laser surgery could cause infection, bleeding, and oral aversion.

The Australian study underestimated the frenotomy rate as it did not capture public hospital data or frenotomies performed by dentists, particularly laser surgery.

Frenotomies were more frequently indicated in older children for speech pronunciation and mouth movement than in breastfeeding infants, said Professor Robert Black, a paediatric otolaryngologist and the director of Children’s Health Queensland.

The procedure was quite rare in a hospital setting, with only a dozen frenotomies performed each year at Children’s Health Queensland, Professor Black  said.

Few children who underwent a frenotomy at a hospital experienced complications such as pain and infection.

There was no indication that frenotomy rates had increased in hospitals, he said.

“I suspect the increase is [in procedures] performed by general practitioners and dentists.”

MJA, 5 February