The Most Important Risk of Tongue Tie Release by Dr Bobby Ghaheri

Dr. Ghaheri writes:

I’m often asked what the harm is in doing a tongue release. “I mean, it’s just a little snip, right?” is what people say.

Let’s go over some generic risks - pain, bleeding, infection, reattachment, damage to surrounding structures (tongue muscle, sublingual gland, salivary ducts, ranula) and lack of breastfeeding improvement are the most common risks cited. Some of them can become quite severe; for instance, bleeding - if the cut is made too deeply or too far off to the sides, significant bleeding can ensue.

But there’s one risk that can be extreme in its effect that must be addressed. Too many practitioners perform releases without even knowing that it’s a possible outcome - feeding/oral aversion.

Oral aversion is a clinical scenario where the infant has extreme reactions to anything happening around their mouths. This can include feeding in extreme cases - when this happens, often the only option is to admit the baby to the hospital and place a nasogastric feeding tube (which unfortunately can prolong the aversive behavior).

What factors can be involved in causing oral aversion?

1) The provider doing the frenotomy is too aggressive - this can happen with scissors and with laser, although I see it more with the laser provider who lingers too long under the tongue. My tongue tie release duration is about 20-30 seconds and I only cut mucous membrane. If the provider hasn’t developed a technique to avoid repeatedly lasering tissue or they go too deep and hit muscle or their laser power is too high, the baby can suffer unnecessarily. Scissor providers can cut into muscle because visibility from bleeding can be limited and can block their view of what needs to be released.

2) Post-procedure wound care can be too aggressive. All too often, providers and lactation consultants feel that the wound under the tongue has to be kept open, so aggressive stretches are prescribed inside the wound. This can be quite uncomfortable and can also promote scar tissue from inflammation. Additionally, exercising the wound too frequently can cause problems so the provider has to balance effectiveness and overdoing it.

3) The state of the baby *before* the procedure can predict if there are issues. What am I referring to here?
-was there a traumatic birth?
-was there excessive procedural intervention after birth? (CPAP, intubation, nasogastric feeding, etc)
-was there evidence that the baby was in an adrenergic state before the procedure? This is the “fight or flight” response that humans exhibit in response to stress. Some babies exhibit this response for an unknown reason - they come out stunned and have significant whole body muscular tension that makes them very rigid.

What is one to do if signs of aversion are present? 

Generically speaking, the first order of business is to keep the baby feeding. This might mean that the provider does NOT do a procedure until the baby is calm enough to tolerate it. It also means that whatever is causing the aversion should be stopped. If the stretches are part of the problem, then they should stop, at least temporarily. I usually advise a 24 hour holiday from the stretches and then modify what I have them do to simplify the regimen. I advise maximizing skin to skin contact, minimizing stimuli (get in a dark, quiet room), and take warm baths together. I also notify their IBCLC immediately (don’t assume that mom has done that) and consider getting a bodyworker involved who can help.

This isn’t an all-inclusive list of factors that play into oral aversion, but it’s meant to open the eyes of providers and parents about what could happen if things go wrong.

Jill Lancaster