Pediatricians' Concerns about Ankyloglossia and Breastfeeding

Background: Ankyloglossia, including lip tie, is becoming a common and perhaps overused diagnosis when breastfeeding difficulties arise in the mother-infant dyad. There is no strong published evidence to support performing frenotomy or of complications related to frenotomy, but some mothers report immediate decreased pain with breastfeeding after frenotomy. Concerns have been raised about the increase in diagnosis and possible complications after frenotomy. Purpose: 1. To survey pediatricians in the AAP Section of Breastfeeding (SOBr) regarding their experiences with ankyloglossia, frenotomy, and related complications using multiple choice and free text answers. 2. To describe common themes that emerged from the free text answers. Methods: An email survey was sent during 4 weeks in August-September 2018 to 450 members of the AAP SOBr Listserv. Questions included demographics, diagnosis of ankyloglossia leading to frenotomy, type of frenotomy performed, and complications of frenotomy. Free text sections were included on multiple questions. Chi square was used to assess relationships between those who performed frenotomy and demographic factors. Two authors (AG and MB) independently coded the open-ended responses and performed content analysis for themes and compared the themes that emerged. Results: 84 (66%) respondents spend <50% of their clinical time with the breastfeeding couple and 4 (3%) spend 100% of their clinical time with the breastfeeding couple. 42 (33%) respondents were <10 years out of training. The majority of respondents (79, 62%) work in general pediatrics. 15 (12%) respondents work in the newborn nursery and 15 (12%) respondents work in neonatology. 11 (8%) respondents work as hospitalists and 8 (6%) respondents listed “other” as their specialty. 68 (49%) respondents perform frenotomy and 67 (98%) use scissors. 48/82 outpatient pediatricians (58%) performed frenotomies compared to 15/42 (36%) inpatient pediatricians (p=.016). 33 pediatricians reported caring for infants with complications of frenotomies: 5 didn't define the complication and 12 reported frenotomy did not improve the problem. 16 pediatricians reported more severe complications by location and method of frenotomy (Table 1). The qualitative data themes were: a) overdiagnosis, especially posterior tongue tie and lip ties, b) anxiety and pressure put on parents, c) divided opinion among physicians and lactation consultants, and d) concerns about dentists performing frenotomies using laser (Table 2). Conclusions: Pediatricians are performing frenotomies largely by clipping. Complications of frenotomies do occur. Oral aversion and scarring seem to be associated with frentomy performed by laser, electrosurgery/bovie or a combination of procedures. Pediatricians report concerns about overdiagnosis of ankyloglossia (especially posterior and lip ties), parental anxiety, and dentists performing the procedure with laser leading to increased cost and complications.