Many Kiwi parents have the thin attachment under the tongues of new babies cut, hoping it will help with breastfeeding, but no one knows how many. Photo / 3pix Studio Associato di Garelli, Maccolini e Piana
Tongue-tie surgery can help a baby’s breastfeeding – or can be risky and unnecessary. Occasionally, newborns have been injured. No agency collects a full set of data but what the Government does gather suggests surgery numbers have tripled in 20 years. Hannah Brown examines what’s driving the spike.
When Dr Graham Sharpe anaesthetised a couple of newborns, something didn’t feel right about the surgery.
“I was asked to anaesthetise a couple of babies for a dentist to do it, and I did it,” the retired anaesthetist and Wellington Regional Charity Hospital board chairman told the Herald.
“I prepared them for the procedure, and afterwards I said, ‘I’m not doing it again because I don’t think this is valid surgery, and it’s risky’.
“That’s what got me interested in this area – I thought, ‘what the hell’s going on here?’”
The surgeries that day a few years ago were tongue-tie surgery, also known as lingual frenotomies, where a short, tight frenulum under the tongue is cut with blunt-end scissors, usually to help with tongue mobility for breastfeeding.
“There are risks around any surgery. If these babies need surgery, it should be done by surgeons,” Sharpe told the Herald.
“And it’s being done in babies without any anaesthesia mostly.
“Anaesthetic for a newborn baby for a tongue operation is actually very complicated and it’s not something to be taken lightly.
“If a newborn does need tongue surgery, it’s a highly specialised complicated procedure and it should be done by a paediatric surgeon or oral surgeon and trained paediatric anaesthetist.”
Then in 2018, a report from the Health and Disability Commissioner caught Sharpe’s eye. “A midwife did one of these frenotomies and the baby bled and got into quite a lot of trouble.”
An article was published in the Medical Journal of Australia the same year, calling the surgery an increasing problem.
“They were basically saying this is a fix for something that’s not a problem,” Sharpe said.
“I wrote to the paper and said this tongue-tie surgery by untrained people for poorly diagnosed pathology must be stopped.”
A generation ago the surgery was relatively rare here.
Since then, an increasing number of Kiwi parents have taken their new babies to have the thin attachments under their tongues cut, hoping it will help with breastfeeding.
According to Health NZ data provided to the Herald under the Official Information Act (OIA), there were 94 tongue tie surgeries nationwide in 2004, and in 2024 the annual total was 282.
There have often been more than 500 performed per year, and 2015 recorded a peak of 700.
The number of babies born annually in New Zealand has remained stable at about 60,000 births per year over that time.
A Health NZ spokesperson told the Herald that procedures have fallen since 2020, after the introduction of clearer clinical guidelines that year.
“The document outlines the clinical guidance for identifying, assessing, diagnosing and treating tongue-tie in Aotearoa New Zealand,” the spokesperson said. The document is embedded later in this story.
But the data is incomplete.
Only surgeries in public hospitals are recorded, yet the majority are performed in the community: by dentists, and in homes and clinics by midwives and lactation consultants, and by GPs and other doctors – and no one is keeping count.
Should they be? The Herald spoke to a range of doctors, midwives and lactation consultants and they were unanimous in wanting a full set of nationwide data collected, so the efficacy of the surgery (and of not doing the procedure) can be tracked and compared.
About 5% of babies are born with a tight frenulum and most of them (an estimated 40 to 75%) can still breastfeed normally.
Last year, the American Academy of Pediatrics, which represents 67,000 US doctors, released a report warning against the surgery’s overuse.
While it is generally safe in NZ, the Government cautions the procedure can result in rare but serious consequences, including haemorrhage, infection, ulcers, pain, oral aversion and damage to the tongue and mouth.
The NZ Midwifery Council, NZ Lactation Consultants’ Association and the Breastfeeding Medicine Association of Aotearoa are all now calling for a thorough, evidence-based breastfeeding assessment in every case before tongue-tie surgery is even considered.
The Health and Disability Commissioner’s 2018 report into a botched tongue-tie surgery reveals that in the family home, the midwife lactation consultant, assisted by the baby’s father, had sliced deeply into the floor of the mouth of an 8-day-old baby, cutting through muscle and damaging an artery.
“Dark venous blood” coming from the diamond-shaped wound in the baby’s mouth couldn’t be stopped and the newborn soaked 11 gauze pads with it before being taken by ambulance to hospital.
There, the laceration in his mouth was surgically repaired by an otolaryngologist and the tongue muscles stitched back together.
Among other things, the report criticised the midwife for not informing the baby’s parents of non-surgical alternatives and not letting them know that there were conflicting views on the merits of lingual frenotomies.
Dr Yvonne LeFort has, at her busiest, performed 20-30 of the surgeries per week.
LeFort is a Canadian-trained GP and lactation consultant who works primarily in breastfeeding medicine in her private clinic in Auckland and has been performing lingual frenotomies here for 24 years.
“The two symptoms of a restricted tongue in the literature are damaged nipples and the baby not being able to keep the milk flowing,” LeFort told the Herald from Europe, where she was presenting at two tongue-tie conferences in Birmingham, Britain, and Tallinn, Estonia.
“When the surgery is effective it can instantly relieve both these symptoms – the mother finally feels no pain, and the baby’s milk intake improves.
“It can be the one thing that is holding the mother and baby from achieving comfort, but there’s a much bigger, more detailed picture to check first.
“The skill,” she says, “is determining which babies will benefit from the procedure.” LeFort believes some surgeries are being done unnecessarily.
When the surgery is effective ... the mother finally feels no pain and the baby’s milk intake improves.
“Not all frenulums need to be treated and it is not always clear how to make that clinical decision, so yes, some will be done when they don’t need to be – but you want those who need them to get them.
“Globally, these surgeries have increased everywhere – in the vicinity of 870% in the US between 2000 and 2012. We are seeing people viewing it very differently from how I view it.
“Parents can be led to believe that by doing the procedure they can get a quick fix for their breastfeeding problems. Sometimes those doing the procedure can foster this and as a result [its] popularity has spread like wildfire.”
LeFort said she now performs only two to three frenotomies some weeks because that’s how many are necessary once she’s checked all the other breastfeeding variables.
“I have a holistic approach to the breastfeeding family. The parent, the partner, the baby, I see them all, and there is a whole realm of assessment that goes on first: positioning, latching, we address any confounding difficulties and try all the things, including assessment of their infant’s tongue function and lingual frenulum.”
LeFort doesn’t agree with lingual frenotomies being performed at home.
Parents can be led to believe that by doing the procedure they can get a quick fix for their breastfeeding problems. Sometimes those doing the procedure can foster this, and as a result [its] popularity has spread like wildfire.
“I think you need to be trained, and have another person with you who’s trained to assist you, because of the risk of serious complications.
“People like to call this a snip, but you have to be accountable for what you’re doing. I call it an incision or procedure and it’s not just a snip – there can be rare but very serious complications: bleeding, infection and sometimes babies can develop oral aversion, refusing to breastfeed – or in some cases refusing any feeding at all as a result of the pain they’ve experienced.
“When I do the procedure the parents can stand right beside me if they want to. It’s their baby.
“We swaddle the baby and then my assistant holds the baby’s head still and lifts the tongue for me, and I take the surgical scissors and cut the frenulum a bit and see how well the tongue moves and I’ve got fantastic lighting that helps me to avoid blood vessels and I hold a gauze square against the incision.
People like to call this a snip, but you have to be accountable for what you’re doing. I call it an incision or procedure.
“The overwhelming thing everyone does next is get the baby feeding straight after the procedure. But what takes the longest is really explaining to the parents the risks, potential benefits – and what we don’t know.
“I used to do 20-30 a week but now I do 15 and sometimes as low as two or three. Because I’m thorough in my assessment from years of experience and I take the time to treat more holistically.”
A private service like this with a breastfeeding medicine doctor takes at least an hour, and costs about $300, which includes the surgery if needed. In New Zealand, doctors who specialise in breastfeeding medicine are only available to those who can afford the service.
The Herald asked Health NZ whether there are plans to integrate any breastfeeding specialist doctors into the public system.
“All midwives and lactation consultants are skilled in providing assistance with breastfeeding,” a spokesperson said in a statement.
“If someone is experiencing problems with breastfeeding, we encourage them to contact their lead maternity carer [LMC] directly.”
The spokesperson also recommended PlunketLine for phone breastfeeding support and bookings for Plunket lactation consultants.
Midwifery clinics can provide newborn frenotomies in many areas.
Midwives are one of a range of professionals – along with nurses, GPs, paediatricians, oral surgeons, paediatric surgeons, ENT surgeons and dental surgeons – who are allowed to perform tongue-tie surgery in New Zealand (“and blacksmiths, airline pilots, road workers,” joked Dr Graham Sharpe).
Tongue-tie surgery isn’t part of general midwifery training – midwives complete an extra course later if it’s a skill they want.
There’s no way of quantifying how many frenotomies are done by midwives, or where – and dentists don’t keep track either.
New Zealand College of Midwives chief executive Alison Eddy said midwives have observed “consumer-driven demand” around the surgery.
“There is a lot of discussion about it on online forums, and I think if breastfeeding isn’t going well in the first few days people are looking for an intervention, a panacea. But we’d want a good assessment because it might not be the panacea you’re looking for and in fact it might create an unnecessary surgical intervention.”
The college is in the midst of updating its 2018 statement on tongue-tie. “We’re probably going to strengthen our position a bit,” Eddy told the Herald.
“We’re seeing the need for a free, equitable service with deep expertise. And it’s vital national data is collected. There isn’t a dataset that says how many babies have had a tongue-tie diagnosed, and out of those how many have had an intervention, and how those interventions have worked – are there any long-term consequences to the surgery?
There is a lot of discussion about it on online forums, and I think if breastfeeding isn’t going well in the first few days people are looking for an intervention – a panacea.
“Then it’s about how the service is accessed. There’s an excellent model here in Canterbury: a specialised clinic, thorough diagnosis, lactation support, build-up of a lot of expertise, and they track and monitor what happens to the babies after the intervention.
“It’s a very specialised, multi-disciplinary assessment and treatment pathway, with expertise and consistency.” Eddy would like to see equivalent services available to families nationwide.
In November 2020, the Ministry of Health released its first national guidance on treating tongue-tie in babies.
Dr Ayesha Verrall, then Associate Health Minister, told the Herald at the time that while some babies needed the surgery, there may possibly have been “unnecessary focus on the condition” and unnecessary procedures.
The guidelines said assessments for tongue-tie should be documented in the baby’s Well Child book, with a summary letter sent to the baby’s healthcare professionals.
But the guidelines aren’t mandatory.
The guidelines said “there is no consensus as to the efficacy” of the surgery, and there was a need for better data collection.
And they said an audit was required.
Five years on, the Herald asked Health NZ and the Ministry of Health whether better data has been collected and whether the audit has been done.
Health NZ said: “The document you are referring to is a Ministry of Health publication, not a Health New Zealand publication. While it includes recommendations about data collection and other areas, these are ministry-level considerations. Health New Zealand was not responsible for the development of the document.
“Data on publicly funded frenotomies performed on a breastfeeding neonate is collected at a local level but is not currently held in a national database.”
Heather Muriwai, chief clinical officer, maternity at the Ministry of Health, replied in a statement.
“At the time the national guidance was written, frenotomy procedures were significantly more common, possibly due to over-diagnosis. During that time, evidence suggested an audit of publicly-funded services could help gather evidence on the long-term effects of tongue-tie and frenotomy.
“The purpose of the national guidance was to assist healthcare practitioners in appropriately identifying and diagnosing tongue-tie, and in the years since, the number of frenotomy procedures has significantly reduced, which suggests that robust training has been effective. This is a positive change, and at this stage, the Ministry of Health does not have any plans to undertake an audit.
“At this stage, there are no plans to mandate private providers to collect or share data on frenotomy procedures with the ministry.”
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