Single-cut full-length scissors-frenotomy (SFSF) improved long-term weight gain and reduced supplementation in breastfed infants with posterior attachment tongue-tie

Introduction
There is substantial controversy about tongue-tie, frenotomy and aftercare. Available studies report subjective parent-reported observations or quantifiable outcomes with short-term follow-up only. Studies about comparison of different approaches for frenotomy or aftercare are lacking.

Objectives
This study aimed at investigating outcomes with quantifiable, objective and long-term measures for scissors frenotomy of tongue-ties with mainly posterior attachment. Additionally, the aim was to develop objective evaluation criteria for future comparison of different types of tongue-ties, frenotomies and aftercare methods.

Methods
We compared treated and untreated tongue-tied infants concerning weight gain, breastfeeding status and amount of supplementation; additionally, the period before and after frenotomy in treated infants. Questionnaires were sent to patients of a tongue-tie outpatient-clinic, an online version was distributed by IBCLCs and documentation of private practice work included. 
CASEs underwent frenotomy before the age of 4 months, CONTROLs after the age of 4 months. The individual weight curve was plotted against the WHO-Standards with LACTDOC. Date(s) of frenotomy, information on breastfeeding status and amount of supplementation were documented. Weight curve and photos (if available) were assessed for each child by two investigators. Percentiles and percentage of the supplementation amount were calculated at birth, 4 months, frenotomy, 4 weeks after frenotomy and latest follow up.

Results
Among 251 CASEs and 142 CONTROLs 52% and 54% were male, respectively. Information about the type of tongue-tie was available for 84% and 85%. Only 2% and 1% were anterior tongue-tie with attachment at the tip of the tongue, 22% and 39% were tongue-ties with a posterior attachment behind the tip of the tongue, however visible, 78 % and 61 % had posterior attachment, not visible. 68% and 55% of the frenotomies were provided by the team of the University Clinic Innsbruck, performing single-cut full-length scissors frenotomies without recommending stretches, but breastfeeding and muscular re-education by gentle exercises. The other frenotomies were scissors frenotomies with no known details.
For CASEs / CONTROLs at 4 months, mean weight percentile was P40,9 vs. P34,7, amount of supplementation 147ml/d vs. 216 ml/d, rate of any breastfeeding 92% vs. 86%, rate of full breastfeeding 68% vs. 62%, respectively. Between birth and 4 months, the drop in percentiles was -P12,1 vs. -P24,0. 
CASEs showed a mean drop in percentiles of -P14,9 before, and a mean increase in percentiles of +P12,1 after frenotomy.

Conclusions
Breastfeeding status, long-term weight gain and amount of supplementation improved in treated when compared to not-treated tongue-tied breastfed infants, in this cohort treated mainly by single-cut full-length scissors frenotomy (SFSF) of tongue-ties with mainly posterior attachment. This quantifiable and objective data confirm that (1) frenotomy in case of a clear tongue mobility impairment by a frenulum with a posterior attachment improves breastfeeding outcomes, (2) favorable results can be obtained without stretching the wound post procedure with counterpressure against the chin (using active wound management, AWM) and (3) SFSF is an adequate low-threshold, low-cost, minimally invasive procedure.