Clinical Indications for Lingual Frenectomy in Children Under Five: A Systematic Review and Meta- Analysis

Background: Ankyloglossia, or tongue-tie, is a congenital anomaly with a reported prevalence of 4% to 16%, resulting from incomplete apoptosis of the lingual gingival lamina and leading to restricted tongue mobility. This condition may impair milk transfer, contribute to maternal nipple pain, and negatively impact breastfeeding effectiveness. Lingual frenectomy is a proposed intervention; however, its clinical indications remain controversial due to inconsistent diagnostic criteria and variable clinical practices. Assessment tools such as the Martinelli Protocol, Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF), Bristol Breastfeeding Assessment Tool (BBAT), and Coryllos classification are inconsistently applied. Furthermore, healthcare professionals hold divergent views: only 10% of pediatricians and 30% of otolaryngologists recognize its impact on feeding, in contrast to 69% of lactation consultants reporting breastfeeding challenges in affected infants. Objective: To systematically evaluate the clinical indications and efficacy of lingual frenectomy in children under five years of age, with a particular focus on its effect on breastfeeding outcomes. Methods: A comprehensive literature search was performed across PubMed, Scopus, Web of Science, LILACS/BBO, Cochrane Library, Epistemonikos, and ProQuest databases. Clinical studies involving children under five years diagnosed with ankyloglossia and evaluating breastfeeding performance pre- and post-frenectomy were included. Methodological quality was assessed using the adapted NICE tool for cohort and cross-sectional studies. Of 83 full-text articles reviewed, 55 met the eligibility criteria. Selection bias was identified in 33% of the studies and detection bias in 93%, largely due to variability in diagnostic criteria and assessment methods. Results: Six studies comparing frenectomy with no intervention were included in the meta-analysis. The pooled analysis using a random-effects model revealed a statistically significant benefit of frenectomy in improving breastfeeding outcomes, with a combined Risk Ratio (RR) of 1.38 (95% CI: 1.11–1.71; p < 0.05). However, substantial heterogeneity was observed (I² = 74.8%, Q = 19.87, p = 0.0013), indicating significant variability across study methodologies and diagnostic approaches. Conclusion: Although current evidence suggests that lingual frenectomy has a statistically significant positive effect on breastfeeding outcomes in young children, the limited number of high-quality studies and considerable methodological heterogeneity prevent definitive clinical recommendations. These findings underscore the need for standardized diagnostic protocols and evidence-based guidelines to ensure timely and effective management of ankyloglossia, ultimately supporting optimal breastfeeding and long-term child health.