My seven-month-old son is tongue-tied and has the notch tip. How old does he need to be before this surgery should be done? Our pediatrician said to wait until he was a year old. I called a specialist in our area at four months and was told to wait until he is six months. I called today to see about making an appointment and was told I needed to wait until he was a year old. He doesn't have any problems with eating. However, he has never been able to hold a pacifier in his mouth for longer than a few minutes.

C.

Tongue-tie repair is a minor surgical procedure that may be performed at any age. The real question is not "At what age should this be done?" but "Should this be done?"

For a seven month-old infant, the question of feeding difficulty is a bit late (such difficulties become obvious in the first few days of life), while concerns about speech development are perhaps a bit premature. Perhaps. Here's the key question: Is it better to practice prevention and perform the operation now (not knowing if your son will ever have speech problems), or is it better to wait until the problem becomes obvious?

In making this decision, you are balancing one set of risks against another. On the one hand are the risks of the operation: pain, bleeding, infection, anesthetic risks, recurrence of the tongue-tie, injury to the salivary ducts or nerves in the floor of the mouth. On the other hand are the risks of allowing a speech problem to develop: Your son may have difficulty learning normal articulation. Your ear, nose and throat doctor (ENT) is the best person to comment on the magnitude of surgical risks, and I encourage you to have this discussion with him or her. A speech/language pathologist ("speech therapist") could best comment on the risks of NOT operating soon.

I think everyone would agree that if you had a crystal ball and could foresee that your son would have an articulation problem, the operation should be done before such problems arise. We have no way of predicting this, but here are a few signs that his tongue-tie might cause speech problems:

• As in your son, notching of the tongue tip is considered one indicator for future difficulties.
  
• If he is unable to protrude his tongue past the upper gums (or incisors, if he has them), this is also a worrisome sign.
  
• Finally, if he is unable to touch the tip of his tongue to the roof of the mouth -- immediately behind the incisors (front teeth) -- or has trouble moving his tongue from side to side, these are also worrisome indicators.
  

What about the "one-year-old" rule (on which, apparently, your ENT and pediatrician are now in agreement)? If there are no feeding difficulties, there's certainly no harm in waiting until age one. I'm curious why they have this rule; you ought to ask your pediatrician about it. Perhaps they are uncomfortable putting a younger infant through a general anesthetic.