Why I’m Rewriting This Blog on Tongue-Tie

 

Back in 2016, I wrote a blog about tongue-tie. It touched a nerve. Some people thanked me for saying what they were thinking; others… not so much. I got A LOT of backlash. I even considered removing the blog from my website for a while—until a GP contacted me saying she often shared it with her clients.

You can read the original blog HERE

While the initial rush of tongue-tie diagnoses seems to have settled a little, there’s still a steady stream of discussion—especially in social media groups and some lactation support circles. The topic continues to stir up big feelings—and even bigger decisions—for families. So I’m revisiting the issue with fresh eyes and updated research.

 

 

Are We Still Over-Diagnosing Tongue-Tie?

 

As a midwife with over 20 years of experience, I can say confidently that I’m no longer hearing of quite so many babies being diagnosed with tongue-tie immediately after birth, before their first breastfeed—which is a relief.

But the conversations haven’t gone away. Parents, GPs, lactation consultants, and dentists still bring it up often.

So the questions remains: are we better at diagnosing tongue-tie—or just over-relying on it to explain a wide range of breastfeeding challenges?

And is surgery the answer?

 

 

What the Latest Research Says About Tongue-Tie

 

2018 Groundbreaking Research: Ultrasound and Tongue Function

 

One of the biggest breakthroughs in recent years has come from Dr Pamela Douglas and  Professor Donna Geddes. Their research, published in Midwifery (2018), used ultrasound imaging to study how babies actually remove milk from the breast.

What they found was game-changing.

Contrary to long-held beliefs, babies don’t extract milk through a ‘stripping’  or ‘peristaltic’ motion of the tongue. Instead, it’s the intra-oral vacuum—created when the baby’s jaw and tongue move down together—that draws milk into the mouth.

When breastfeeding is painful or ineffective, this research suggests the issue is often not anatomical (i.e. a short frenulum), but biomechanical: poor fit and hold between baby and breast, which leads to reduced milk transfer and nipple pain. And crucially, these issues can often be resolved without surgery.

 

2019 Another Key Perspective: Understanding the Anatomy (Nikki Mills)

 

In 2019, Nikki Mills and colleagues used cadaver dissection to study the lingual frenulum. They found that what we often call a “tongue-tie” is actually a normal anatomical fold—not a discrete band. Its appearance varies, and this variation doesn’t always affect feeding.

The paper went on to argue that terms like “posterior tongue tie” aren’t anatomically accurate—and that just because a frenulum looks tight, doesn’t mean it’s functionally restrictive. This is vital. Because it means that visible tissue under the tongue should only be considered a problem if it’s actually causing feeding issues—not just because it’s there.

 

2022 A Small but Significant Study: Gestalt Breastfeeding and Tongue Function

A 2022 case series by Dr Pamela Douglas, Dr Sharon Perrella, and Professor Donna Geddes offers compelling early evidence for how breastfeeding fit and hold—done well—can influence infant tongue function without the need for surgery.

Using ultrasound imaging, they examined five breastfeeding dyads before and after a brief gestalt breastfeeding intervention. Four of the infants had previously been diagnosed with oral ties, and most mothers had ongoing nipple pain despite comprehensive lactation support.

Here’s what they found after just one short intervention:

• The nipple was positioned closer to the hard-soft palate junction, a marker of improved latch.

• There was increased intra-oral nipple and breast tissue volume.

• Nipple slide (movement during sucking, which can contribute to pain) decreased.

• And in one case, the baby who had previously struggled to latch began feeding more consistently from the breast.

These results mirror the changes seen in previous post-frenotomy ultrasound studies, raising the question: could improving fit and hold eliminate the need for some surgeries altogether?

It’s a small study, yes—but its implications are big. It suggests that optimising breastfeeding biomechanics might resolve issues currently being attributed to tongue-tie, with less risk, less pain, and more empowerment for parents.

2025 A Gold-Standard Trial: A Randomised Controlled Study

A 2025 double-blind randomised controlled trial (Dinh et al.) tested the effect of frenotomy on babies with breastfeeding problems. Half received the surgery, half received a sham procedure. Neither parents nor assessors knew which group the babies were in.

This study concluded that frenotomy did not offer measurable improvements in breastfeeding outcomes in the immediate newborn period, suggesting that surgery should not be a routine recommendation without first exploring other options.

Result: No significant difference in latch scores or maternal pain between the two groups.

This suggests frenotomy may not always be the solution it’s often presented as.

 

 

The ABM releases it’s statement: Anatomy Alone Isn’t Enough

 

 

In 2021, the Academy of Breastfeeding Medicine (ABM) released a position statement summarising the current state of evidence on tongue-tie and frenotomy. It echoed many of the concerns raised by clinicians and researchers: there’s no universal diagnostic standard, a lack of high-quality long-term data, and significant variation in how tongue-tie is assessed and treated.

“The presence of a sublingual frenulum alone, a common and normal anatomic structure, is not an indication for surgical intervention.”

The ABM stresses the importance of a thorough, skilled breastfeeding assessment—one that considers maternal comfort, milk transfer, nipple condition, and infant growth—before any decision is made.

Tools like the Hazelbaker score or Kotlow classification (scoring systems that assess tongue appearance and movement) shouldn’t be used in isolation to justify surgery.

They also noted that conservative measures—like improving positioning, latch, and milk transfer—can resolve many breastfeeding challenges without the need for a frenotomy. And when surgery is indicated, it should be offered with full informed consent, including the risks, benefits, and alternative options.

 

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A Summary of Best-Practice Recommendations

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Dr Cassie Rickard, Perinatal GP, recently summarised the current best-practice approach to tongue-tie assessment and treatment. These are supported by major organisations like the ABM, Speech Pathology Australia, and the Australian Dental Association:

✔️ A tongue-tie diagnosis should never be based on appearance alone—it requires evidence of restricted movement and functional feeding difficulty.

✔️ Non-surgical strategies are first-line, including support for positioning, latch, and supply.

✔️ Frenotomy should only be considered when there is a clearly defined structural issue that hasn’t improved with conservative care.

✔️ In infants, scissor frenotomy is preferred over laser, which carries additional risks including thermal and nerve damage.

✔️ Stretching wounds or bodywork exercises after surgery is not recommended and may cause aversion.

✔️ Posterior tongue-tie is not a medically recognised diagnosis and may lead to overtreatment.

✔️ There is no evidence to support the release of lip or cheek ties to improve breastfeeding or future speech/dental outcomes.

✔️ Post-operative breastfeeding support is essential.

The Social Media Influence: A 2,395% Increase in Buzz

 

A 2021 study analysed over 5,900 tweets related to ankyloglossia and frenotomy. From 2009 to 2018, tweets on the topic increased by 2,395%.

“There is a large amount of non-scientific information and opinions disseminated that may be shaping decisions.”

This tells us something important: parents are often receiving more information from social media than from their own health professionals.

Social media can be a source of support—but also misinformation. That’s why clinical decisions need more than hashtags and Facebook advice.

 

A Balanced Clinical Review: Still More Questions than Answers

 

A 2023 review by paediatric gastroenterologist Stephen Borowitz, published in Frontiers in Pediatrics, offers a timely reality check. The paper examines the global surge in tongue tie diagnoses—particularly in the US, Canada, and Australia—and contrasts this with countries like Japan and Scandinavia, where such increases have not occurred, despite higher breastfeeding rates.

Borowitz concludes that:

• There is no universally accepted definition of ankyloglossia.
• Diagnostic tools (like the Hazelbaker or Kotlow assessments) lack rigorous validation.
• Most infants diagnosed with tongue tie are asymptomatic.
• Frenulotomy may offer short-term pain relief, but has not been shown to improve breastfeeding duration or long-term outcomes.
• And importantly, recent anatomical findings show the frenulum contains motor and sensory nerves—suggesting frenotomy might not be as benign as once thought.

What’s also rarely acknowledged is the soothing power of sucking for newborns. It’s possible that the observed improvement in feeding immediately after a frenotomy might not be because the surgery solved the problem—but because the baby, distressed from the procedure, is calmed by the act of feeding.

As Borowitz points out, non-nutritive sucking has been shown to reduce pain in other settings, like circumcision, where babies often feed vigorously afterwards.

(Borowitz, 2023). It raises an important question: are we sometimes mistaking post-procedure deeper latch for soothing for success?

 

 

 

What About Future Speech Issues?

 

Understandably, many parents worry that if they don’t get their baby’s tongue-tie released early, it could cause speech problems down the track.

But here’s what the research tells us:

A 2020 study by Salt et al. found no significant differences in speech production, tongue mobility, or intelligibility between children with treated, untreated, or no tongue-ties.

A 2024 Danish review found no consistent improvement in speech after tongue-tie release, despite rising rates of intervention.

Another 2024 study (Melong et al.) found no statistically significant improvement in articulation or intelligibility after surgery.

It means that speech issues are common in young children, with or without tongue-tie—and that not every speech sound challenge is caused by a frenulum. The evidence does not support surgical intervention to prevent future speech issues.

 

 

What About Dental Problems or Other Risks?

 

According to the Australian Dental Association Ankyloglossia and Oral Frena Consensus Statement (ADA, 2022):

“Malocclusion, gum recession and dental decay cannot be predicted based on the anatomic appearance of the frenum in infancy or early childhood… Surgical management should not be undertaken based on speculation about future problems despite lack of current problems.”

But it’s also important to understand that frenotomy is not without risk. The ADA outlines both acute and chronic complications, including:

• Bleeding or haematoma
• Infection or oral aversion
• Submandibular gland duct injury
• Lingual paraesthesia (numbness)
• Severe complications such as airway compromise and, in rare cases, hypovolemic shock

Even though the procedure may seem minor, complications—especially in very young infants—can be serious. That’s why a clear diagnosis based on function is so important before proceeding with surgery.

In short: appearance alone doesn’t justify surgery, and intervention should never be based on the hope of preventing problems that may never arise.

 

 

Final Thoughts:

This new information may stir up strong feelings—especially for those who’ve already walked the path of tongue-tie diagnosis and frenotomy. And that’s completely understandable.

Let me be clear: this isn’t about blaming or shaming anyone. Tongue-tie is real, and there is evidence from practice that for some babies with a classic, anterior tie clearly impacting feeding—a simple scissor frenotomy can make a meaningful difference.

And feeding challenges like nipple pain, a baby slipping off the breast, low supply, or poor weight gain can be incredibly distressing. But these symptoms don’t always mean there’s a tongue-tie. Often, they reflect positional instability—or ‘fit and hold’ issues—which can usually be improved with skilled breastfeeding support.

In recent years, we’ve seen a significant increase in tongue-tie diagnoses and interventions. While some are necessary and appropriate, it’s likely that many are not. Tongue-tie has also been increasingly suggested as the reason for unsettled behaviour, wind, or sleep difficulties—many of which are actually normal newborn experiences as babies adapt to life outside the womb.

Surgery is unlikely to improve these broader issues and may even pull your attention away from more supportive actions you can take—things that nourish your baby’s emotional development and protect your own well-being too.

What I hope this blog brings is balance. A gentle reminder that not every feeding challenge is due to a tongue-tie and that anyone working with breastfeeding families has a responsibility to stay up to date with the latest, evidence-based practice.

For the parents reading this who are feeling a bit triggered by previous decisions: please know that you made the best decisions you could with the information, support, and emotions you had at the time. That’s what we all do.

This blog is for parents making these decisions right now—who are feeling unsure, overwhelmed, or just trying to do the best for your baby—I hope this blog helps you feel more informed and more supported.

This is about weighing up the potential risks and benefits of any procedure and making the best decision for your unique situation—based on the evidence, the function, and your instincts as a parent.

The goal is not perfection—it’s informed choice. And that’s what good care should always support.

 

 

REFERENCES

 

1. Academy of Breastfeeding Medicine (LeFort et al.). (2021). ABM Position Statement on Ankyloglossia in Breastfeeding Dyads. Breastfeeding Medicine, 16(4), 278–281. https://doi.org/10.1089/bfm.2021.29179.ylf

2. Australian Dental Association (ADA). (2022). Policy Statement 2.13 – Ankyloglossia and Oral Frena. Retrieved from https://www.ada.org.au

3. Borowitz, S. M. (2023). What is tongue-tie and does it interfere with breast-feeding? – A brief review. Frontiers in Pediatrics, 11, 1086942. https://doi.org/10.3389/fped.2023.1086942

4. Douglas, P. S., Perrella, S. L., & Geddes, D. T. (2022). A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: Case series. BMC Pregnancy and Childbirth, 22, 94. https://doi.org/10.1186/s12884-021-04363-7

5. Douglas, P. S., & Geddes, D. T. (2018). Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants. Midwifery, 58, 145–155. https://doi.org/10.1016/j.midw.2017.12.007

6. Dinh, L. A., El-Rabbany, M., Aslam, S., & Ricalde, P. (2025). Does lingual frenotomy improve breastfeeding in newborns with ankyloglossia? A randomized controlled trial. Journal of Oral and Maxillofacial Surgery. Advance online publication. https://doi.org/10.1016/j.joms.2025.04.006

7. Grond, S. E., Kallies, G., & McCormick, M. E. (2021). Parental and provider perspectives on social media about ankyloglossia. International Journal of Pediatric Otorhinolaryngology, 146, 110741. https://doi.org/10.1016/j.ijporl.2021.110741

8. Melong, J., Bezuhly, M., & Hong, P. (2024). The effect of tongue-tie release on speech articulation and intelligibility. Ear, Nose & Throat Journal, 103(7), NP450–NP454. https://doi.org/10.1177/01455613211064045

9. Mills, N., Pransky, S. M., Geddes, D. T., & Mirjalili, S. A. (2019). What lies beneath: The anatomy of the lingual frenulum. Clinical Anatomy, 32(7), 1025–1030. https://doi.org/10.1002/ca.23406

10. Salt, H., Claessen, M., Johnston, T., & Smart, S. (2020). Speech production in young children with tongue-tie. International Journal of Pediatric Otorhinolaryngology, 134, 110035. https://doi.org/10.1016/j.ijporl.2020.110035

11. Thorup, A., Graungaard, A. H., & Vaeth, M. (2024). Treatment of tongue-tie and breastfeeding: A systematic review and critical appraisal of guidelines. International Journal of Pediatric Otorhinolaryngology, 169, 111622. https://doi.org/10.1016/j.ijporl.2023.111622