The Research on Tongue Ties

A deep dive into the research behind whether tongue ties impact breastfeeding and speech and whether it is necessary that tongue ties be "fixed"

Source: Anna Shvets/Pexels

This week’s newsletter is on tongue ties, which seems like a niche topic but is actually one of the most requested topics on my Parenting Translator platform. If you are past the baby stage and/or don’t have a child with a tongue tie, you might think this topic doesn’t apply to you, but I think this topic is actually a great example of when research doesn’t line up with practice and why parents need access to the research. Medical professionals are likely to give parents different guidance based on their area of expertise and/or leave the decision up to the parents. Therefore, it is really important that parents understand the potential pros and cons in order to make an informed decision. I also wanted to write this newsletter because I couldn’t find this research compiled in one place anywhere else, so I hope this newsletter will help parents who (like myself) have been faced with this difficult decision.

Listen to the audio version here:

My Personal Experience with Tongue Ties

The first time I heard about tongue ties was after I had my second child. My second child had some minor issues with breastfeeding (painful latch and relatively slow weight gain). I took him to a breastfeeding clinic where a pediatrician diagnosed him with a minor anterior tongue tie (meaning it was visible and in the front of his mouth so it could be easily clipped). The pediatrician gave me the choice of whether I wanted her to “release” it (that is, cut it with scissors) or wait to see if breastfeeding improved on its own. After asking about potential side effects and pain to the baby (which she said would be minimal), I decided to allow her to release it. He cried for a few seconds and then it was over. Breastfeeding immediately improved and it felt like I had made the right choice.

After having my fourth child this past August, it quickly became apparent that breastfeeding was not working as it should— she was not gaining weight and breastfeeding was extremely painful for me. I was completely at a loss for why it wasn’t working this time— it didn’t look like she had a tongue tie and her latch seemed fine. Nearly all of the professionals that I saw also seemed stumped as to why breastfeeding wasn’t working. When I discussed the problem with friends or on social media, it was frequently suggested to me that it must be a tongue tie. When I sought consultation from the experts on this topic, I felt even more confused. The pediatricians I saw told me “absolutely not a tongue tie,” one lactation consultant said “maybe” and the other one said “no,” and the pediatric dentist told me “probably a very posterior tongue tie” and that I should fix it with a laser procedure. I was struck by how there could be so much disagreement about what seemed like an anatomical diagnosis and disturbed by the idea of using a laser to burn away part of my newborn’s mouth without a clear diagnosis. There was also a part of me that kept asking about a tongue tie in hopes that this was the case. Of course, I didn’t want my child to have a tongue tie but it seemed like such a simple explanation that would provide an instant solution (that is, releasing the tongue tie). Not being one to settle for an unclear answer, I talked to experts all over the world on this topic— some advised that I fix the tongue tie in infancy or it would would cause countless problems down the road and some advised I do nothing insisting that medical professionals were taking advantage of vulnerable and desperate parents to make money off of unnecessary procedures to fix tongue ties.

In the end, I didn’t feel comfortable pursuing the procedure without a clear diagnosis particularly since fixing a posterior tongue tie would be a more invasive and potentially riskier procedure than it had been to fix my son’s anterior tongue tie. I consulted with countless lactation consultants, did oral-motor exercises with her, and continued pumping and giving her bottles while also practicing breastfeeding at nearly every feed until finally around 2 months she very gradually started breastfeeding better and better every day. She is now exclusively breastfeeding without any issues whatsoever. I still don’t really know whether she has a tongue tie or even why she struggled with breastfeeding but, after to talking to many other parents who struggled with breastfeeding, I know that I am not alone in my confusion.

The Tongue Tie Controversy

Tongue ties have become a hot topic in recent years. So many women struggle with breastfeeding (research finds that more than half of mothers stop breastfeeding earlier than they would like) and it often isn’t clear why breastfeeding isn’t working or how to fix it. As awareness grows about tongue ties, it almost seems like identifying and releasing tongue ties might be the the silver bullet we have all been looking for to make breastfeeding easier. Online and on social media, I have even seen claims that tongue ties are linked with not only breastfeeding difficulties but also speech impairments, difficulty feeding and eating, dental problems, sleep apnea and altered breathing during sleep, and digestive issues such as reflux. At the same time, there is now an industry of people making money off of diagnosing and treating tongue ties. Although I want to believe that no one would ever perform an unnecessary procedure on a baby, it is hard not to question whether professionals might be motivated (maybe even subconsciously) to over-diagnose and over-treat tongue ties.

So can the research help parents to make sense of the decision whether to treat a tongue tie? How do tongue ties actually impact breastfeeding? Are tongue ties really linked with other negative impacts later in a child’s life such as speech impairments?

Some Background Information

A tongue tie (the medical term for tongue tie is ankyloglossia) is a congenital condition (translation: something a child is born with) that involves a shorter or tighter lingual frenulum (translation: the small piece of skin that connects the tongue to the bottom of the mouth). This small piece of skin causes reduced ability to move the tongue, which may then impact the child’s ability to latch on to the breast and extract milk for successful breastfeeding. Tongue ties are typically fixed by a frenotomy which involves using scissors or a scalpel to cut the frenulum, or in some cases using a laser to remove the frenulum. Tongue ties can either be anterior (Picture A) or posterior (Picture B). The distinction is not completely clear in research or practice, but anterior tongue ties are typically considered to be visible in the front of the tongue, while posterior tongue ties are near the back of the tongue and may not be visible but felt upon examination.

Source: Messner, A. H., Walsh, J., Rosenfeld, R. M., Schwartz, S. R., Ishman, S. L., Baldassari, C., ... & Satterfield, L. (2020). Clinical consensus statement: ankyloglossia in children. Otolaryngology–Head and Neck Surgery, 162(5), 597-611.

Are Tongue Ties Being Over-Diagnosed?

Tongue ties may seem to be a recent trend but they have actually been recognized for a very long time. Tongue ties were reported and treated in babies as early as the 1600’s. In fact, midwives would often keep one fingernail longer and sharper in order to cut tongue ties in newborn babies.

Currently, tongue ties are estimated to occur in about 4 to 11% of newborns. The reported rate of tongue ties has increased dramatically in recent years. One study estimated that the rate of tongue tie diagnoses increased 843% (!!!) from 1997 to 2012. This exponential increase may be related to increased awareness of this condition as well as greater emphasis on exclusive breastfeeding. Yet, some professionals claim that tongue ties are being over-diagnosed and have raised the alarm that infants and children may be having unnecessary corrective procedures as a result.

Do Tongue Ties Actually Impact Breastfeeding?

Research suggests that tongue ties are associated with breastfeeding difficulties for some, but not all, infants. Research finds that breastfeeding problems are slightly more likely in infants with a tongue tie (55% of mothers of infants with a tongue tie report breastfeeding problems versus 42% of mothers of infants without a tongue tie). Research also finds infants with tongue ties are slightly less likely to be breastfed for two months (83% of infants with a tongue tie versus 92% of infants without a tongue tie breastfeed for at least two months). These studies are correlational, meaning we do not know whether the tongue tie is actually causing the difference between groups but it is clear from these studies that many infants have breastfeeding problems even without a tongue tie. In addition, research finds that about 50% of breastfed babies with a tongue tie do not experience any breastfeeding issues at all, suggesting that tongue ties don’t always cause breastfeeding problems.

We also have some data from randomized controlled trials (translation: the highest quality research studies that allow researchers to determine cause) to help us to better understand the impact of tongue ties on breastfeeding. A recent Cochrane review including only randomized controlled trials (translation: Cochrane reviews are research reviews that are considered very high-quality and are released by an independent non-profit organization) found that fixing a tongue tie consistently resulted in less pain with breastfeeding for mothers. However, research was mixed as to whether fixing a tongue tie actually improved infant feeding (two studies found no difference and one study found improved infant feeding). Yet, these studies all had methodological problems, including small sample sizes and an unclear definition of tongue tie. In most of these studies, the mothers and the researchers were not “blind” meaning they knew whether the child had their tongue tie fixed (and thus they might have biased to report that it worked). All studies also lacked longer term follow-up data, meaning that research has yet to show whether tongue ties or fixing tongue ties has any impact on long-term breastfeeding success.

It is also important to note that although tongue ties can cause nipple pain, tongue ties are actually not the most common cause of nipple pain in breastfeeding mothers. In most cases (73%) nipple pain is caused by improper latch and positioning, while it is only caused by tongue ties in 23% of mothers.

Do Tongue Ties Have Other Negative Impacts?

Despite what you might read online, the research is really limited here and higher quality studies are needed.

Research is mixed as to whether tongue ties impact speech development— some studies find an association between tongue ties and later speech problems and some find no association. Research is also mixed as to whether releasing a tongue tie (a frenotomy) improves speech in children. A recent study found no difference in speech production or intelligibility in children after releasing a tongue tie. Yet, a recent randomized trial found improved speech production and intelligibility when the frenotomy was performed when the child was between 3 to 5 years but no difference in speech outcomes when the frenotomy was performed from 2 to 3 years.

Research has found a link between tongue ties and sleep apnea in children but further research is needed. There is also some research that releasing a tongue tie may make sleep apnea worse.

There is some evidence that tongue ties impact reflux but higher quality research is needed on this topic.

Do Tongue Ties Need to Be Fixed?

Given the lack of clear findings indicating that tongue ties actually cause infant feeding problems and other developmental issues, some professionals have started to question whether we should be doing painful procedures on infants or children to “fix” them (these procedures are referred to as a frenotomy). Some private practitioners may even be making a significant profit off of fixing tongue ties, which of course raises ethical issues. Further complicating this question is the lack of a standardized tool to determine whether a frenotomy is necessary. There is also a lot of disagreement among professionals as to whether fixing a tongue tie is necessary for improving breastfeeding. 53% of ENT doctors recommend a surgical fix of a tongue tie when the infant has feeding issues yet only 21% of pediatricians do.

Research on the frenotomy procedure itself is limited (particularly research on using a laser to release a tongue tie) but the research we do have indicates that most infants recover quickly and are able to breastfeed immediately after the procedure. Research also finds few negative side effects of this procedure. However, in rare cases, there may be complications such as bleeding, oral aversion (translation: refusing to breastfeed or take a bottle), or requiring a repeat procedure. One study found that 60% of infants cried after a standard frenotomy (that is, when clipped with scissors) but 85% of these infants stopped crying within 20 seconds.

So is a frenotomy really necessary? As described above, about 50% of breastfeeding babies with a tongue tie do not experience any problems with breastfeeding and even for those who do, a frenotomy may not be the best way to fix the problem. A recent study found that most infants (63%) referred for frenotomy ended up not needing the procedure when they first worked with a lactation consultant to improve the infant’s latch and positioning. A recent randomized controlled trial also found no difference in breastfeeding success at 3 months in participants offered lactation consultation plus a frenotomy versus lactation consultation alone. These results suggest that families should probably see a lactation consultant first to improve their baby’s latch and positioning before seeking a frenotomy, since this intervention is less painful and has no potential for negative side effects.

The research on whether a frenotomy is necessary is even more unclear for mild and moderate tongue ties. A randomized controlled trial of infants with mild and moderate tongue ties found no significant differences in breastfeeding outcomes with a frenotomy (yet frenotomy did increase mothers’ self-confidence in breastfeeding).

It is also unclear whether the stretching exercises and massage recommended after a tongue tie procedure are necessary and research has to yet to find a standardized post-procedure regimen.

There is also currently a lack of evidence that a particular method of releasing a tongue tie (such as laser versus scissors) is better in terms of outcomes and healing.

What about Lip Ties, Posterior Tongue Ties, and Buccal Ties?

The research is also lacking on “lip ties, “posterior tongue ties,” and “buccal ties.” One issue with lip ties is that they are even less clearly defined in the research than tongue ties and there is no consensus on how to diagnose them. However, a recent study found no correlation between lip anatomy and breastfeeding success. This study also found that having a tongue tie doesn’t make an infant more likely to have a lip tie. Another study of infants that had both a tongue tie and lip tie found that 98% of infants had successful breastfeeding after only receiving a tongue tie release— suggesting that the lip tie release may not be necessary for most infants. However, there are no randomized controlled trials on lip ties so further research is needed.

The definition of a posterior tongue tie is also not well-defined and clinicians have not reached a consensus on exactly what this term means— some use the term to refer to a frenulum near the back of the tongue that isn’t always visible but this definition is not standardized. A small randomized controlled trial recently found some evidence for improved breastfeeding after a laser frenotomy of a posterior tongue tie. However, further research is needed on posterior tongue ties, particularly since a posterior tongue tie is more difficult to release and could have more negative side effects.

There is also no evidence that releasing a buccal tie (translation: a “cheek tie”) will improve breastfeeding and some experts believe it may make breastfeeding problems worse.

Overall Translation

Tongue ties likely do contribute to breastfeeding difficulty in some way for some infants. If you are struggling to breastfeed or experiencing painful breastfeeding, you will likely want to get your infant assessed for a tongue tie. When seeking this assessment, you may want to consult with several different types of experts including your pediatrician, a lactation consultant, and an Ear, Nose, and Throat (ENT) doctor since research finds that different medical professionals may have different perspectives on tongue ties.

However, tongue ties are not necessarily the explanation for every breastfeeding problem and fixing a tongue tie is not the silver bullet that will fix all breastfeeding problems. The research is not clear that tongue ties necessarily have to be “fixed” in order for a baby to successfully breastfeed and the research is even less clear as to whether tongue ties result in later speech, feeding, and sleep issues. The research we do have suggests that you may want to wait until after age 3 to fix a tongue tie when doing so strictly to improve speech.

If your child is diagnosed with a tongue tie or you suspect a tongue tie, first make sure the problem cannot be resolved by first addressing latch and positioning issues. You may also want to check for other explanations as to why breastfeeding is not working and allow time for nipple pain to improve on its own (research finds that nipple pain usually decreases to mild levels after 7 to 10 days postpartum regardless of what you do). Even in infants with a confirmed tongue tie, research finds that working with a lactation consultant often makes releasing the tongue tie unnecessary.

If working with a lactation consultant doesn’t seem to be working, then you may want to weigh the pros and cons of a frenotomy in consultation with a trusted medical professional. There may be situations in which a frenotomy will save your breastfeeding relationship and there may be situations in which a frenotomy is an unnecessary and painful procedure for your baby.

Above all, remember that any way you choose to feed to your baby will result in a healthy and happy child and trust yourself that only you know the best decision for your infant given your unique situation.

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Welcome to the Parenting Translator newsletter! I am Dr. Cara Goodwin, a licensed psychologist with a PhD in child psychology and mother to four children (currently a newborn, 3-year-old, 5-year-old, and 8-year-old). I specialize in taking all of the research that is out there related to parenting and child development and turning it into information that is accurate, relevant, and useful for parents! I recently turned these efforts into a non-profit organization since I believe that all parents deserve access to unbiased and free information. This means that I am only here to help YOU as a parent so please send along any feedback, topic suggestions, or questions that you have! You can also find me on Instagram @parentingtranslator, on TikTok @parentingtranslator, and my website (www.parentingtranslator.org).

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