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Breastfeeding is often, especially at the start, difficult. Milk can take time to come in, infants can struggle to get the hang of a good latch, and all this can lead to painful nipples, inefficient feeding, and low weight gain. The experience of struggling to nurse can be emotionally fraught, especially given the pressure that many women feel to breastfeed. It should be said: claims about the benefits of breastfeeding very often overstate what data supports, and bottle feeding, with formula or pumped milk, is a great option. However, for people who do want to breastfeed, if it is not working as expected, it’s natural to look for solutions.
One commonly proposed solution, in particular when the issue is related to latching, is a procedure to release a tongue or lip tie.
As background, the tongue attaches to the floor of the mouth with a cord called the frenulum. In some people, this cord is very short, which can limit tongue mobility. For infants, this can affect the ability to breastfeed, since the mechanics rely on the tongue. Lip tie refers to a similar (but less common) condition in which the cord that attaches the upper lip to the gums is short or placed very low, limiting lip mobility.
There are several different types of tongue-tie procedures, just as there are several different types of tongue ties, more or less severe ones, and ones attached further to the front (anterior) or back (posterior) of the mouth. This procedure involves cutting some or all of the frenulum to allow it to move more freely. You may hear different terms (frenotomy, frenectomy, frenulotomy) to refer to this surgery, but there are very small differences between these procedures. For the purposes of this article, I’ll use the term “frenotomy.”
Over the past decade, use of the procedure has increased. There isn’t enough systematic data to be clear on how much, but individual practice patterns show an increase in surgery in infants under 2 months in particular. This certainly does not reflect a change in how infants’ mouths are shaped over this period. It may reflect overuse of the procedure, or it could reflect an evidence-based change in our understanding of its value.
There has been pushback against this increase, from both the popular press and the American Academy of Pediatrics, with experts arguing that more careful consideration should be given before the procedure.
My goal here is to review the evidence on both benefits and harms of tongue-tie procedures.
Do tongue-tie procedures improve breastfeeding success?
The truth is, we have little good evidence on the benefits of frenotomies.
It’s possible to imagine a good study to evaluate this. Such a study would recruit a large sample of infants with breastfeeding issues. They would be randomly allocated to either frenotomy or to a control group that did not receive the procedure. They would be followed over time, and outcomes would include continuation of breastfeeding, pain reported by mom, and some objective measurement of breastfeeding efficacy.
There is a recent trial that tried to do something quite close to this, called FROSTTIE. This trial compares frenotomy coupled with breastfeeding support to breastfeeding support alone to see if adding frenotomy to the breastfeeding support improves its success. Unfortunately, it ran into two problems. First, it was started right before the COVID-19 pandemic, and ultimately, recruitment stalled, and the authors were unable to come close to the planned sample size.
Second, and more problematic, a large share of the control group — the group not allocated to the frenotomy — got one anyway: 74% of this group opted for the procedure. In a trial like this, the randomization is not enforced; people are randomized into one group, but they can choose differently. The hope is that enough people stick with their assigned group that you have differences on average. Here, since such a large share of the control group actually did have the procedure, it is hard to learn much from comparing the two groups. The authors didn’t find any evidence of any differences in breastfeeding outcomes, but the limitations of the trial make it hard to draw conclusions from.
The failure of this trial was disappointing because the only data we had before it was already unconvincing. There is a long review article, as well as a review that includes a small number of randomized studies. If we focus on the randomized trials, the evidence varies. In three randomized trials in which breastfeeding effectiveness was evaluated by an external observer, two found no differences, and one found some small improvements.
There are studies that show much more positive results. Generally, these rely on maternal reports without randomization. For example, data from Denmark found that 78% of women indicated a moderate to high improvement in symptoms after the procedure. This type of before-after design, especially with self-reports, is unreliable. Without a control group, we do not know if things would have improved otherwise. Self-reports can be driven by a desire to think things have improved, even if the objective reality is the same.
All of the existing studies have one fundamental drawback: short follow-up, often only a few days. The goal of this procedure, in a broad sense, is to improve the experience of breastfeeding so people are able to do it longer. We have no reliable evidence either way on whether this is true.
Ultimately, there is very limited evidence to actually prove that frenotomies are highly beneficial for breastfeeding success. Basically, we need more data, although it doesn’t seem likely that the effects would be huge.
Do tongue-tie procedures make breastfeeding less painful?
The primary outcome focus in many of these trials is breastfeeding success, but a secondary outcome is usually maternal pain. And on that count, the data is better. Within the randomized data, there is more consistent evidence of reductions in maternal pain (largely nipple pain). In studies with before-after designs, we also observe this.
These results are sometimes dismissed, perhaps under the view that if the reductions in pain do not improve breastfeeding success, what’s the point? Of course, a reasonable person might say the reduction in pain is the point, and improving the experience of new mothers is not something to be ignored.
Are there long-term drawbacks to tongue-tie procedures?
In the systematic data reviews, harms from this procedure are limited. A comprehensive look at harms from a large number of studies and case reviews noted that most studies found no significant harm or minimal harm. Minor post-surgery bleeding was the most common. A 2020 study looked for case reports of serious complications from this procedure from 1965 to 2020 and found 34 infants with serious complications. This is a very small share of the total infants who have had this procedure. Most complications involved short-term issues with feeding post-surgery.
This isn’t to say that the procedure has no risks. Any surgical procedure entails some small risk, and we can see from the limited case reports that there are examples of more significant complications. However, in the vast majority of cases, this procedure doesn’t result in harm.
I think this is important to say because I’ve heard from a number of people basically asking, Did I make a huge mistake doing this? Have I done something terrible to my child? Should I be looking for long-term negative consequences? The answer is no. The procedure may not have helped, but there is no reason to beat yourself up.
So, should your baby get a frenotomy?
What we have here is a procedure with limited systematic evidence to support it, but also limited evidence of harm, and a lot of people who think it works. Breastfeeding often gets easier over time or with advice about position and latching, so even if this procedure has no impact at all, it is still likely that many people will find breastfeeding improves afterward.
Put simply, the placebo effect is powerful. We know from countless other settings that people who are treated with sugar pills or sham procedures can receive significant benefits just from thinking they are being treated. It may be that this is a big part of what is happening here.
Given the power of the placebo effect, it may prove very difficult to actually learn about the real effect.
The fact that many people — both individuals and providers — feel that this works is, paradoxically, making it more difficult to figure out if it actually works. The main problem in the FROSTTIE trial was that people wanted the procedure so much that a huge share got the procedure even if they were not in the group assigned to the procedure. Moreover, even if people had stuck to their assigned groups, if the reason that this procedure “works” is because people think it works, then research like this will still show it works.
In the end, we would likely need a different research design to really figure out how effective the procedure actually is.
In the meantime, however, the advice of the AAP seems very reasonable to me. A frenotomy should not be a first-line option to improve breastfeeding. It should be considered only after less invasive options are considered and only after a serious evaluation by your pediatrician.
The bottom line
- Breastfeeding can be challenging, especially early on, and when latching issues arise, some parents consider a frenotomy — a procedure to release a tongue or lip tie that may be interfering with feeding.
- Despite widespread use, we have very limited and low-quality evidence that frenotomies significantly improve breastfeeding outcomes. However, there is some limited evidence that frenotomies do improve maternal pain associated with breastfeeding.
- Frenotomies do come with some small risks, but serious problems are very rare, and most babies have no lasting issues, so if you did decide to get the procedure and it didn’t help, you don’t need to worry that you’ve done something harmful.
- Ultimately, a frenotomy should not be a first-line option to improve breastfeeding. It should be considered only after less invasive options are considered and only after a serious evaluation by your pediatrician.
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I’m curious if there’s any good evidence for the whole list of non breastfeeding reasons to clip a tongue tie we were given by our lactation consultant – things relating to posture, mouth breathing, sleep apnea etc. there are lots of single data points on Reddit of adults getting their tongue tie clipped and finding postural improvements, and my adult orthodontist (both he and i are adults!) told me he thinks my tongue tie may be the reason my teenage orthodontic work has all undone. But seems to be all individual observation and no experimental data on any of it.
I’m very curious about this as well. Many of my friends in Italy are having their babies evaluated for tongue tie, and in several cases, specialists are recommending clipping to address posture issues. I’m not sure what the evidence says, but it seems to be an increasingly common procedure there too. I wonder whether these recommendations come more from a genuine belief in its effectiveness or from financial incentives to perform the surgery.
We had one of our baby’s tongues clipped and it took about 2 seconds, didn’t really make him cry, and made a world of difference to my off the chart pain levels. I think the harms are very limited with a qualified provider.
Also, since I can’t see a way to comment on the licorice post, as someone who is allergic to the stuff, I know many things that it’s in: many toothpastes, breath mints, teas that aren’t specifically labelled as licorice (like I think all yogi brand teas), etc. You don’t have to be consciously consuming it to be getting more than you realize.
Sounds like one of those procedures where both benefits and risk are small and the choice can be largely influence by personal philosophy. I also think there are other issues here besides breastfeeding. I was born with a tongue tie and I hated it! It didn’t cause serious problems but I found it embarrassing, I couldn’t stick out my tongue or roll my Rs, etc. I finally convinced my mother to let me get the procedure when I was 12. No regrets. When my daughter was born she was tongue tied so opted for the procedure as an infant. It was a MUCH simpler process. Anyway just wanted to give a different POV.
I’m being the crazy commenter with many comments I suppose on this post.
I feel rather strongly against body modifications unless necessary. I’m very pro-science and pro modern medicine.
But this whole tongue tie clipping just feels too much.
Datapoint of one: husband has a tongue tie, and he does just fine in all his adulting. Had trouble nursing as an infant, but we all agree now that it likely had to do with parent needing more support.
Datapoint of one, my son has a tongue tie and he’s nursing still in toddlerhood. Nursing was very painful at the beginning, for months I think, and at some point became completely normal. I don’t think the pain had anything to do with the tongue tie; and I also think continuation of nursing has a lot to do with my son’s motivation, possibly physical components of my body, and that the context of my life allowed it. I think of nursing as a skill, one that I only learned in the moment, and is possible but also has other factors, like swimming, like singing, like doing advanced math — think of the many many factors to get basic and advanced competence in those. The context for the practice of nursing has so many factors. I also think that this culture’s emphasis on the idea of control and no pain (I’m all for no pain too) and other things, might influence the push for the tongue tie fix. Again, of course, not all “tongue ties” are the same, not all parents are the same, etc.
Data counterpoint of one: I breastfed my first baby for 18 months. When Baby2 was born, she wasn’t able to latch effectively. Every time she fed, I had the deformed “lipstick-shaped” nipple that indicates a shallow latch. I visited the pediatrician and the lactation consultants, who after all the interventions (nipple shields, tube feeding, bottle trials) agreed she had a tongue tie. The day she had it snipped was a clear inflection point on her growth chart of daily weigh-ins: ___/
We were advised for our 2 month old to have a frenectomy for lip, tongue, and cheek ties due to challenges she was having with gas and reflux. She has always been bottle fed and the assessment was her latch was poor on the bottle leading to the intake of excess air. Is there any helpful data on when these procedures are done for other reasons aside from breastfeeding challenges? We were also told it could potentially help with speech development etc. later in her life.
I’m a datapoint of one, my son is a toddler. So far, no speech issues, and no solids eating issues.
We shall see when he’s finally trying the Spanish /r/ 😀 but so far he seems very eager and doing valiant tries
Hi MOMOf3, I actually wrote about your last question and it was published this morning. Hopefully you find the answer helpful!
This is a great summary on the research related to breastfeeding, but there are possibly other benefits to consider here as well. My siblings and I are all adults with tongue ties that were not fixed, and those of us that prefer partnering with women can attest to the fact that certain mouth related activities are a lot more difficult and even painful to participate in without a mobile tongue, if you catch my drift. If the surgery is simple and harmless, I see no reason not to give my kids better tongue mobility.
Yes there totally are “social” reasons to get the procedure! I wouldn’t even call it surgery. With my weeks old daughter they just snipped it in the clinic and I managed to soothe her in seconds by breastfeeding her. There isn’t a lot of tissue or nerves there.
Exactly! I have a friend who said she suffered a lot from not having her tongue tie fixed as a kid as well. When you know there are potential drawbacks and the risk is minimal, and you know that there will be the least amount of pain and suffering the earlier you do it, why not do it? Especially for very pronounced cases where you can immediately see it the moment they cry.