Are Frenotomies Worth It?

Emily Oster

9 min Read Emily Oster

Emily Oster

Are Frenotomies Worth It?

Data on the benefits and risks of fixing tongue ties

Emily Oster

9 min Read

What does the data say about the increasingly common practice of cutting tongue-ties in infants to improve breastfeeding success? Before getting into it, I want to acknowledge where this starts from — namely, from the fact that breastfeeding is often, especially at the start, difficult. Milk can take time to come in, and many infants (and their moms) struggle to get the hang of a good latch. This can lead to painful nipples and to inefficient feeding, and then low weight gain.

There are many baseline solutions to this: lactation consultants can help, as can pediatricians and doulas. Formula supplementation can also be supportive during this period.

The experience of struggling to nurse can be emotionally fraught — I say this from experience — and it is natural to look for solutions. Which, I think, may explain the growth over time of tongue-tie procedures, called frenotomy. This procedure, in which a small cut is made in the underside of the tongue to allow it to move more freely, is billed as a solution for improving breastfeeding success and lessening nipple pain. 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 young babies (0 to 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.

Several weeks ago, the New York Times published a long and quite scary article on this topic. The premise of the article is that the procedure is overused by people greedy for profit. It paints a dark picture, including some difficult-to-read stories that seem to reflect an almost violent use of the procedure on babies. The article does not do a detailed review of the data, however, on either benefits or harms.

My goal here is to review both the evidence on benefits and what we know about risk.

Evidence on benefits

There are a number of reasons why doctors might perform a frenotomy. It sometimes comes up in the context of speech issues for older children, for example (we will leave these issues for another time). But the most common reason is for infants who are having difficulties breastfeeding. This might be identified by infants having trouble getting enough milk or in cases when breastfeeding is painful for mom. The procedure involves cutting the tissue that connects the bottom of the tongue to the bottom of the mouth.

(There are many nuances here — tongue-ties can be more or less severe, attached further to the front or to the back of the mouth, and there are also lip-ties. The already limited evidence does not typically distinguish among these.)

Big-picture summary: We have little good evidence on the benefits of frenotomy.

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 general breastfeeding support. 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. 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 that hard to draw conclusions from.

The failure of this trial was disappointing, because the data that comes before it is unconvincing. There is a long review article, and a review including the 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 differences.

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.

Within the randomized data, there is more consistent evidence of reductions in maternal pain. This is perhaps not surprising, since it also relies exclusively on self-reports.

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.

(Sidebar: All of this focuses on breastfeeding success, but if you’re struggling here, it’s worth re-reading this chapter from Cribsheet to be clear that many of the benefits of breastfeeding you hear about are overstated.)

Evidence on harms

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 harms. Minor, limited 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 infants who have had this procedure. Most complications involved 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 (like those highlighted by the New York Times). 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.

Summary

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.

If that is true, we get into a philosophical discussion. Is it ethical to perform this procedure if it improves people’s experiences, even if that is just a placebo? Generally in medicine, the answer to this is no. But it’s slippery. Imagine you thought this actually worked for a small share of people and worked due to a placebo effect for a large share, but you didn’t know who was who. Then it might feel perfectly okay to do the procedure widely.

Of course, we like evidence. The placebo effect is interesting, but I’d like to know if it works for real.

This is proving hard.

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 they were not willing to stick with their assigned group if they weren’t assigned to get it. This is a huge problem for research design. The authors of that trial end their article discussing it by saying we need alternative approaches to evaluate this, which seems spot-on to me. As usual when we talk about breastfeeding, we do not have enough evidence-based support — whether it’s mastitisbreast milk storage, or this issue — we don’t know enough and we deserve more.

In the end, the New York Times is almost certainly right that we’re doing more of these procedures than are necessary. A frenotomy should not be a first-line option — it should be considered only after a serious evaluation of the infant and of the breastfeeding issues. If it is suggested to you, you might consider a second opinion.

Bottom line

  • There is limited evidence that frenotomy procedures improve breastfeeding efficacy.
  • There is slightly more evidence on impacts on maternal pain, but this is entirely based on self-reports.
  • In systematic data, the harms of the procedure are minimal.
  • It should not be a first-line treatment for breastfeeding problems.
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In the future, before hopping onto the latest trend, check the data first. Unlike Cabbage Patch Kids, parenting trends can add a lot of unnecessary stress and challenges to your plate. What’s a recent trend that you’ve been wondering about?

#parentdata #emilyoster #parentingtips #parentingadvice #parentinghacks

Parenting trends are like Cabbage Patch Kids: they’re usually only popular because a bunch of people are using them! Most of the time, these trends are not based on new scientific research, and even if they are, that new research doesn’t reflect all of what we’ve studied before.

In the future, before hopping onto the latest trend, check the data first. Unlike Cabbage Patch Kids, parenting trends can add a lot of unnecessary stress and challenges to your plate. What’s a recent trend that you’ve been wondering about?

#parentdata #emilyoster #parentingtips #parentingadvice #parentinghacks
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I’m so grateful you’re all here as a part of this, and I want to thank you! If you’ve been waiting for the right moment to sign up for full access to ParentData, this is it. ⭐️ Comment “Link” for a DM with a discount code for 20% off of a new monthly or annual subscription to ParentData! 

Thank you again for being the best community of readers and internet-friends on the planet. I am so lucky to have you all here.

#parentdata #emilyoster #expectingbetter #cribsheet #familyfirm #parentingcommunity

As of this week, 1 million copies of my books have been sold. This feels humbling and, frankly, unbelievable. I’m so thankful to those of you who’ve read and passed along your recommendations of the books.

When I wrote Expecting Better, I had no plan for all of this — I wrote that book because I felt compelled to write it, because it was the book I wanted to read. As I’ve come out with more books, and now ParentData, I am closer to seeing what I hope we can all create. That is: a world where everyone has access to reliable data, based on causal evidence, to make informed, confident decisions that work for their families.

I’m so grateful you’re all here as a part of this, and I want to thank you! If you’ve been waiting for the right moment to sign up for full access to ParentData, this is it. ⭐️ Comment “Link” for a DM with a discount code for 20% off of a new monthly or annual subscription to ParentData!

Thank you again for being the best community of readers and internet-friends on the planet. I am so lucky to have you all here.

#parentdata #emilyoster #expectingbetter #cribsheet #familyfirm #parentingcommunity
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Just eat your Cheerios and move on.

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According to the data we have, parents should sleep in the same room as a baby for as long as it works for them! Sharing a room with a child may have negative impacts on both child and adult sleep. We should give families more help in navigating these trade-offs and making the decisions that work best for them.

#emilyoster #parentdata #roomsharing #sids #parentingguide

The AAP’s guidelines recommend sleeping in the same room as your baby “ideally for the first six months.” However, the risk of SIDS is dramatically lower after four months, and the evidence in favor of the protective effect of room sharing is quite weak (both overall and even more so after four months). There is also growing evidence that infants who sleep in their own room by four months sleep better at four months, better at nine months, and even better at 30 months.

With this in mind, it’s worth asking why this recommendation continues at all — or at least why the AAP doesn’t push it back to four months. They say decreased arousals from sleep are linked to SIDS, which could mean that babies sleeping in their own room is risky. But this link is extremely indirect, and they do not show direct evidence to support it.

According to the data we have, parents should sleep in the same room as a baby for as long as it works for them! Sharing a room with a child may have negative impacts on both child and adult sleep. We should give families more help in navigating these trade-offs and making the decisions that work best for them.

#emilyoster #parentdata #roomsharing #sids #parentingguide
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Watch the full segment at the link in my bio 🔗

#tamronhall #tamronhallshow #emilyoster #parentingsupport #workingparents

It was an absolute pleasure to be featured on the @tamronhallshow! We talked about all things data-driven parenting and, in this clip, what I call the plague of secret parenting. To balance having a career and having a family, we can’t hide the fact that we’re parents. If mothers and fathers at the top can speak more openly about child-care obligations, it will help us all set a new precedent.

Watch the full segment at the link in my bio 🔗

#tamronhall #tamronhallshow #emilyoster #parentingsupport #workingparents
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Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#emilyoster #parentdata #parentdatapodcast #parentingpodcast #householdtips #fairplay #invisiblelabor

Invisible labor. It’s the work — in our households especially — that has to happen but that no one sees. It’s making the doctor’s appointment, ensuring birthday cards are purchased, remembering the milk.

My guest on this episode, @everodsky, has come up with a solution here, or at least a way for us to recognize the problem and make our own solutions. I’ve wanted to speak with Eve for ages, since I read her book Fair Play. We had a great conversation about the division of household labor, one I think you’ll get a lot out of!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#emilyoster #parentdata #parentdatapodcast #parentingpodcast #householdtips #fairplay #invisiblelabor
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Good news: fancier vitamins are not better.  Folic acid is the most important prenatal ingredient. Iron (with vitamin C) and DHA are also nice to have. Other included ingredients have only weak or no evidence to support their use. (If you do not consume animal products, add B12, plus a few others depending on your diet.)

Vitamins are just vitamins. Any prenatal vitamin that contains these is enough. 

Comment “Link” for a DM to an article with everything you need to know about prenatal vitamins.

#emilyoster #parentdata #prenatalvitamins #pregnancydiet #pregnancytips

Prenatal vitamins 💊 If there is any product that seems designed to prey on our fears, it’s this one. You’re newly pregnant and you want to do it right. Everyone agrees you need prenatal vitamins, so you get them. But do you want to be that person who just… buys the generic prenatal vitamins?

Good news: fancier vitamins are not better. Folic acid is the most important prenatal ingredient. Iron (with vitamin C) and DHA are also nice to have. Other included ingredients have only weak or no evidence to support their use. (If you do not consume animal products, add B12, plus a few others depending on your diet.)

Vitamins are just vitamins. Any prenatal vitamin that contains these is enough.

Comment “Link” for a DM to an article with everything you need to know about prenatal vitamins.

#emilyoster #parentdata #prenatalvitamins #pregnancydiet #pregnancytips
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#parentdata #emilyoster #newborncare #parentingadvice #parentingtips

When it comes to introducing your newborn to the world, timing matters. It’s a good idea to minimize germ exposure in the first 6-8 weeks; after that, it’s inevitable and, very likely, a good idea! This doesn’t mean you need to be trapped inside. The most significant exposure risks are from seeing other people at home — family, etc. These interactions are not infinitely risky, but they do pose more risk than a walk or a trip to the grocery store, since they involve closer interaction. Think simple and make sure everyone is washing their hands before holding the baby. 💛

#parentdata #emilyoster #newborncare #parentingadvice #parentingtips
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The first edition of Hot Flash is out now! Comment “Link” for a DM to learn more about the late-reproductive stage.

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🔥 Hot Flash from ParentData is a weekly newsletter on navigating your health and hormones in the post-reproductive years. Written by Dr. Gillian Goddard, Hot Flash provides all of the information you need to have a productive, evidence-based conversation about hormonal health with your doctor.

#emilyoster #parentdata #hotflash #perimenopause #womenshealth

The first edition of Hot Flash is out now! Comment “Link” for a DM to learn more about the late-reproductive stage.

There are times when we expect hormonal shifts. Our reproductive lives are bookended by puberty and menopause. We discuss those changes often because they are definitive and dramatic — a first period is something many of us remember clearly. But between ages 13 and 53, our hormones are changing in more subtle ways. During the late-reproductive stage (in your 40s), you can expect a lot of changes in your menstrual cycle, including the length and symptoms you experience throughout. It’s an important time in our lives that is often overlooked!

🔥 Hot Flash from ParentData is a weekly newsletter on navigating your health and hormones in the post-reproductive years. Written by Dr. Gillian Goddard, Hot Flash provides all of the information you need to have a productive, evidence-based conversation about hormonal health with your doctor.

#emilyoster #parentdata #hotflash #perimenopause #womenshealth
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Now tell me in the comments: what’s a parenting move you’ve made recently that feels right to you?

#parentingcommunity #parentingsupport #parentingquotes #emilyoster #parentdata

There are plenty of reels telling you how to parent. Plenty of panic headlines saying that “studies show” what’s best for your kid. Even good data, from a trusted source, can send us into a spiral of comparison. But I want you to remember that no one knows your kid better than you. It’s important to absorb the research, but only you will know the approach that works best for you and your child. 💙

Now tell me in the comments: what’s a parenting move you’ve made recently that feels right to you?

#parentingcommunity #parentingsupport #parentingquotes #emilyoster #parentdata
...

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Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #parentdatapodcast #emilyoster #emilynagoski #comeasyouare #cometogether #longtermrelationship #intimacy #relationships

Let’s talk about sex (after) baby! Today on the podcast, I was lucky enough to speak with @enagoski about her new book on sexual connection in long-term relationships. Especially after having kids, this is something many people struggle with. Emily tells us to stop worrying about what’s “normal” and focus on pleasure in its many forms.

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #parentdatapodcast #emilyoster #emilynagoski #comeasyouare #cometogether #longtermrelationship #intimacy #relationships
...

Ever wondered if you can safely use leftover baby formula? 🍼 The CDC says to throw out unused formula immediately because of the risk of bacterial growth. However, research suggests that bacterial concentrations do not appreciably increase after 3, 12, or even 24 hours at refrigerator temperatures. Good news! This means there’s not a strong data-based reason to throw out formula right away if you store it in the fridge.

Comment “Link” for a DM to an article on another common formula question: should you throw away old formula powder?

#emilyoster #parentdata #babyformula #babyfeeding #parentingstruggles

Ever wondered if you can safely use leftover baby formula? 🍼 The CDC says to throw out unused formula immediately because of the risk of bacterial growth. However, research suggests that bacterial concentrations do not appreciably increase after 3, 12, or even 24 hours at refrigerator temperatures. Good news! This means there’s not a strong data-based reason to throw out formula right away if you store it in the fridge.

Comment “Link” for a DM to an article on another common formula question: should you throw away old formula powder?

#emilyoster #parentdata #babyformula #babyfeeding #parentingstruggles
...

What’s the most important piece of advice for new parents? Here’s one answer, but I want to hear from you! Share your suggestions in the comments ⬇️

#emilyoster #parentdata #parentingtips #parentingadvice #newparents #parentingcommunity

What’s the most important piece of advice for new parents? Here’s one answer, but I want to hear from you! Share your suggestions in the comments ⬇️

#emilyoster #parentdata #parentingtips #parentingadvice #newparents #parentingcommunity
...

What's in the bag of a Vagina Economist? 👀 Someone please tell me this looks familiar to you.

What`s in the bag of a Vagina Economist? 👀 Someone please tell me this looks familiar to you. ...

Comment ”link” for a DM to learn more about tongue ties 🔗

Breastfeeding is often difficult, especially at the start. For babies with tongue ties, many infants (and their moms) struggle to get the hang of a good latch. This can lead to painful nipples and to inefficient feeding, and then low weight gain.

So what does the data say about the increasingly common practice of cutting tongue-ties in infants to improve breastfeeding success? Several weeks ago, @nytimes published a long and quite scary article on this topic.

After diving into the data, here is what I found. There is limited evidence that frenotomy procedures improve breastfeeding efficacy and the harms of the procedure are minimal. Many women do report that it alleviates pain and helps them with breastfeeding. However, it should not be a first-line treatment for breastfeeding problems.

#parentdata #emilyoster #tonguetie #tonguetiebabies #breastfeedingsupport

Comment ”link” for a DM to learn more about tongue ties 🔗

Breastfeeding is often difficult, especially at the start. For babies with tongue ties, many infants (and their moms) struggle to get the hang of a good latch. This can lead to painful nipples and to inefficient feeding, and then low weight gain.

So what does the data say about the increasingly common practice of cutting tongue-ties in infants to improve breastfeeding success? Several weeks ago, @nytimes published a long and quite scary article on this topic.

After diving into the data, here is what I found. There is limited evidence that frenotomy procedures improve breastfeeding efficacy and the harms of the procedure are minimal. Many women do report that it alleviates pain and helps them with breastfeeding. However, it should not be a first-line treatment for breastfeeding problems.

#parentdata #emilyoster #tonguetie #tonguetiebabies #breastfeedingsupport
...