Tongue-tie (ankyloglossia) is one of the most debated topics in infant feeding today. As lactation consultants, we often encounter families struggling with feeding difficulties, wondering if a restrictive lingual frenulum is the culprit. But with varying professional opinions, evolving research, and inconsistent access to care, how can we best support these families?

Understanding the Complexity of Tongue-Tie

Tongue-tie occurs when the lingual frenulum—the thin membrane under the tongue—is unusually short or tight, restricting tongue movement. This can interfere with breastfeeding by impairing the infant’s ability to latch effectively, leading to nipple pain, poor milk transfer, and maternal distress. However, diagnosis and management remain controversial.

A 2017 Cochrane Review (O’Shea et al., 2017) found limited high-quality evidence that frenotomy consistently improves breastfeeding outcomes. Some studies reported immediate improvements, but long-term benefits were unclear. The FROSTTIE trial (Knight et al., 2023) echoed these concerns, concluding that there was insufficient evidence to determine whether frenotomy combined with breastfeeding support improved breastfeeding success more than support alone.

The Rise in Tongue-Tie Diagnoses and Treatment

Over the past decade, awareness of tongue-tie has surged, leading to increased diagnoses and procedures. In the UK, a 2023 study (Carter et al., 2023) found that 74% of NHS trusts offered tongue-tie services, up from 43% in 2016. Similarly, in the U.S., a 2019 study (BBC News, 2019) reported that two-thirds of babies referred for frenotomy did not actually require the procedure and could breastfeed successfully with proper support.

A recent study (Booth et al., 2025) analyzed social media content related to tongue-tie and found high levels of misinformation, with 88.7% of posts containing inaccurate information. The study also noted that IBCLCs were less likely to share misinformation compared to other health professionals, reinforcing the critical role of lactation consultants in providing evidence-based guidance. Additionally, the readability of social media posts on tongue-tie was often above the recommended level for public understanding, making it difficult for parents to assess the accuracy of claims.

This rise in procedures has been attributed to several factors, including:

• Greater awareness among parents and providers.
• Increased advocacy from private practitioners offering laser frenectomies.
• The challenges parents face in accessing consistent, expert breastfeeding support within healthcare systems.
• The spread of misinformation on social media, leading parents to seek unnecessary interventions.

The Role of the Lactation Consultant

As IBCLCs, we are uniquely positioned to guide families through the tongue-tie maze. Here’s how we can provide evidence-based, ethical care:

1. Thorough Assessment

Not all feeding difficulties are caused by tongue-tie. Consider alternative explanations, such as:

• Poor positioning and latch.
• Maternal factors like nipple anatomy or milk supply issues.
• Infant conditions such as prematurity, neurological immaturity, or disorganized sucking patterns.

Using assessment tools like the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) can help provide objective data.

2. Optimizing Breastfeeding Support First

Before referring for a frenotomy, work intensively on positioning, latch optimization, and other feeding strategies. A study by Unicef UK (2024) emphasizes that many tongue-tie cases are asymptomatic and improve with skilled lactation support.

3. Collaboration with Healthcare Providers

Frenotomies should be performed by trained professionals who understand infant feeding. Some ENT specialists, pediatricians, dentists, and midwives offer the procedure, but accessibility and provider knowledge vary. Encourage families to seek practitioners who use an evidence-based approach rather than those promoting surgical intervention as the first line of treatment.

4. Managing Expectations

Parents often expect immediate improvement post-frenotomy, but outcomes vary. Some infants show rapid progress, while others need ongoing therapy, such as suck training or craniosacral therapy. Explaining realistic outcomes can help prevent frustration.

The Bigger Picture: Addressing Healthcare Gaps

One of the biggest challenges in tongue-tie management is healthcare inequity. Families with financial means may opt for private frenectomies, while others struggle to access care through the healthcare system. The National Institute for Clinical Excellence (NICE, 2005) recommends that frenotomy should be performed by trained providers and that parents understand both the benefits and risks. However, with health visitor shortages and limited lactation support in many regions, families often turn to private providers, some of whom may over-treat due to financial incentives.

Moving Forward

Tongue-tie is not a simple yes-or-no diagnosis, and the decision to pursue frenotomy should be made carefully, considering all available evidence and clinical expertise. As lactation consultants, we must:

• Stay up-to-date on the latest research.
• Advocate for improved access to skilled lactation support.
• Provide balanced, evidence-based guidance to families.

By doing so, we ensure that parents receive the right support—whether that means a referral for a frenotomy or simply the reassurance that their baby’s feeding challenges can be managed with skilled lactation care.

References

Booth, L., Aldaihani, A., Davidson, J., Wilson, C., Lawlor, C., Hong, P., & Graham, M. E. (2025). Misinformation and readability of social media content on pediatric ankyloglossia and other oral ties. JAMA Otolaryngology–Head & Neck Surgery, 151(2), 143-150.

Carter, E., Armstrong, L., Kindred-Spalding, E., et al. (2023). Is access to NHS tongue-tie services equitable for mothers and babies in the UK? British Journal of Midwifery, 31(10), 670–675.

Knight, M., Ramakrishnan, R., Ratushnyak, S., et al. (2023). Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: The FROSTTIE RCT. Health Technology Assessment, 27(1), 1–73.

National Institute for Health and Care Excellence (NICE). (2005). Division of ankyloglossia (tongue-tie) for breastfeeding. Retrieved from https://www.nice.org.uk/guidance/ipg149

O’Shea, J. E., Poster, J. P., O’Donnell, C. P., et al. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews, 2017(3), CD011065. https://doi.org/10.1002/14651858.CD011065.pub2

Unicef UK. (2024). Tongue-tie in babies. Retrieved from https://www.unicef.org.uk

BBC News. (2019, July 12). Babies ‘don’t need tongue-tie surgery to feed’. Retrieved from https://www.bbc.co.uk/news/health-48934994#:~:text=Babies%20with%20tongue%2Dties%20rarely