Tongue-Tie: Exploring the Controversies

and Setting the Record Straight

Tongue-tie (ankyloglossia) has become one of the most divisive topics in parenting and healthcare. Scroll through any parenting forum or social media feed, and you’ll see it blamed for everything from breastfeeding struggles to colic, reflux, speech delays, sleep issues, and the results of the latest US elections. Some hail tongue-tie release as a lifesaver and a solution for all that ails the baby, while others call it a fad fuelled by fear and misinformation, with the truth - as always - lying somewhere in between.

Parents often find themselves caught in the crossfire, bombarded by well-meaning advice, dramatic anecdotes, and even pressure from professionals with questionable motives. Is tongue-tie really the invisible villain ruining countless parenting journeys, or have we placed too much blame on this tiny piece of tissue? It’s time to peel back the layers, challenge the myths, and get to the truth about tongue-tie. Let’s explore whether this so-called epidemic is rooted in science or hysteria.

What Is Tongue-Tie?

Tongue-tie is a condition where the lingual frenulum, the small band of tissue connecting the underside of the tongue to the floor of the mouth, restricts tongue movement. Anatomically, it’s defined as a congenital condition where the frenulum attaches to the underside of the tongue and may be short, tight, or thick. Functionally, it may impede the tongue’s ability to move freely, potentially causing challenges in certain situations like breastfeeding.

Tongue-tie is present in about 5 to 10% of newborns, with boys being affected more frequently than girls. However, only a small percentage of those infants experience issues related to their tongue tie. The increase in diagnoses and treatments, particularly in countries like the US, Canada, Australia, and here in Ireland has been driven more by heightened awareness (and the desire to make a quick euro) than by an actual rise in prevalence. Interestingly, countries like Japan and parts of Europe like Scandinavian countries which have high breastfeeding rates, have not reported similar trends.

So, what’s fuelling this rise? It largely stems from the insufficient support breastfeeding mothers receive during those critical first days after delivery. A lack of healthcare worker education in lactation medicine, the low number of midwives in maternity hospitals, and the scarcity of International Board-Certified Lactation Consultants create a perfect storm, allowing some predatory services to thrive. Social media also plays a significant role, creating awareness but also spreading misinformation. The condition is often associated with a range of unrelated symptoms, leading to unnecessary interventions. For example, while tongue-tie is often cited as a cause of poor breastfeeding and maternal nipple pain, studies show that not all breastfeeding challenges are linked to it, and its impact on other conditions, like reflux or speech issues, is unfounded.

Recent discussions have suggested a link between maternal folic acid supplementation and an increased incidence of tongue-tie in infants. However, current scientific evidence does not support this association. A recent systematic review found insufficient evidence to establish a relationship between folic acid intake during pregnancy and the occurrence of ankyloglossia (tongue-tie) in infants. The review emphasized that the benefits of folic acid supplementation, particularly in preventing neural tube defects, far outweigh any unproven risks. Therefore, it is crucial for expectant mothers to adhere to recommended folic acid guidelines to ensure optimal fetal development.

The Misinformation Machine

Social media is a double-edged sword in the world of tongue-tie. On one hand, it has increased awareness among parents. On the other, it has spread significant misinformation. According to a 2024 JAMA Otolaryngology study, 88% of Instagram posts about tongue-tie contain inaccuracies. Only 11% of posts were found to have no misinformation (yikes!).

Here’s the troubling part: most of these posts come from accounts run by non-physician healthcare practitioners, such as lactation consultants, chiropractors, and holistic therapists. Nearly 89% of the analysed social media posts about tongue-tie contained misinformation, with 83% of these posts having more than half of their content deemed inaccurate. Posts from International Board Certified Lactation Consultants (IBCLCs) were slightly less likely to include misinformation compared to non-IBCLCs (67% versus 90%). However, there was no noticeable difference in misinformation levels between posts from healthcare practitioners versus non-healthcare practitioners or between business and personal accounts.

The most common areas of misinformation were related to symptoms (54%), lip ties (37%), long-term complications (25%), and management (24%). Less frequently, inaccuracies were found in topics like buccal ties (16%), diagnosis (9%), and anatomy (7%). Interestingly, posts with more words tended to have less misinformation, suggesting that longer, more detailed content may be better vetted or more evidence based.

Many of these individuals have a financial interest in promoting frenotomy, offering paid courses or boutique surgical services. This creates a conflict of interest that drives fear-based decision-making among parents.

The JAMA study also highlighted readability issues. The majority of posts were written at a ninth-grade reading level, exceeding the recommended sixth-grade level for public health materials. This makes it harder for parents to access and understand accurate information, leaving them vulnerable to misleading claims.

How Does Tongue-Tie Affect Breastfeeding?

So in a world of misinformation and disinformation, having accurate and evidence based information on this divisive topic is of vital importance so lets explore what a tongue tie is and how it can affect your baby’s breastfeeding.

The movement of the tongue is the most critical factor in effective, pain free milk removal during breastfeeding. For an infant to feed effectively, the tongue must:

• Be down in the mouth to allow milk flow to the back of the mouth.

• Create a peak negative intra-oral pressure (vacuum) for maximum milk flow and proper breathing.

• Rise to shut off milk flow when swallowing occurs.

When tongue-tie is severe, it may hinder this movement, leading to:

• A shallow latch and a loss of seal, with symptoms like clicking, clamping, or chewing.

• Maternal nipple pain, which can result in blocked ducts, mastitis, or inadequate milk supply.

• Poor milk transfer, causing weight gain issues in the infant despite frequent feeding.

According to data, 10 to 20% of infants with tongue-tie experience breastfeeding problems compared to 3% of infants without it. Frenotomy, a procedure to release the frenulum, has been shown to reduce maternal nipple pain in the short term. However, evidence for long-term improvement in breastfeeding is inconsistent. Researchers emphasize that the methodological shortcomings of existing studies limit the certainty of these findings.

Before considering frenotomy, a thorough assessment of both the infant and the mother is essential. Lactation consultants and medical professionals should examine:

• Infants: Oral anatomy, tongue position, lateralization, protrusion, and suck reflex. Specific assessments such as passive and active tongue lift and digital suck evaluations (performed with the infant upright) provide critical insights into tongue function. Proper examination also includes an evaluation of the sublingual appearance and palpation of the frenulum.

• Mothers: General health, nipple condition, breast tissue, and any signs of blocked ducts, mastitis, or other complications. Emotional well-being and social support systems should also be assessed, as stress and anxiety can exacerbate breastfeeding challenges.

Timing is another key factor. Evidence suggests that frenotomy is most effective when performed within the first seven days of life for confirmed cases of tongue-tie causing breastfeeding issues. Studies report that most mothers whose infants underwent the procedure during this period found it helpful, with many continuing to breastfeed successfully post-frenotomy. However, these benefits are contingent on accurate diagnosis and appropriate timing—underscoring the need for skilled, evidence-based assessments before surgery.

It is equally important to emphasize that frenotomy should only be performed when all non-invasive interventions, such as latch optimization, breastfeeding positions, and milk supply management, have been explored. In many cases, these measures resolve the issues without the need for surgical intervention. This approach aligns with findings showing that movement of the tongue, along with evidence of inadequate milk transfer rather than anatomical appearance alone—is the most critical factor in effective milk removal.

Frenotomy: What to Expect and Potential Side Effects

So what exactly is a frenotomy? A frenotomy, a procedure to release a tight tongue-tie (frenulum), may be recommended if your baby is struggling with breastfeeding or showing signs of feeding difficulties. Although the idea of a small cut near your baby’s tongue can sound unsettling, the procedure is common and generally considered safe.

Your baby is usually gently swaddled to keep them comfortably still. Sometimes, a mild sweet solution is given to help soothe your baby during the procedure. In many cases, no local anaesthesia is used because the frenulum itself has very few nerve endings, and the procedure is very quick. Some parents, however, opt for a small amount of numbing gel to provide extra comfort.

The healthcare provider will use sterile scissors, a scalpel, or increasingly, a soft-tissue laser to release the tight frenulum under the tongue. The actual cut is tiny and lasts only a few seconds. Laser techniques can reduce the small amount of bleeding that may occur and often shorten recovery time.

After the Procedure

Most babies can breastfeed immediately afterward. Offering the breast not only soothes your baby but also helps confirm if feeding improves. Minor bleeding, if any, usually stops quickly on its own. Your baby’s healthcare team may suggest gentle tongue exercises or stretches to keep the tissue from reattaching as it heals, though experts debate whether these exercises are always necessary.

Following Up and Watching for Side Effects

In most cases, babies recover well and show no lasting issues. However, as with any procedure, there can be potential side effects or complications, including:

• Mild Discomfort or Fussiness: Your baby may be slightly irritable for a short period after the procedure.

• Tenderness or Swelling: The area under the tongue may feel tender or swollen for a day or two.

• Reattachment of the Frenulum: In some cases, the tissue can partially or fully reattach, potentially requiring another procedure.

• Infection (Rare): Although very uncommon, there is a slight risk of infection. Keeping the area clean and following your provider’s instructions will help reduce this risk.

• Continued Feeding Difficulties: While many babies experience immediate improvement in feeding, some may still need extra support from a lactation consultant to adjust their latch and ensure effective nursing.

To help your baby feed comfortably in the long run, consider scheduling follow-up visits with a lactation consultant. They can guide you through proper breastfeeding techniques, answer any questions about healing, and help ensure that your baby’s feeding improves after the frenotomy.

What Tongue-Tie Doesn’t Cause

Despite its association with breastfeeding challenges, tongue-tie is falsely blamed for a variety of other issues, including:

• Bottle-feeding difficulties: Studies have shown no impact of tongue-tie on bottle-feeding, likely because bottle-feeding mechanics differ significantly from breastfeeding.

• Speech issues: Most children with tongue-tie develop normal speech without intervention. Frenotomy is not a guaranteed solution for speech delays or articulation problems.

• Colic and reflux: Claims that tongue-tie causes these conditions are unsubstantiated. Feeding mechanics related to tongue-tie are unlikely to result in gastrointestinal symptoms.

• Tension and other body issues: Links between tongue-tie and conditions like body tension, torticollis, or sleep apnoea lack scientific support (I mean that’s totally bonkers …).

Setting the Record Straight

When it comes to tongue-tie, parents deserve clear, evidence-based guidance—without fearmongering or hidden agendas. Here’s what you need to know:

1. Feeding Challenges Are Complex: Breastfeeding difficulties seldom stem from a single cause. Latch issues, positioning, and milk supply often play a role. Not every setback is linked to tongue-tie.

2. Surgery Isn’t the First Step: Frenotomy should only follow a thorough, expert evaluation and the careful trial of less invasive measures. If it’s not truly needed, it shouldn’t be done.

3. Beware of Hype and Profit Motives: Turn to trusted healthcare providers who ground their recommendations in solid research—not in financial incentives or unfounded claims.

4. Timing Matters—But Only When Warranted: Early intervention can help if tongue-tie is the confirmed source of feeding problems. Otherwise, hasty treatment may cause more harm than good.

Tongue-tie is real and can affect some babies, but it’s not the all-purpose scapegoat it’s often made out to be. By cutting through the myths and relying on proven science, parents can confidently choose what’s best for their child’s health and well-being.