Is there evidence to support tongue tie releases?

Tongue-Tie Release: Evidence and Recommendations

Direct Answer

Tongue-tie (ankyloglossia) release is supported by evidence for improving breastfeeding outcomes in infants with documented feeding difficulties, but the evidence quality is limited and the procedure should be reserved for cases with objective breastfeeding impairment after proper assessment.

Clinical Context and Evidence Quality

The evidence base for tongue-tie release consists primarily of observational studies and a small number of randomized controlled trials, with only 316 infants enrolled across five RCTs 1. A systematic review concluded there is a limited number of studies with quality evidence supporting the procedure 2. Despite these limitations, the available data does show both objective and subjective improvements in specific breastfeeding parameters 2.

Objective Evidence Supporting Tongue-Tie Release

When performed in appropriately selected infants, frenotomy provides measurable improvements in:

• LATCH scores (breastfeeding assessment tool) improved in 3 studies 2
• SF-MPQ index (Short Form McGill Pain Questionnaire) improved in 2 studies 2
• IBFAT scores (Infant Breastfeeding Assessment Tool) improved in 1 study 2
• Milk production and feeding characteristics improved in 3 studies 2
• Infant weight gain improved in 1 study 2
• Maternal pain scores improved in 4 studies 2
• Maternal perception of breastfeeding improved in 14 studies 2

Patient Selection Criteria

Not all infants with tongue-tie require intervention—approximately 50% of breastfeeding babies with ankyloglossia will not encounter any problems 1. This makes proper assessment critical:

• Use the Hazelbaker Assessment Tool for lingual frenulum function, which is the most comprehensive clinical assessment available 1
• Document objective breastfeeding difficulties (poor latch, inadequate milk transfer, poor weight gain) rather than relying solely on the anatomical presence of a tongue-tie 2, 1
• Children with severe Hazelbaker scores or documented difficult breastfeeding are most likely to benefit 3
• Consider a 2-3 week observation period before intervention, as this is reasonable timing to distinguish persistent problems from normal early breastfeeding adjustment 1

Timing and Procedure Considerations

The sharpest increase in frenotomy procedures has occurred in neonates, with rates increasing over 10-fold from 1997 to 2012 in the United States 4. However, rushing to early intervention may be inappropriate given that many cases resolve spontaneously 1.

The procedure should be performed by trained professionals (otolaryngologists, trained pediatricians, or experienced lactation consultants with appropriate credentials) to minimize complications 1.

Safety Profile and Complications

While frenotomy is generally well-tolerated, complications do occur and may be more severe than commonly appreciated:

• Major complications reported include poor feeding (n=7), hypovolemic shock (n=4), apnea (n=4), acute airway obstruction (n=4), Ludwig angina (n=2), and sublingual mucocele 4
• A systematic review identified 47 major complications in 34 patients across the literature 4
• Recurrent tongue-ties requiring repeat procedures were the most common significant adverse event in RCTs 2
• Risks to neonates may differ from risks to older children and adults, requiring age-specific monitoring 4

The critical caveat is that reporting of complications after frenotomy is lacking, and practitioners across specialties should monitor outcomes more rigorously 4.

Speech Outcomes

There are no significant data to suggest a causative association between ankyloglossia and speech articulation problems, and no definitive improvements in speech function were reported following tongue-tie division 2. This indication should not drive decision-making for the procedure.

Clinical Algorithm for Decision-Making

1. Identify objective breastfeeding problems: Poor latch, inadequate milk transfer, failure to thrive, severe maternal nipple pain
2. Perform Hazelbaker Assessment: Document severity of anatomical restriction and functional limitation 1
3. Optimize breastfeeding technique: Ensure proper positioning, latch assistance, and lactation support
4. Observe for 2-3 weeks: Allow time for natural improvement and skill development 1
5. If persistent objective problems with severe Hazelbaker score: Proceed with frenotomy by trained professional 3, 1
6. Post-procedure monitoring: Assess for immediate complications and document feeding improvement 4

Key Pitfalls to Avoid

• Do not perform frenotomy based solely on anatomical appearance without documented functional impairment 1
• Do not rush to intervention in the first 1-2 weeks when normal breastfeeding establishment is still occurring 1
• Do not dismiss the placebo effect—subjective maternal satisfaction may improve regardless of objective benefit, making proper assessment essential 1
• Do not perform the procedure without proper training—complications including life-threatening events have been reported when performed by inadequately trained providers 4
• Do not use speech concerns as primary indication—evidence does not support this 2