Early Human Development 90 (2014) 765–768

Contents lists available at ScienceDirect

Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Tongue tie: The evidence for frenotomy

Alastair Brookes 1, Douglas M. Bowley ⁎
Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom

a r t i c l e i n f o a b s t r a c t

Keywords: Tongue tie or ankyloglossia is a congenital variation characterised by a short lingual frenulum which may result in
Tongue tie restriction of tongue movement and thus impact on function.
Ankyloglossia Tongue tie division (frenotomy) in affected infants with breastfeeding problems yields objective improvements
Division in milk production and breastfeeding characteristics, including objective scoring measures, weight gain and re-
Frenotomy ductions in maternal pain. For the majority of mothers, frenotomy appears to enhance maintenance of
Frenulotomy
breastfeeding.
Breastfeeding
Tongue tie division is a safe procedure with minimal complications. The commonest complication is minor bleed-
ing. Recurrence leading to redivision occurs with rates of 0.003–13% reported; this appears to be more common
with posterior than anterior ties.
There are limited reports indicating that prophylactic frenotomy may promote subsequent speech development;
however, evidence is currently insufficient to condone this practice and further good quality research into this
area is warranted.
© 2014 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
2. Effect on breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
3. Effect on speech development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
4. Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768

1. Introduction
Tongue tie [TT] or ankyloglossia is a congenital condition
characterised by a short lingual frenulum which may result in restric-
tion of tongue movement and thus impact on function. The incidence
of TT is reported to be 4 to 16% of neonates with a 2–3:1 male prepon-
derance [1–5]. Segal et al. [6] hypothesised that the lack of standardised
diagnostic criteria accounts for some of the variability in the reported
incidences; in addition, a genetic link has been postulated for tongue
tie, so variations in the incidence may also relate to the intrinsic differ-
ences in the study populations [7].
TT has been divided since the times of the ancients; however to-
wards the end of the 20th century, the prevailing opinion amongst pae-
diatricians was that tongue ties did not cause problems and should be
left alone. With enhanced recognition of the potential health benefits
of breastfeeding for both infant and mother and with appreciation of
the financial implications of bottle feeding, there has been a global
drive towards the promotion of breastfeeding. The division of TT is
now considered, by some, to form part of the measures to support
new breast-feeding mothers [8–10].
We aim to review the evidence for TT division and establish its role
in current clinical practice.

2. Effect on breastfeeding
⁎ Corresponding author. Tel.: +44 424 1427.
E-mail addresses: alastair.brookes@doctors.net.uk (A. Brookes),
doug.bowley@heartofengland.nhs.uk, dougbowley@nhs.net (D.M. Bowley). Infants with TT may experience breastfeeding problems affecting
1
Tel.: +44 424 1427. both mother and infant. Typically reported problems include poor

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766 A. Brookes, D.M. Bowley / Early Human Development 90 (2014) 765–768
latch (including signs of frustration such as head-banging), maternal
nipple pain (including bleeding, cracked or ulcerated nipples, mastitis
and distorted “lipstick” nipples) and signs of an unsatisfied baby i.e. fre-
quent or continuous feeds often with “fussing”. Not all breastfed infants
with TT will have breast-feeding difficulties. Messner et al. reported an
incidence of 25% and Ngerncham et al. reported incidences of 11.8%
and 37.9% in moderate and severe tongue ties respectively [2,3]. It is im-
portant to note that Ngerncham et al. clearly illustrated the multifacto-
rial nature of breastfeeding problems identifying maternal nipple
length/inversion and sensation of the infant's tongue on the nipple as
independent risk factors for problems [3]. O'Callahan et al. demonstrat-
ed that breastfeeding difficulties can occur irrespective of whether the
tongue tie is anterior or posterior, although they did note a preponder-
ance in posterior tongue ties amongst the patient group referred [13].
Objective assessment tools to gauge the degree of tongue tie and to
evaluate breastfeeding difficulties have been developed., such as: the
Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF),
the Latch, Audible swallowing, nipple Type, Comfort Hold (LATCH) and
Infant Breastfeeding Assessment Tool (IBFAT) scores [11,12]. In addition,
there have been five RCTs to evaluate the effects of tongue division in in-
fants with breastfeeding difficulties although none without design issues
[5,14–17]. Of these, four have utilised objective assessments [14–17].
The first of these trials randomised 57 babies with TT and feeding
difficulties, both breast and bottle, to either 48 hour feeding support
or frenotomy and feeding support. The subjective maternal assessment
of improvement in feeding was the sole outcome measure. 96% of the
intervention group reported improved feeding as opposed to 3% of the
control group however there was no blinding with regard to the inter-
vention and the control group was offered frenotomy after assessment,
potentially indicating a lack of equipoise [5].
Dollberg et al. randomised 25 infants, after an assessment feed to
either of 2 sequences: 1) TT division followed immediately by breast-
feeding; then sham procedure followed immediately by breastfeeding
or 2) sham procedure followed immediately by breastfeeding; then
tongue tie division followed immediately by breastfeeding. The two se-
quences were arranged to blind the assessors and participants to the
timing of frenotomy. Their main outcome measures were maternal
pain, assessed on a visual analogue scale, and LATCH score on feeding im-
mediately post-division. They reported an improvement in LATCH scores
post-frenotomy from 6.4 to 6.8 although this failed to reach statistical sig-
nificance (p = 0.06) however there was a significant decrease in pain
scores from 7.1 to 5.3 post-division [16].
Buryk et al. reported 58 infants randomised to either frenotomy or a
sham procedure with the parents blinded to the intervention. They
demonstrated significant improvements immediately post-procedure
in IBFAT scores (+ 2.3 versus − 0.41) and maternal pain assessed on
SFMPQ (Short Form McGill Pain Questionnaire) scores (− 11.8 versus
− 5.75). All bar one of the babies in the control group underwent
frenotomy within 2 weeks of the sham procedure [15].
Berry et al. used a reported a double blinded trial of frenotomy versus
non-division in 60 infants [14]. The outcomes were changes in observer
breastfeeding scores, on a score adapted from the LATCH and IBFAT
scores, maternal pain, assessed on a numeric scale and maternal subjec-
tive assessments of changes in breastfeeding. 78% of mothers in the treat-
ment group reported an immediate improvement in feeding however
47% of the control group also reported an improvement, the 31% differ-
ence between these groups was statistically significant. The observer
scores improved in 50% of the treatment group and 40% of controls and
there was no significant difference between the two groups in terms of
nipple pain (− 2.5 versus −1.3, p = 0.13). The authors hypothesised
that the discrepancy between their findings and those of Dollberg et al.
in terms of maternal pain on feeding immediately post-procedure may
be because their study population was about three weeks old compared
with 2–3 days. They proposed that as a result of the additional time be-
fore intervention the mothers' nipples would have established soreness
and the soreness usually takes 2–3 days to heal once a baby is
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breastfeeding correctly. The immediate improvements reported in the
control groups of this and the previous study possibly demonstrate the
placebo effect associated with this surgical procedure.
Emond et al. randomised 107 tongue tied infants with breastfeeding
difficulties to either intensive breastfeeding support or frenotomy and
intensive breastfeeding support with changes in LATCH score at 5 days
as the primary outcome measure. However, it is of note that they ex-
cluded infants deemed to have a severe tongue tie potentially diluting
the difference between the groups. There was a further follow-up at
8 weeks. The control group were offered frenotomy at the 5 day fol-
low-up. There was no difference in the change in the LATCH score
with both groups improving by 1. There were changes in the secondary
outcome measures with a mean improvement in HATLFF of 4.5 in the
frenotomy group versus no change in the controls, a non-significant im-
provement in maternal pain scores (−2 versus −1) but no change in
IBFAT score in either group at 5 days. There was a significant improve-
ment in Breastfeeding Self-Efficacy score-short form (BSES-SF) scores
at 5 days (9 versus 1). 85% of the control group opted for frenotomy
after 5 days and in this group there was an improvement in BSES-EF
score of 10 between the 5 day and 8 week follow-up.
In addition to the above RCTs, there have been numerous studies
evaluating objective outcome measures in TT division for breastfeeding
problems. Geddes et al. and Srinivasan et al. both demonstrated signifi-
cant improvements of 1.5 and 2.5 respectively in average in LATCH
scores post-frenotomy [10,18].
Geddes et al. undertook sub-mental ultrasounds of 24 breastfeeding
infants pre- and 1 week post-frenotomy to assess changes in breast-
feeding dynamics [10]. They identified two distinct sucking patterns
pre-frenotomy: the first group placed the nipple close to the junction
between the hard and soft palates pinching the base of the nipple and
the second group placed the nipple further away thus pinching the tip
to a pencil point. In both these groups, frenotomy appeared to lead to
resolution or lessening of these anomalies. They also demonstrated sig-
nificant increases post-frenotomy in mean infant milk intake (50.5 ml
vs 69.1 ml), in mean milk transfer rate (5.6 ml/min vs 10.5 ml/min)
and in mean maternal 24 milk production (455 ml vs 615 ml). These
data are supported further by a USS based study in a single
breastfeeding dyad which reported improvements in breastfeeding dy-
namics including an increase in 24 hour breastfeed volume from 190 ml
pre-frenotomy to 810 ml post-procedure [10].
Consistent with the changes in breastfeeding dynamics reported
by Geddes et al., studies have shown improved breastfeeding effi-
ciency post-frenotomy with significant decreases in length of feeds,
number of feeds per day and increases in the interval between
feeds [19,20].
In line with these data indicating improved breastfeeding efficiency,
Miranda et al. demonstrated that: two weeks post-TT division, 90% of
the babies gained weight centiles (mean 41st ± 3 to 56th ± 2) and
Amir et al. found at 3 month follow-up that 17% of babies undergoing
frenotomy had improved weight gain post-procedure although less
than 10% reported weight gain as an issue prior to TT division [20,21].
Four further studies have objectively examined maternal nipple pain
post-frenotomy. Srinivasan et al. assessed maternal pain pre- and post-
intervention with the SF-MPS score [18]. They demonstrated that pain
scores decreased significantly post-procedure with decreases of −11.4
in the pain rating index (PRI) and − 1.5 in the present pain intensity
components. They also reported that 92% of mothers were pain free at
3 month follow-up. Ballard et al. reported immediate improvements
in maternal nipple pain post-frenotomy with decreases of 6.9 to 1.2 in
mean pain scores on a numeric scale [1–10,22]. Geddes et al. and Argiris
et al. also reported significant decreases in mean pain scores on a nu-
meric scale [1–10] of 3.6 to 0.5 at follow-up ≤ 7 days post-procedure
and 6.63 to 1.42 at 6 week follow-up [10,23].
A number of studies have looked at subjective outcome measures
post-TT division. These may be divided into those reporting immediate,
short to medium and long term outcomes. 3 papers reported immediate
 A. Brookes, D.M. Bowley / Early Human Development 90 (2014) 765–768
improvements in breastfeeding with rates of 40% (4/10), 57% (123/215)
and 70% (32/46) [23–25].
7 studies detailed short to medium term outcomes. Griffiths report-
ed that 80% (173/215) of mothers felt that breastfeeding was improved
at 24 h [25]. Masaitis and Kaempf followed up 36 infants at 1 week post-
frenotomy and found complete resolution of the presenting problems in
75% and partial resolution in 19% [26]. Wallace and Clarke reported that
beyond the 40% reporting an immediate improvement in breastfeeding
a further 30% reported an improvement by 2 weeks post-procedure [24]
and Sethi et al. also reported improvements at 2 weeks in 77% (40/52)
[27]. Dollberg et al. reported improvements in breastfeeding in 75%
(180/244) at two weeks with 54% (132/244) of mothers feeling that
the improvement was significant. They also reported that 50% of nipple
injures had healed within four days of the procedure [28]. Miranda and
Milroy also followed up 51 infants at 2 weeks with 100% of mothers
reporting improved pain, nipple cracking and bleeding, 89% improved
latch and 63% improved breastfeeding [20]. A further study reported
6 week follow-up in 46 cases with major improvements in
breastfeeding in 40 (87%), improved latch in 36 (78%) and improved
suck in 30 (64%) [23].
In terms of longer term follow-up, Masaitis and Kaempf and
Srinivasan et al. both reported 3 month follow-up with the former find-
ing that 100% (36/36) of mothers felt that the presenting problem had
resolved and that they would have the procedure done again. In the lat-
ter study 92% (23/25) of mothers reported no nipple pain and 88% (22/
25) felt that the procedure had been beneficial [18,26]. Amir et al. re-
ported 6 month follow-up in 35 patients and found that 83% felt that
there had been an improvement following the frenotomy [21].
There are no studies comparing rates of continued breastfeeding in
infants undergoing frenotomy with untreated controls however several
studies report rates at various timepoints. These rates may be compared
with the national rates of 47.2% and 36.5% breastfeeding at 6 to 8 weeks
in England and Scotland [29,30]. Argiris et al., Srinivasan et al. and
Hogan et al. reported 89% breastfeeding at 6 week follow-up, 77.8% at
3 months and 60% at 4 months respectively [5,18,23]. Berry et al. de-
scribed rates of 65% at 3 months and 51% at 4.5 months [14] and
Dollberg et al. reported continued breastfeeding in 89% at 2 weeks,
68% at 3 months and 56% at 6 months [31]. When comparing these
rates with the national rates it is important to consider that the studies
are likely to select for motivated individuals however the sizeable differ-
ence between the rates strongly suggests a positive influence with
frenotomy.
In summary, although there is a degree of heterogeneity in the liter-
ature and reported data, frenotomy in infants with tongue tie and
breastfeeding difficulties yields objective improvements in LATCH and
IBFAT scores, milk production and breastfeeding characteristics, weight
gain for the infant and reduction in maternal pain. Furthermore there
are indications that frenotomy may positively promote maintenance
of breastfeeding. In the various trials, a proportion of mothers have
demonstrated the placebo effect in subjective outcomes after sham TT
division in babies with breastfeeding difficulties; however, there are
clear improvements in maternal perception of feeding and pain scores
over and above these effects for surgical frenotomy.
3. Effect on speech development
There are some data indicating an improvement with speech articu-
lation with division of TT in affected individuals and therefore there has
been some debate as to whether neonatal frenuloplasty may positively
influence subsequent speech and language development although it is
known that speech development is often normal in the presence of a
TT [32,33].
There is a paucity of data relating to the effect of neonatal TT division
on subsequent speech development and those studies that have been
published are based on small numbers.
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767
Messner and Lalakea studied 21 children between the ages of 1 and
12 years undergoing frenotomy for tongue ties. 15 of 21 had speech and
language difficulties preoperatively. 15 patients were available for post-
operative review of whom 9 demonstrated improvement on speech and
language assessment, 2 had ongoing problems and 4, who had normal
preoperative assessments, were unchanged. Overall average parental
perception of speech intelligibility improved from 3.4 to 4.2 out of 5
[34].
Dollberg et al. studied 25 children aged 4–8 years of whom 8 had un-
dergone neonatal frenotomy, 7 had untreated TT and a further 8 were
unaffected controls. The children were independently assessed by 2
blinded speech pathologists using a standardised articulation test with
respect to word production accuracy and word-, sentence-, and flu-
ent-speech intelligibility. They found that the untreated children had
more than twice as many misarticulation errors as those who had un-
dergone frenotomy and both groups with TT had a higher rate of
misarticulation errors than the controls. Inspite of these errors however,
there were no significant differences in word-, sentence- and fluent-
speech intelligibility between the groups [28].
A more recent study by Walls et al. [35] compared 71 children who
had undergone frenotomy with 15 untreated children and 18 unaffect-
ed controls. They found statistically significant differences in speech de-
velopment between those who had undergone frenotomy and the
untreated children and no difference in development between patients
with frenotomy and the controls. A drawback to the study is that al-
though it utilised a questionnaire prepared by a speech pathologist it
was dependent upon the parental assessments of the children's speech.
Although there are some possible positive indications, at present,
there is no substantial evidence to support prophylactic frenotomy on
the basis of promoting subsequent speech development and further
good quality research into this area is warranted before any meaningful
conclusions can be drawn.
4. Safety
For any procedure to be acceptable in clinical practice not only must
it be justifiable in terms of indications and efficacy but it must also have
a complication rate commensurate with the morbidity of the condition
being treated i.e. for a low morbidity condition such as tongue tie a very
low complication rate is obligatory.
The most commonly identified complication is bleeding. Argiris et al.
reported unquantified blood loss in 24 of 26 (52%) [23] and Berry et al.
reported a small amount of bleeding at home in 3 of 60 (5%) [14].
Griffiths. reported a “few drops of blood” in 113 of 215 patients (52%)
and “small quantity of bleeding” in 18 of 215 (9%). Griffiths also report-
ed the presence of an ulcer, after 48 h, at the site of the division in 4 pa-
tients (1%) and soreness lasting more than 24 h in 1 patient (0.5%) [25].
Yeh reported self-limiting bleeding occurring in the majority of 2800
cases but no other complications [36]. A further 11 studies with a total
of 930 procedures specifically reported no complications [5,10,15,17,
20–22,24,27,37,38]. It is important to note that, although exceptionally
rare, severe bleeding with injury to the sublingual vessels or massive
submandibular oedema can occur and therefore it is suggested that
the procedure should be performed by adequately trained personnel
within a clinical setting where escalation of treatment can occur if re-
quired [12,39,40].
In terms of pain or distress for the infant, there are no reported issues
with pain during or following the procedure and it is of note that
Masaitis and Kaempf reported 8% and Griffiths reported 18% of babies
sleeping through the procedure [25,26]. It is worth noting that in one
study it was found that the administration of topical benzocaine was as-
sociated with an increased crying time [41]. In our own practice, we rou-
tinely administer 24% sucrose to the infant immediately prior to the
procedure.
Recurrent TT can occur with scarring at the site of the division.
Klockars and Pitkaranta, Argiris et al. and Steehler et al. reported
768 A. Brookes, D.M. Bowley / Early Human Development 90 (2014) 765–768
redivisions in 4 of 32 (13%), 3 of 46 (6.5%) and 8 of 302 (2.6%) of patients
respectively [23,37,42]. Hong et al. showed that recurrence requiring re-
division was more common in posterior than anterior TT [43]. Some-
what discordant with these figures was the rate of 0.001% (3 of 2800)
reported by Yeh [36].
During the NICE assessment of the procedure, the possibility of se-
vere complications due to injury to the tongue or division of the sub-
mandibular salivary ducts was articulated. However, to date, there are
no reports of either of these complications in the literature and thus
they may be presumed to be largely theoretical.
5. Conclusion
Whilst at present there are no good quality data to support prophy-
lactic TT division on the grounds of potential issues with speech devel-
opment, there is evidence that in problematic breastfeeding dyads, a
TT may be a significant contributory factor and division is frequently
beneficial. There are some radiological data demonstrating mechanistic
changes in feeding technique post-frenotomy supporting the hypothe-
sis that intervention has a direct effect. Given the very low morbidity
of the procedure frenotomy should therefore be considered where a
TT can be demonstrated in the presence of breastfeeding difficulties.
Given the multifactorial nature of breastfeeding issues this should be
performed within the context of a more holistic approach with
breastfeeding support.
Conflicts of interest
None declared.
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