Fort Worth, TX,
14:10 PM

Does My Baby Need His Tongue-Tie Cut? 5 Health Experts Answer Top Questions

Just because you see a thin band of tissue underneath your child’s tongue doesn’t mean it necessarily needs to be cut. But let’s explore when to worry.

By Diane Arnaout, M.D.

I remember scrolling through a Facebook group for physicians a few years ago, and a popular post rolled onto my screen, written by a confused pediatrician.

“What the heck is up with all these moms wanting their baby’s tongues cut?”  It was followed by hundreds of comments of confusion and agreement from other physicians.

I chuckled a little because the tremendous pressure on parents to have their baby’s tongue evaluated is something I literally talk about every day now -- and I hardly talked about it at all when I started my career.

One study showed that from 1997 to 2012 the incidence of tongue-tie diagnosis went from 3,900 to 32,000 – a nearly 10-fold increase -- in a matter of 15 years! This might be because more moms are choosing to breastfeed compared to a few decades ago.

So what’s up with tongue ties? And when should you think about getting your baby’s tongue tie cut (frenotomy)?

Tongue ties are a hard thing to write about, as it is a topic that can be pretty controversial. Depending on whom you talk to, the advice you get will change. That’s because we’re still lacking large, sweeping studies that prove one way or another that the procedure helps more than harms. Also, a gentle reminder that some folks who perform the procedure make very significant income because of it – thus creating biased advice in some ways, I think.

Clipping a tongue tie comes with risks: infection, tongue ulceration, bleeding, tongue damage, and salivary duct damage are all possible.

What is a tongue-tie?

Tongue-tie, or Ankyloglossia, means the tongue has a tight band of tissue underneath it that restricts the tongue’s movement. The tongue typically can’t be stretched upwards very well, beyond the lower teeth or lips.

The existence of a “tongue-tie” and merely HAVING a tongue frenulum (a small fold of tissue that secures the tongue to the floor of the mouth) are not the same thing!

There are different types of tongue ties – some attach to the front of the tongue, some to the middle area, and some to the back.

All tongues have some portion of tissue tethering itself down to the floor of the mouth. Just because you see a thin band of tissue underneath your child’s tongue doesn’t mean it necessarily needs to be cut. But let’s explore when to worry.

When writing this, I decided to phone some trusted friends, because a well-rounded approach is vital. There’s a lot of information here, but I hope it gives you food for thought in making this important decision for your child.

A dentist: Drew Jamison, D.D.S., with Fort Worth Children’s Dentistry (“D”)

A Speech-Language Pathologist: Sara Adams with Cook Children’s (“SLP”)

A lactation consultant (and fellow pediatrician): Andrea Wadley, M.D., with 127 Pediatrics (“LC”)

An Ear-Nose-and-Throat (ENT) physician: Kristen Honsinger, M.D., with Cook Children’s (“ENT”)

What trends are you seeing when it comes to tongue ties?

D: There is certainly an increase in inquiries about tongue-tie in our office. I would estimate at least double the number of inquiries in the past eight to 10 years. Most of these come from new mothers looking for a solution to difficulties nursing. A majority are feeling stressed and feel like they have reached a dead end. Most have also already worked with a lactation specialist and treating the tongue-tie is a "last-ditch effort". We don’t offer this procedure in our office. I have always worked to practice evidence-based dentistry. I'm waiting for more data. I want to make certain that the procedures we provide are in the best interest of our patients. We are certainly open to including these procedures in the future, just not quite yet.

SLP: In our speech therapy and feeding evaluations, parents have questions about if the tongue-tie needs to be clipped or not. They have often received different recommendations or opinions from their different healthcare providers about “to clip or not to clip.” Parents are concerned not only about a baby’s ability to breastfeed or bottle-feed, but they also have questions about if a tongue-tie will cause speech sound differences. For speech sound concerns, the evidence we have says that tongue-tie is not directly related to articulation (speech sound) disorders in most situations.

LC: The trend that I am seeing is that the diagnosis of “tongue-tie” is the explanation for a lot of breastfeeding problems in the community. Tongue, lip and now cheek ties are "en vogue" diagnoses to the point where some will refuse Vitamin K administration, but be upset that I decline to do an elective tongue-tie clipping on their child due to the bleeding risk.

ENT: In the ENT world, we’re seeing more people referred by lactation specialists, speech therapists and other non-physician providers. Previously, most of the referrals came from pediatricians. Another trend we are seeing is referrals for speech issues/concerns related to ties. To date, there have been no good quality research studies linking tongue-tie with any kind of speech delay, speech issues such as articulation problems, or feeding issues besides breastfeeding problems. There is good quality research suggesting that tongue-tie release in babies may improve maternal pain with nursing and may improve latch and therefore breastfeeding outcomes.

Are all tongue ties “bad”?

D: No. We have a large number of patients that could be diagnosed as "tongue-tied" that we simply monitor. Most of these patients thrive. If they ever have concerns that involve speech or other issues, we try and work with speech pathology to discuss diagnosis and treatment.

SLP: Not necessarily, some children have tongue ties and can drink, eat, and talk with no difficulties. This is why it is important to have the child evaluated by a medical professional that is familiar with tongue ties and can help look at those functions.

LC: Not all tongue ties are bad. As the baby grows, often the "tie" or frenulum will stretch and grow over time. Occasionally, ties will need to be corrected later in life, but often kids get by just fine without having them repaired. If the baby has a visible tongue-tie but is transferring milk well from the breast or sucking well from the bottle, I often leave these alone and follow up over time.

ENT: It’s normal to have a frenulum or “tie” under the tongue -- most babies (and adults!) do and it’s a normal part of the anatomy. An evaluation by a qualified specialist is necessary to determine whether or not the frenulum is restricting tongue movement or causing other difficulties, however.

When do you think it’s a good idea for parents to seek out frenotomy (tongue-tie clipping)? Are there any patterns you watch for or anatomical problems you notice in an exam?

D: I can certainly expand on philosophy here, but to remain concise, we typically tell parents: If you feel like you have exhausted all other options, including consultation with lactation consultants, then we promote the procedure. Scientific literature confirming effectiveness and results are scarce. However, we find that about half of our patients report an improvement in nursing.

SLP: If the tongue-tie is impacting the child’s ability to eat or drink – then it is time to consider frenotomy. I look at the overall function of eating or drinking to help determine if the family should talk to their doctor about that procedure. Sometimes, a tongue can look severely tied, but the child still has a great range of motion and no difficulties with eating or drinking. Sometimes a “mild” looking tongue-tie can present with really significant difficulties eating or drinking. You can’t always go by how it looks. For breastfeeding babies, if the mom is experiencing pain with feedings and has tissue damage to her breasts – then I collaborate with physicians about a frenotomy.

LC: I consider clipping tongue ties for babies whose tongues have a "heart shape" when they are extended. If they are unable to lift the tip of the tongue, it is very difficult to breastfeed. If the mom is having a lot of pain with breastfeeding and has lesions/blisters/bruising along the edge of the nipple that is in a "tube of lipstick" distribution this could be due to a tongue-tied baby or if the mom's nipple is shaped like this after every feeding and does not "round out" quickly. I also consider them for breast (or bottle) feeding babies who are taking in a lot of air with feedings, clicking with feeds, or who cannot sustain a latch long enough to transfer milk from the breast. I will also evaluate "posterior" (back of the tongue) or submucosal tongue ties if the baby is not transferring milk well and all of the other factors are accounted for.

ENT: In general, the sooner the better. One of the main goals we have is to help parents who choose to breastfeed to be able to do so- and making sure that we fix a tongue-tie when necessary can be an integral part of this. If there is something that we need to fix, it’s generally best to try to do it as soon as possible so that both the baby and mom can reap the benefits as soon as possible.

Should tongue-tie clipping be done in the newborn period, or do you think there are instances where it should/could be done later in life?

D: I think I answered this in the second question, however, I emphasize limiting any procedure unless necessary.

SLP: Hopefully, if there are concerns noticed with breast or bottle feeding, the procedure is done quickly so that we can support breastfeeding or can help that baby bottle feed. I have seen a few instances where the patient was older, about 12-18 months because the difficulty became more apparent as they were not able to use their tongue appropriately as they began to chew foods.

LC: As a newborn hospitalist, I would clip tongue ties during the newborn period if they were causing very obvious problems or mothers were having significant pain with breastfeeding. Often, I would clip them if the mom was an experienced breastfeeder and had lots of pain or had a previous baby with a tongue-tie that needed to be clipped. Now as an outpatient physician, I will clip tongue ties that have been referred to me by other professionals who have evaluated the mom and baby. These are often done around 1 to 2 months of age. After the parents have exhausted other options.

ENT: It’s easiest if we’re able to do a tongue-tie release procedure before around 3 to 4 months of age because the procedure can be done in the office. When a child gets much older than that, it’s typically recommended to do the procedure in the operating room. Since the research shows that the procedure improves breastfeeding outcomes, it is best performed as soon as possible.

If parents are on the fence about the procedure, who do you think they should reach out to? Do you think they should get advice from more than one profession?

D: I think a team approach is best when diagnosing and treating a tongue-tie. Different specialists’ understanding and communication of specific concerns lead to a well-informed treatment plan. If it is related to nursing, I would follow the advice of a lactation consultant or pediatrician.

SLP: Lactation consultants can help with questions on the latch at the breast. Speech pathology can help with feeding/bottle concerns and speech sound concerns. Dentists and ENTs are also great resources because they can provide insight as well. If you have a concern or are unsure, reach out to qualified health care professionals that are willing to listen to your concerns and that have knowledge on tongue ties – have an open and honest dialogue with them and come prepared with your questions.

LC: If parents are on the fence, I would recommend getting opinions from several trusted physicians. Pediatricians, family doctors, ENT and of course physicians with extra lactation training would be ideal. I would warn families to beware of "professionals" who are pushing the procedure without having done a full evaluation (which includes a feeding assessment).

ENT: I think the child’s pediatrician should always be the first one to evaluate a child and determine if they may benefit from a tongue-tie release. As far as asking other professions what they think/recommend, I would say that it is not uncommon to receive very different advice and recommendations based on who you ask. Each provider likely gives their recommendations based on their own experiences, training and background. ENT physicians also tend to rely heavily on what research papers have shown to help us to determine who will and likely will not benefit from a tongue-tie release.

Some take-home points from me, a pediatrician:

  • Tongue-ties are a complex issue that is still being studied, and many factors should be taken into account when trying to figure out whether or not a procedure is needed.
  • Not all tissues under the tongue are “tongue ties.” The vast majority of tongue frenula cause absolutely no issues. And many tight tongue ties can stretch out over time.
  •  Be careful about what you read on the internet. I can tell you from experience – there is a lot of garbage out there, and I’ve seen many babies fall victim to a painful and unneeded procedure because a parent was so worried about something they read online.
  • I’d say that in my personal experience of 12 years as a pediatrician, tongue tie clipping leads to improvement of a feeding or nursing issue maybe 50% of the time. And 50% of the time, it does not help.
  • According to our current evidence, tongue ties do not seem to affect speech. Again, this is based on what we know now.
  • Some older kids do report having difficulty licking their lips or teeth or licking an ice cream cone. This is one of the rare reasons older kids may need it cut.
  • If you’re wondering about getting your baby’s tongue tie cut, consider talking to more than one specialist – the more, the better, especially if you are considering getting a “posterior tie,” or back of the tongue, cut.
  • I’d definitely consider getting your baby’s tongue-tie evaluated if he struggles with drawing milk out of the breast or bottle if you are a mother who continues to experience a lot of pain with nursing after more than 2 weeks, and/or if he cannot extend his tongue past his lower teeth or lips (plus struggles with one of the issues above).
  • When you read the comments of this post, you’re going to see a lot of “just do it! It helped my baby!”, or “getting the tongue tie cut was the worst decision ever…” – please remember that every child is anatomically and physiologically different, and one person’s experience may not be what you experience.

I hope this post helped give you the slightest bit of clarity on a topic that is not so clear.

For as many tiny studies I found showing that cutting a tongue tie doesn’t help a baby feed, I found an equal number showing that it does in fact help. The truth is, we need more data -- more big studies involving lots of babies -- before our answers will be clearer and more confident when it comes to tongue ties.

The baby in the picture is a sweet patient of mine. He has a normal tongue frenulum that might appear worrisome when you see it, but as a newborn, he was able to transfer milk easily, and he thrived.

Now, for some extra reading!

Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012.

Breastfeeding: What to do about Ankyloglossia.

A systematic review: The effects of frenotomy on breastfeeding and speech in children with ankyloglossia.

Treatment of ankyloglossia and breastfeeding outcomes: a systematic review.

Frenotomy for tongue-tie in newborn infants.

Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review.

The effect of ankyloglossia and tongue-tie division on speech articulation: A systematic review.

  Get to know Digital Medical Advisor Diane Arnaout, M.D., a Cook Children's pediatrician at Forest ParkDiane Arnaout, M.D.

"I didn’t realize how important the job of the pediatrician was until I had kids of my own. My education, experience in medicine, and cocky attitude made me feel like I knew it all before my first one came around. He proceeded to make me very aware of how little I actually knew.

Thankfully he survived, as did the next one, and they’ve helped me to grow and to help YOU, the parent, in so many ways. Sure I’m here to make sure your kids are healthy and happy at all ages. But I’m also here to make sure you’re educated, to make sure your family is thriving, and to make you feel confident in caring for your kids. From diaper rashes to sleep problems to school difficulties - I’m here to help.

I write a lot about common problems and ailments online – you can find me busy on Facebook and Instagram, and I write articles for the Cook Children’s Checkup Newsroom blog. A lot of stuff you’ll hear me say in the office will be typed out on there, too. And we’re in a day and age where the internet helps make connections – you can connect with me on there, or e-mail me anytime.

It takes a village to raise a child – and I’m so grateful to be a part of yours. And as Master Yoda teaches us – “Always pass on what you have learned.” I fully plan to!"

To schedule an appointment with Dr. Arnaout, click here.