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Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain

BMJ 2020; 371 doi: (Published 26 November 2020) Cite this as: BMJ 2020;371:m3928

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Re: Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain

Dear Editor,

In reference to the article entitled “Posterior tongue-tie and lip-tie: a lucrative private industry where the evidence is uncertain” published 26th November 2020”, the eminent scientific evidence regarding the importance of breastfeeding is not mentioned at all. To protect, promote and support the attempt of breastfeeding for 6 months as the WHO recommends (1), and to overcome any breastfeeding difficulties during this attempt should always be the goal of any health care professional.

Clinical experience has identified tethered oral tissues (‘’tongue- and/or lip-tie’’) in a breastfeeding infant, as a potential source of maternal nipple discomfort and trauma, and of impeded breast milk transfer by the infant, thereby being considered a risk factor for premature breastfeeding cessation. The primary importance of performing a thorough skillful clinical breastfeeding assessment, including the consideration of the differential diagnoses, and addressing these potential confounders, cannot be overstated (2). Tongue- and lip-ties are normal structures in a newborn (3,4). But after a thorough assessment, the diagnosis of these structures is that they are considered tethered oral tissues, and thus a frenotomy can be an effective way to increase maternal comfort and breast milk transfer by the infant.

As with any intervention, a frenotomy should be a shared decision between the surgeon and the parents of the newborn incorporating this family’s values and preferences, with attention to the risks and the benefits of each alternative. First, a non-surgical professional support is indicated with a follow-up in a setting where breastfeeding can be assessed. Next, when the non-surgical is not successful, a surgical intervention may be chosen. The final decision to perform a frenotomy is one that requires a high level of clinical skill, judgment, and discernment. This has nothing to do with a lucrative private industry.

We agree there is still a need for more studies. There is an ongoing need for high-quality research in specific areas related to the treatment of tongue-tie or other tethered oral tissues as lip- and buccal-ties. Of note, the Cochrane review of O’Shea (5) and the study of Francis et al. (6) did not mention serious complications after performing a frenotomy of tongue-ties. The mentioned experiences in other letters to the editor regarding complications and assaults on newborns cannot be taken as representative. There is no mention of a treatment protocol, a complete oral and physical investigation, and non-surgical professional support by a multi-disciplinary team which could have prevented these kind of complications. Even many of the mentioned complications in the study using New Zealand Paediatric Surveillance Unit (NZPSU) registry (7) were caused by performing the frenotomy in Hospitals. Therefore, even in Hospitals, it is important that only experienced surgeons perform a frenotomy following a strict surgical protocol after trying non-surgical support first by a multidisciplinary team in newborns. All surgeons who perform frenotomies at newborns need to be aware of the risks of the procedure they undertake, which are then clearly communicated to the parents and acknowledged by their written informed consent. Such surgeons must be prepared to provide appropriate immediate postsurgical management and support as required.

Recently we published the BRIEF study (8) to highlight the importance of sound and experienced clinical judgment in a systematic order to determine the possibility of surgical treatment, should non-interventional professional support not suffice in patients with breastfeeding difficulties. We advocate that the decision to perform a frenotomy is made only after a thoroughly oral and physical investigation by a multi-disciplinary team and should not only be made depending on the appearance of the anatomy of the tethered oral tissue (regardless of the grading system used). Following this strict protocol of non-surgical support by a multidisciplinary team first, we concluded that the frenotomy of a tongue-tie and or lip-tie is a safe procedure with no reported post-operative complications after 6 months, if done by an experienced surgeon. This means that only experienced surgeons should perform these procedures with deep knowledge of the oral anatomy. The overall goal is to perform the surgery in a minimally invasive way, effectively dividing the sublingual frenulum to release the restriction of the tongue and restore an adequate range of movement, allowing for effective and comfortable breastfeeding. The discussion should not be about anterior or posterior ties, but about how the frenotomy is performed. A frenotomy of course, should only be performed without causing any damage to the surrounding tissues and structures. As we thoroughly described in our article, in case of an anterior- or posterior tongue-tie it is important not to disturb the fascia of the underlying genioglossus muscle. We do not advocate deep incisions submucosally due to the risks of damage or bleeding. In case of a superior lip-tie, the maxillary labial frenulum was released off the alveolar ridge up to the mucogingival junction.

If tethered oral tissues are the cause of breastfeeding difficulties a frenotomy can be a safe procedure resulting in significant improvement of breastfeeding self-efficacy, nipple pain, and gastro oesophageal reflux problems, if done cautiously by an experienced surgeon (8). By following the protocol of non-interventional support first, the risk of over treatment or under treatment can be minimized, as well as the risk of (severe) complications. By choosing for a 6 month follow-up we did not see any complications in oral or motor development as for example swallowing solid foods. The serious consequences of undiagnosed tethered oral tissues at a later age are various, such as speech problems, dental problems (9), pediatric sleep apnoa (10), orthodontic problems (11) due to an incorrect swallowing pattern (12). Therefore, a multidisciplinary team should always be the standard for any patient.

1. World Health Organization (2017) Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.
2. Caloway C, Hersh CJ, Baars R, Sally S, Diercks G, Hartnick CJ. Association of feeding evaluation with frenotomy rates in infants with breastfeeding difficulties. JAMA Otolaryngol Head Neck Surg. 2019 Jul 11:e191696. doi: 10.1001/jamaoto.2019.1696. Online ahead of print.
3. Santa Maria C, Aby J, Thy Truong M, Thakur Y, Rea S, Messner A (2017) The superior labial frenulum in newborns: what is normal? Glob Pediatr Health 4:1–6. 2333794X17718896
4. Flinck A, Paludan A, Matsson L, Holm AK, Axelsson I (1994) Oral findings in a group of newborn Swedish children. Int J Paediatr Dent 4:67–73.
5. O'Shea JE, Foster JP, O'Donnell CP, Breathnach D, Jacobs SE, Todd DA, Davis PG (2017) Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev 3. CD011065. 10.1002/14651858.CD011065.pub2
6. Francis DO, Chinnadurai S, Morad A, et al (2015) Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 May. Report No.: 15-EHC011-EF. PMID: 26065053. books/NBK299120/pdf/Bookshelf_NBK299120.pdf.
7. Hale M, Mills N, Edmonds L, et al (2020). Complications following frenotomy for ankyloglossia: A 24-month prospective New Zealand Paediatric Surveillance Unit study. J Paediatr Child Health 56:557-562.
8. Slagter KW, Raghoebar GM, Hamming I, Meijer J, Vissink A (2020). Effect of frenotomy on breastfeeding and reflux: results from the BRIEF prospective longitudinal cohort study. Clin Oral Investig 2020 Dec 14.
9. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY (2017). Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional - morphological study. Orthod Craniofac Res 20:237-244. https://doi:10.1111/ocr.12206.
10. Guilleminault C, Huseni S, Lo L (2016). A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res 29;2(3):00043-2016. https://doi:10.1183/23120541.00043-2016.
11. Lee YS, Ryu J, Baek SH, Lim WH, Yang IH, Kim TW, Jung SK (2021) Comparative analysis of the differences in dentofacial morphology according to the tongue and lip pressure. Diagnostics (Basel). 11:503. doi: 10.3390/diagnostics11030503.
Silva M, Manton D 2014 Oral habits--part 2: beyond nutritive and non-nutritive sucking.

Competing interests: No competing interests

23 June 2021
Kirsten W Slagter
Gerry M. Raghoebar, Inge Hamming, Jiska Meijer, Arjan Vissink
Department of Oral and Maxillofacial Surgery, University Medical Centre Groningen
Hanzeplein 1, 9700 RB Groningen, the Netherlands