Tongue and lip ties are a controversial topic, with many different opinions and perspectives, and very little quality research.
I am often asked 'do you believe in tongue and lip ties?' so I thought I would explain the approach that I use as an IBCLC (International Board Certified Lactation Consultant), and also that our midwifery team at Held Midwifery use. This is my approach and my interpretation of the available evidence, as well as my experience working with families. It is a long article but I hope it will help you on your journey.
If you have already gone down the path of laser tie release with your little one, you may find some of the points in this article uncomfortable. Please know that this is absolutely not my aim. My aim for this article is for it to reach the hands of those who are currently pregnant or have a new baby, and wondering about ties. I have deliberated about sharing this blog for months, mainly because I didn't want to contribute to any mamas feeling guilt or sadness for the decisions they have made. Remember that we can only make the best decision with the information that we have at the time. I have no doubt that all of you reading this are making decisions around potential ties with your baby's best interest at the forefront.
I also want to mention that I hold no judgement over the decisions you make for your baby - it can be tricky to navigate, and my job is to support my clients to make the right decision for their baby. As a health professional I believe it our role to provide factual, unbiased and ethical information for families - and then it's up to you what you choose to do.
I am going to share some of the high quality research that I use in my practice, and also some of the benefits/risks of treatment, as well as other options. You may not agree with my interpretation of the research, and that is okay. You can read the research I refer to in this post at the bottom of this page.
First up, I think it’s really important to make a distinction between tongue ties, and other oral ties. Often the research lumps them all together which is inaccurate. We have good evidence that a classic tongue tie can indeed impact breastfeeding - it may lead to nipple pain and damage and poor milk transfer. So when I am asked ‘do you believe in tongue ties’ my answer is always ‘yes’. However, the research around lip, buccal or posterior tongue ties is less clear.
What is a tongue tie?
A tongue tie, or ankyloglossia, is a condition where the lingual frenulum (the band of tissue under the tongue) is abnormally short, thick, or tight. This can restrict the tongue's range of motion, making it difficult for a baby to move their tongue freely. The lingual frenulum comprises a fold in the mucosa and fascia which extends across the floor of the mouth and attaches to the underside of the tongue. It’s important to note that the presence of a lingual frenulum in itself is normal anatomy and if it is stretchy and does not restrict tongue movement then it is not a tongue-tie.
In infants, a restricted tongue it can interfere with breastfeeding, as the baby may struggle to latch properly, which can lead to poor attachment, nipple pain/damage for mum and potential growth issues if a baby is not able to transfer milk well from the breast.
In toddlers, older children or adults, a tongue tie may cause speech difficulties or trouble with eating/starting solids, but this occurs in the minority of infants with a tongue tie. It isn’t possible to accurately predict which babies with a tongue tie will go on to have these issues, and the ADA (Australian Dental Association) does not recommend routinely revising a tongue tie in a baby to prevent these possible issues that may or may not arise in the future. I have linked the ADA
Ankyloglossia and Oral Frena Consensus Statement in the link below if you’d like to read further about tongue tie and dental concerns.
What is the difference between an anterior or posterior tongue tie?
I do not generally use the terms 'anterior' or 'posterior' tongue tie because really it doesn't matter whether the restriction is on the front or anterior part of the tongue, or further back. It is whether tongue function is impacted by the restriction or not. In 2004 there was a theory discussed about the potential for a ‘sub mucosal tongue tie’ - where it was thought that the tongue restriction was essentially buried at the back of the tongue in the genioglossus muscle, and could only be diagnosed by pushing back against the base of the tongue. However this theory has been discredited in more recent research by Nikki Mills in 2019, which showed that there is not a band of connective tissue at the base of the tongue, and that instead what was being palpated as a ‘submucosal tongue tie’ was actually just the normal septum of the genioglossus muscle.
The ADA states ‘There is a lack of evidence from dissection studies to support such an entity. Use of this term can result in a normal lingual frenum being classified as abnormal. The term 'posterior' tongue tie should not be used as a medical diagnosis.’ I've linked to this research below.
What are the options if my baby has a tongue tie?
If you have been told by a health professional that your baby has a tongue tie you have a number of options.
When I am working with families I want them to know that they do have options, and to understand the benefits and risks of each of those options so they can make a truly informed decision.
You can opt to have the tissue restricting the tongue released with a scissor frenotomy (a procedure to cut the tissue with sterile scissors, usually performed by a general practitioner or pediatrician).
You can opt for a laser frenotomy with a paediatric dentist.
You can opt to do nothing at this stage.
You could work with an IBCLC and/or other healthcare providers to improve feeding, and revisit frenotomy if no improvement is seen.
Important Note: If you've been told your baby has a tongue tie I highly recommend seeing an IBCLC lactation consultant before a frenotomy. This is regarded as best practice, and it is important to take a holistic approach and ensure we are not missing any other potential causes of nipple pain and/or low supply before proceeding with a surgical procedure.
Scissor frenotomy vs laser frenotomy.
At present the research has not conclusively shown which method is better. The current available evidence that we have suggests both may offer similar ability to release a tongue tie.
In my experience and interpretation of the research there are more potential risks in laser frenotomy in babies compared with scissor frenotomy - including ongoing pain and subsequent oral aversion. I have sadly worked with a number of babies who have refused the breast after laser tie release, likely because of the oral aversion that developed after the procedure. There is also increased risk of bleeding and damage to other oral structures with laser. A scissor frenotomy in my experience carries less of these risks.
I have also witnessed both scissor frenotomy and laser frenotomy - through working with paediatricians and also spending a full day in a laser dentist clinic when I first became an IBCLC (which is not required as part of our IBCLC training but I wanted to understand the procedure firsthand). From my clinical experience I would confidently say babies are less distressed with scissor than laser. The procedure is also usually quicker. I am concerned about the potential impact of the pain caused from laser tie release for these little babies. Pain relief is not routinely given to babies/infants having this procedure, yet if we were to release a tie with laser in an adult local anaesthetic would generally be used.
Wound stretching is often recommended after laser tie release, and is not usually recommended with scissor release. This is to stop the wound edges from healing together, but requires stretching the wound a number of times a day for a few weeks. There is currently no evidence that wound stretches are required or beneficial, and I do believe that they can increase the risk of oral aversion because of the pain caused when doing the stretches.
What is a lip, buccal or cheek tie, or posterior tongue tie?
A lip tie is thought to occur when the frenulum (the band of tissue connecting the upper lip to the gum) is too tight or restrictive. However, there is no evidence based consensus of what constitutes a 'lip tie' or restricted tissue. Recent breastfeeding research has also shown that the upper lip has much less of a role in breastfeeding than originally thought - when I first trained as a midwife the advice we gave to women was that both baby's top and bottom lips need to be flanged out at the breast (like the K shape on a box of Special K cereal!). But this has been disproven in recent research. The top lip does not need to flange out, it just needs to sit in a neutral position at the breast. Because there is currently no research suggesting that lip ties can impact breastfeeding, and no actual definition of what a lip tie is, in our practice we are not concerned about lip ties and breastfeeding. I don't really even use the term 'lip tie' when working with families.
Unfortunately the majority of studies describing lip-tie or were editorials, or commentary from providers who perform frenotomy for lip ties, which is incredibly biased and I don't think can be relied upon. The thinking with a buccal (or cheek tie) is again that there is an abnormal frenulum attachment inside the cheek, which restricts movement of the cheek tissue. Like lip ties, there is no evidence for buccal ties impacting breastfeeding and as an IBCLC it is not something I am concerned about. I have discussed posterior tongue ties earlier in this blog.
In summary, based on the current research the only ties we are really concerned with when it comes to breastfeeding are tongue ties.
But then why do so many lactation consultants recommend lip/buccal/posterior tie release?
To be honest, I'm not sure - I wonder if it is because we all have differing backgrounds, and potentially differences in our interpretation of the research. As part of my undergraduate and also postgraduate midwifery degrees there is a strong focus on critiquing research. Often we can find research for or against anything, but is that research good quality, unbiased and peer reviewed? Not always. Often I see other lactation consultants refer to studies that are merely case studies from clinics that perform laser lip/cheek tie release, and I do not believe that we can rely on that research at all as the risk of bias is high, and there is generally no control group to compare outcomes against.
Perhaps it is from their own personal experience - but again as a health professional we are meant to provide evidence based care, not just our personal experience or opinion. Personal experience and peer support can be great (such as at mothers groups or in social media groups), but when a professional is diagnosing or recommending a surgical procedure to a family this recommendation should come from their professional experience and the research.
I am also concerned about the ethical considerations of lactation consultants who also work in dentist clinics where laser tie release is provided - this is a conflict of interest that should always be disclosed to parents before they are referred from a lactation consultant to a dentist/paediatric clinic where the midwife/IBCLC is employed. In all other areas of health care this conflict would need to be disclosed, and unfortunately in our industry it doesn’t always happen.
What if I have had my baby's ties released via laser - can you still support me?
Absolutely! As mentioned earlier in this article - you need to make the decision that feels right for you. We am not here to judge the decision that you make, and we are more than happy to support you through any stage of your feeding journey. There is so much more to feeding than just tongue function.
If you had a baby with ties you would think differently about all of this.
The statement above has been said to me before, and I can understand where this mum is coming from.
As a health professional I need to be basing my recommendations around the current research that we have, however we DO still need more research in this area, so if you decide to go ahead with a laser tie release because YOU feel it is in your baby's best interests then that is absolutely your choice and I support you in that. Maybe in 10 years I will be rewriting this article because we have new research that changes my opinion.
I considered including my own journey navigating ties with my son when he was a newborn, but I think we need to refrain from including personal opinion when advising parents because it is such an emotive topic. But I do want you to know that as a mum, I have been in your shoes. I made the decision that felt right for my family while considering the available research, which is what I want you to be able to do too.
In conclusion
Supporting parents with breastfeeding is something that I am so passionate about. My approach is always about supporting a mum to get breastfeeding working well with the least intervention possible. This is my approach to birth too - it is a process that usually goes smoothly with good support, but may sometimes benefit from medical interventions. Breastfeeding is no different.
I will absolutely refer to an appropriate provider to diagnose and release a tongue tie if I believe function and feeding are negatively affected and the parents would like to explore potential frenotomy, but before recommending a surgical procedure I am going to look at the whole picture (think positioning, improving milk transfer, increasing supply if relevant, feeding history, non surgical interventions etc). In my experience the vast majority of feeding concerns can be improved with good lactation support, and are usually unrelated to ties.
If you would like evidence based, non judgemental support in navigating feeding challenges or tongue tie please reach out for a consultation with myself or Nerissa. We would love to support you!
Written by Hannah Willsmore RM, IBCLC in February 2025.
Recommended further reading and research:
Nikki Mills Tongue Function Research - What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum
The Conversation - Deep cuts under babies’ tongues are unlikely to solve breastfeeding problems article (an older article from 2016).
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