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October 2025Research on ankyloglossia, or tongue tie, continues to grow, but questions about the need for frenotomy have persisted since 2023, when ENTtoday reported ongoing debate among otolaryngologists (ENTtoday. https://tinyurl.com/pdmmza7a). More recently, Becker’s Hospital Review listed the procedure as a healthcare bad behavior (Becker’s Hospital Review. https://tinyurl.com/3apnrz3b/).
Despite exponential increases in studies, “very few have helped answer or clarify the big questions: How much does ankyloglossia affect feeding and speech? How do we reliably diagnose it? How much does frenotomy help? How do we choose which infant should have a frenotomy? These are difficult questions to study and get answers to,” said Jonathan Walsh, MD, associate professor of otolaryngology–head and neck surgery in the division of pediatric otolaryngology at Johns Hopkins School of Medicine in Baltimore.
Research, Consensus Statements Influencing Clinical Practice
A 2025 systematic review found a continued rise in publications focused on ankyloglossia and lingual frenotomy without an increase in evidence clarifying the associated controversies (Otolaryngol Head Neck Surg. doi:10.1002/ohn.1264).
While many studies are attempting to help, most are adding to the uncertainty, Dr. Walsh said. “We need to do the difficult work of well-designed clinical trials.” He cited a 2023 randomized controlled trial that found no difference between frenotomy and observation for breastfeeding outcomes at three months (Health Technol Assess. doi: 10.3310/WBBW2302). “This added some higher-quality data to previous studies, but still does not answer our big questions,” Dr. Walsh said.
In 2024, the American Academy of Pediatrics (AAP) published a clinical report titled “Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants” (Pediatrics. doi:10.1542/peds.2024-067605).
In addition to recognizing that ankyloglossia is a variant of normal anatomy, Nikhila Raol, MD, MPH, associate professor in the department of otolaryngology–head and neck surgery at Baylor College of Medicine in Houston, noted that “the two most important statements made in the AAP report are that 1) other causes of poor breastfeeding should be considered before blaming issues on tie, and 2) a billable provider should perform the frenotomy and avoid other non-evidence-based treatments.
“By including these things, consideration of the complexity of breastfeeding is acknowledged, as is the likely overuse of frenotomy that is occurring in various settings that are difficult to track,” Dr. Raol said. She has been conducting active research on ankyloglossia, which was the subject of her recent Fulbright–Nehru award-sponsored research in India.
“We followed nearly 500 mother–infant dyads in India, with about 20% having ankyloglossia (almost all mild to moderate), for six months to evaluate breastfeeding maintenance outcomes,” she explained. “We found that regardless of whether or not ankyloglossia was present, the majority of these mothers were able to continue breastfeeding at six months. We found that improved education around breastfeeding and support for mothers are likely the most important factors for success.” The study was recently accepted for publication in the journal Pediatrics.
Kristina W. Rosbe, MD, professor and chief of pediatric otolaryngology in the department of otolaryngology–head and neck surgery at University of California in San Francisco (UCSF), highlighted that the AAP statement identified “limited science to support frenotomy other than severe anterior tongue tie and no evidence to support frenotomies of ‘posterior tongue tie’ and ‘lip tie’ to help with feeding.”
In 2023, UCSF’s pediatric otolaryngology division introduced a model for managing newborn feeding issues, prioritizing initial clinical swallow evaluations by dually certified speech–language pathologists and lactation consultants. A 2025 study of 1,454 patients by Dr. Rosbe and colleagues found the model shifted care patterns, increasing use of speech–language pathologist/lactation consultant services and reducing frenotomies. It also improved access to care for publicly insured patients, highlighting its potential to advance health equity (Int J Pediatr Otorhinolaryngol. doi: 10.1016/j.ijporl.2025.112355).
Evaluating Sleep Apnea, Speech Delay Claims
Dr. Rosbe evaluates claims linking tongue tie to sleep apnea and speech delays “very suspiciously.”
“I do not think tongue tie contributes to these conditions for the vast majority of children.” For severe anterior tongue tie, some data support an association with articulation challenges, Dr. Rosbe added.
A growing body of research is helping physicians better understand ankyloglossia and speech delays, Dr. Walsh explained. Most speech delays are likely multifactorial and not directly caused by ankyloglossia. While some patients may benefit from frenotomy, others with severe tongue restriction show no articulation issues, and some with significant speech delays have little or no restriction. In such cases, the hope that a frenotomy will help often exceeds the evidence. Dr. Walsh added that while a few studies suggest a minor link between ankyloglossia and sleep apnea, many draw conclusions beyond the data. Confirmation bias is common, with associations misinterpreted as causation. He suggested that the medical community needs to recognize these associations and rigorously investigate whether they are real and not surrogates for another unidentified craniofacial characteristic, ideally before launching outcome-based frenotomy studies.
Bobak A. Ghaheri, MD, an otolaryngologist at the Oregon Clinic in Portland, evaluates claims linking tongue tie to sleep apnea or speech delays on a case-by-case basis and with hesitation. While Dr. Ghaheri does not believe frenotomy is curative for sleep apnea, he noted that evidence supports its use as an adjunct treatment. In the case of speech, “the majority of studies are plagued by poor surgical technique (i.e., only doing partial tongue tie releases). I’ve had a tremendous amount of success with speech after a tongue tie release because my surgery is different than most others,” he said.
Dr. Raol does not advocate for frenotomy to reduce the risk of or to treat sleep apnea. “If a patient is symptomatic, I will look for a source of other obstruction that is more likely to be the cause of the sleep apnea.” For speech delay, she refers to speech pathology for a full functional assessment and to identify the speech articulation deficits.
“While I believe there are some articulation deficits that may be due to tongue tie, given the lack of evidence, I routinely have my patients do speech therapy first, and if they plateau in therapy and the speech therapist identifies a speech issue that may be due to the tongue tie, then I will consider clipping the frenulum,” Dr. Raol said. “I do, however, counsel families that, given that there is no strong evidence, frenotomy may not fix the articulation issue.”
Dr. Raol highlighted the fact that much of the data on speech “comes from the English language, and in this multilingual world and country we live in, articulation in some languages may be affected more than in others.”
Non-ENT Providers
Otolaryngologists have never been the sole provider of frenotomies, but the dissemination of overstated claims of frenotomy benefits in feeding, speech, and sleep apnea may mean that more non-ENT providers are performing the procedure, explained Dr. Walsh. “Pediatric dentistry is one such field that
has seen large growth in the procedure.”
“More regulation is likely not the answer, as the other providers are usually operating within the scope of their license. What is significantly lacking is standardized training in how to critically review research publications in addition to understanding anatomy, infant feeding and swallowing, airway and neurodevelopment,” Dr. Walsh said. “Weekend courses, online training, and tongue tie boot camps are not adequately giving the knowledge and nuance needed but are likely propagating unsupported claims of the benefit of frenotomy.”
As director of a complex pediatric aerodigestive team, Dr. Walsh often sees tongue tie blamed for major feeding and swallowing issues, with frenotomy offering no improvement and delaying proper diagnosis. While tongue tie professionals mean well, most lack training beyond tongue and feeding anatomy and overestimate what the research supports. “Standardized training has limitations, as we are still lacking certainty on diagnostic criteria and identifying which infant truly would benefit from frenotomy,” he said.
Collaboration with colleagues is essential, Dr. Walsh emphasized, “as many of these treatment decisions are complex, and care decisions extend beyond any one specialty.” Conflicting opinions about the need for surgery are acceptable, but it is critical to ensure that there is shared language and understanding of the anatomic findings and clinical symptoms, and families deserve “intellectual honesty” about what the evidence shows. “Too often families are confused and conflicted by the wide range of claims and beliefs about tongue tie and the benefit of frenotomy,” he said.
Steven L. Goudy, MD, MBA, professor of otolaryngology and director of pediatric otolaryngology at Emory University School of Medicine, and medical director of otolaryngology at Children’s Healthcare of Atlanta, is not concerned if practitioners are following guidelines of the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS), AAP, and American Academy of Pediatric Dentistry (AAPD).
“If they are practicing outside of those guidelines, I have concerns,” Dr. Goudy said. “Moms and babies are a vulnerable population that should be protected.” In cases where the indications for intervention or the underlying medical issues are complex, Dr. Goudy works closely with pediatric speech and
language pathologists.
According to Dr. Rosbe, “Physicians who can care holistically for the mother–patient dyad and understand that breastfeeding challenges are often multifactorial should be the ones providing this care as part of a multidisciplinary care model.” When collaborating with lactation consultants, dentists, or pediatricians when there are conflicting opinions, “we listen to other points of view but also stress to these colleagues and parents that an anatomic problem with the tongue is rarely the sole cause of breastfeeding challenges,” Dr. Rosbe said.
Dr. Raol suggested that ENT providers are best suited to complete the procedures, given their understanding of the anatomy. “While the procedure is technically fairly simple, complications can occur,” she said. “Regardless of who is performing the procedure, a functional assessment is necessary to see if the procedure is indicated.”
While Dr. Ghaheri is supportive of dentists treating tongue ties, “when it comes to others who are not trained for the procedure (naturopaths, midwives,
etc.), I’m less optimistic.”
“The fact that ENTs and our Academy generally oppose the topic doesn’t negate the need for the services,” Dr. Ghaheri said. If more ENTs “fulfilled the medical need for the procedure, we’d have fewer non-ENTs doing it.”
Dr. Ghaheri noted that pediatricians, dentists, and ENTs have no training in infant tongue function for breast/bottle feeding and in older children for dysphagia/speech. “Those functional assessments come from lactation consultants, speech pathologists, and occupational therapists. So, there’s very little conflicting opinion in my practice because I’m only looking at the functional assessment of the patient when determining the need for surgery.”
Earl Harley, MD, professor of otolaryngology and pediatrics and chief of pediatric otolaryngology at Georgetown University and Medstar Georgetown Hospital, both in Washington, D.C., supports training but is opposed to regulating who can perform the procedure.
“Anyone who has a full understanding of the complexities of breastfeeding and tongue tie and is able to fully assess both mom and infant should be able to perform the procedure,” Dr. Harley said. “The problem I see is that tongue tie has become big business, and there is a notion that lasers are superior to cold techniques when there is a lack of evidence. We will be reporting on the comparison of the two techniques in the near future.”
Addressing Misinformation
Misinformation and exaggerated claims are the number one problem driving the rates of frenotomy among dentists and physicians, and the confusion among parents, said Dr. Walsh. “What makes it difficult for parents is that many of the exaggerated claims are not coming from only parent blogs and non-medical providers; the claims are being propagated by dentists, lactation consultants, speech pathologists, pediatricians, and ENTs alike.”
“It takes considerable time to build trust, thoroughly evaluate the symptoms and exam, and understand the beliefs and concerns of the parent,” Dr. Walsh said. “If one approaches these appointments with disinterest, disregard, and dismissal, then we are doing the patients and their parents a disservice. They will likely leave your office and go down the street to the next doctor who will cut the tongue. If you build trust, demonstrate care, and show empathy, then it allows you to educate the family and make informed shared decisions.”
“The risk discussion is important when performing any procedure,” Dr. Walsh said. “What I have changed over the years is how much more time I spend discussing the limitations of frenotomy and preparing the family for the very real possibility that the symptoms will not improve after the frenotomy.”
Dr. Rosbe acknowledges that there is a lot of misinformation about ankyloglossia on social media and that challenges with breastfeeding can be extremely frustrating and exhausting for new moms.
“I try to emphasize that we should have a shared goal to do what is best for their child and that I do not want to perform an unnecessary procedure that may not have a benefit,” Dr. Rosbe said. “I continue to counsel about risks of bleeding, infection, retethering, and that the procedure may not help.”
To address misinformation about ankyloglossia that parents encounter online, Dr. Goudy provides parents with the statements from the AAO–HNS, AAP, and AAPD and helps them choose the best recommendations for their family. Dr. Harley addresses online misinformation by posting topics on his social media related to oral ties and other factors associated with nursing.
Facing Disparities
Disparities in who gets referred for tongue tie evaluation or who can afford the procedure are likely related to larger issues such as access to primary care and cultural practices of breastfeeding and bottle feeding, according to Dr. Walsh.
“Timely access can be difficult for many patients,” Dr Walsh said. “What I feel is a larger area of referral disparity is that some hospitals or practices have a lactation consultant with high diagnosis and referral rates, and others with low diagnosis rates, thus indicating it is likely driven by the diagnosis and beliefs of the individual referring provider.”
“Culturally sensitive care is difficult to ensure, but should always be strived for. Continually educating yourself and your staff on terminology and cultural differences is important to create a safe and inclusive environment of care,” Dr. Wash said.
Dr. Harley acknowledged a disparity based on economic status, with patients going to “other providers who do not take medical insurance, so they come to us to have the procedure performed for what their insurance plan will pay.”
Dentists may have to charge for the procedure because the patient does not have dental insurance, said Dr. Ghaheri, and “if you’re unable to afford out-of-pocket costs for the procedure, you’re unfairly punished.”
To ensure culturally sensitive care for nontraditional families or for those using terms like ‘chestfeeding,’ Dr. Goudy partners with the “pediatric speech pathologist and others in the ecosystem to support these families.”
Procedural Volume Changes
It’s hard to ascertain the exact number of frenotomy surgeries performed annually because they’re diagnosed and treated by other providers besides otolaryngologists, and there are wide practice variations.
Dr. Ghaheri feels the current rate of tongue tie surgeries is lower than it should be.
Dr. Walsh does not believe the rates of frenotomy are continuing to increase. “I am not sure if it has finally stabilized or if this marks a shift in referral practices away from medical centers to free-standing tongue tie centers and dental practices.”
Dr. Harley has seen a drop in tongue tie surgeries in his practice since 2023, which may correspond to the period when he stopped using a laser for a variety of reasons. “We are now seeing more parents opting for laser dentistry,” he explained.
“There are a lot of unnecessary tongue and lip tie procedures being performed by non-otolaryngologists,” said Dr. Harley. “Data show that many children with tongue tie who do not have a procedure performed but have proper support by a lactation consultant or speech–language pathologist will continue to nurse.”
This need for adequate breastfeeding support is echoed by Dr. Rosbe and Dr. Raol.
Since introducing the UCSF multidisciplinary model, Dr. Rosbe has seen the rates of frenotomy significantly decrease. The current rate of tongue tie surgeries “does not reflect medical necessity but reflects [s] the lack of adequate breastfeeding support that we, the healthcare system, provide new mothers. Once we added this lactation expertise and support to our care model, rates of frenotomy decreased significantly.”
Dr. Raol believes that the problem of tongue tie is more of an economic problem than a medical issue. “While there are certainly children who benefit from frenotomy, as we’ve seen the number of procedures grow in the U.S. without significant strides in improving breastfeeding maintenance rates, I think what we really need is better support for our breastfeeding mothers and less reliance on a procedure that may ultimately not be needed.”
“Better research will help us decide who are appropriate candidates for frenotomy,” Dr. Raol concluded.
Katie Robinson is a freelance medical writer based in New York.
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