Understanding Tongue-Tie: What the Evidence Says About Assessment and Treatment

By Birth & Baby University · Last updated: October 2026 · 8 min read

Few newborn topics divide professionals as sharply as tongue-tie. Parents encounter it on social media, from friends and sometimes from clinicians who describe it as the hidden cause of feeding trouble. Others in the field warn that it is overdiagnosed. A postpartum doula is likely to be asked about it by a parent in pain or worried about a baby’s latch, and the honest answer sits between enthusiasm and dismissal. This article summarizes the evidence and the 2021 to 2024 position and clinical statements from the Academy of Breastfeeding Medicine (ABM) and the American Academy of Pediatrics (AAP), and explains how a doula can support a family without stepping into diagnosis.

Key takeaways

Quick answer: tongue-tie (ankyloglossia) is a restrictive lingual frenulum that limits tongue movement. Frenotomy, the release procedure, reduces nipple pain for some breastfeeding parents in the short term, but trials do not show a consistent improvement in how well babies feed. Current professional guidance asks for a skilled feeding assessment and conservative help first, and reserves frenotomy for significant functional impairment.

• A Cochrane review of five randomized trials (302 infants) found that frenotomy reduced mothers’ nipple pain in the short term but did not show a consistent positive effect on infant breastfeeding, and rated the findings limited by small, flawed trials.
• The AAP’s 2024 clinical report says it is not clear whether releasing a tight frenulum in neonates improves breastfeeding, that many symptoms overlap with other feeding difficulties, and that a team approach is needed. Its press summary says to consider nonsurgical options first.
• The ABM’s 2021 position statement says frenotomy can be effective when a restrictive sublingual frenulum is present and pain or poor milk transfer cannot be corrected by conservative measures, calls tongue-tie a functional diagnosis, and says the presence of a frenulum alone is not an indication for surgery.
• Diagnosis and treatment have risen sharply. A US hospital database study reported a 110.4% rise in diagnoses between 2012 and 2016, with unanswered questions about diagnostic criteria.

What the research says

Trials of frenotomy. O’Shea and colleagues’ Cochrane review (2017) pooled five randomized trials with 302 infants younger than three months. Pooling two studies (155 infants) showed no change on a 10-point feeding scale (mean difference -0.1, 95% confidence interval -0.6 to 0.5), while a third study (58 infants) showed improvement on a 12-point scale. Three pooled studies (212 mothers) showed a reduction in maternal pain on a 10-point scale (mean difference -0.7, 95% confidence interval -1.4 to -0.1). No adverse effects were reported. The reviewers noted serious methodological shortcomings: small samples, blinding in only two studies, and control infants who were often offered the procedure anyway, suggesting a lack of equipoise. No study reported long-term breastfeeding success. They concluded that frenotomy reduced nipple pain in the short term, with no consistent effect on infant breastfeeding, and called for better trials.

Position and clinical statements. The ABM’s position statement on ankyloglossia in breastfeeding dyads (2021) notes a lack of agreement worldwide on diagnosis and treatment and a lack of high-quality studies. It describes tongue-tie as a functional diagnosis, says an anatomically normal frenulum may be inappropriately labeled “restricted” when breastfeeding problems actually arise from other causes, and emphasizes a thorough, skilled breastfeeding assessment that considers other explanations. When a classic tongue-tie significantly restricts function, a frenotomy can be offered as a shared decision, with conservative management and follow-up as an alternative. It warns of risks with deeper incisions, including bleeding, hematoma and nerve injury, cites case reports of life-threatening hemorrhage, calls for follow-up after any procedure, says evidence is lacking for post-procedure stretching or topical substances, and says there is no published evidence that treating upper lip or buccal ties improves breastfeeding.

The AAP’s clinical report by Thomas and colleagues (2024) states that whether releasing a tight frenulum improves breastfeeding is not clear and that a team partnership is needed because symptoms overlap with other breastfeeding difficulties. The AAP’s summary of the report says diagnosis rates in newborns range from 1.7% to 10.7% in three studies from the United States, Canada and England, that no evidence supports laser over other methods, that other treatments such as craniosacral and myofascial therapies are not well studied, and that the AAP recommends reserving frenotomy for significant functional impairment when nonsurgical interventions have failed, while collaborating with lactation consultants and speech-language pathologists. It states that the procedure is safe and poor outcomes are rare, and advises against recommending post-frenotomy stretching exercises. This article draws on the report’s abstract and the AAP’s summary, not the full report.

Consensus and trends. The American Academy of Otolaryngology-Head and Neck Surgery’s 2020 clinical consensus statement used a modified Delphi process with 89 statements; 41 reached consensus, 17 were near consensus and 28 did not, and the authors attribute the gaps to knowledge gaps and a lack of evidence. Wei and colleagues’ analysis of US hospital data (2020) found diagnoses of ankyloglossia rose 110.4% between 2012 and 2016, with similar increases in frenotomy, and associations with insurance type, income and region, while questions about diagnostic criteria and which infants should be treated remained unanswered. Variation by region and insurance is one reason the field worries about overdiagnosis, but the data cannot show how much of the rise is appropriate recognition and how much is excess.

What this means for doulas

• Stay neutral and informed. Neither “tongue-tie is the cause” nor “tongue-tie isn’t real” is supported. Professional guidance says it can matter, that many feeding problems have other causes, and that assessment comes first.
• Describe observations, not diagnoses. Painful latch, clicking, slipping off the breast and poor weight gain are symptoms that overlap with many issues. A doula can describe them, support positioning and responsive feeding, and suggest an assessment with a lactation consultant or pediatric provider.
• Do not recommend or schedule procedures, and do not teach wound care. The AAP and ABM both say evidence is lacking for post-procedure stretching, so follow the treating clinician’s own instructions.
• Be cautious with unproven therapies. The AAP summary says physical therapy, craniosacral and myofascial approaches are not well studied and may carry out-of-pocket costs. Present them as unproven, not as dangerous or effective.
• Support the parent in pain. Pain relief and milk removal matter, and the ABM statement stresses help for maternal pain, so connect families to skilled care promptly rather than waiting.

Putting the evidence into practice

1. Collect the story. When did the pain or feeding trouble start, what has been tried, what is the baby’s weight trend, and who has assessed the baby?
2. Work on what can be changed. Positioning, latch comfort and support for expressing milk if needed are within a doula’s feeding support, while the family waits for evaluation.
3. Refer to a team. Encourage a visit with the pediatric provider and a lactation consultant, and ask whether a speech-language pathologist or other specialist is needed, as the AAP suggests.
4. Prepare families for decisions. Help them list questions: What exactly is restricted? What other causes are being considered? What are the risks, the alternatives and the follow-up plan?
5. Know the red flags. After any procedure, bleeding that does not stop, signs of infection, refusal to feed or poor weight gain need prompt contact with the treating clinician or the pediatric provider.

For related feeding topics see How to Recognize Effective Milk Transfer Without Relying on Feeding Duration Alone and Newborn Weight Loss and Weight Gain: What’s Typical and When Is Evaluation Needed?.

Limits and uncertainty

The trial evidence is small and limited, outcome measures differ between studies and there is no agreed definition or grading system for tongue-tie. The AAP and ABM statements are expert guidance, not trials, and the two reach slightly different emphases: the ABM statement describes serious complications in case reports, while the AAP summary describes the procedure as safe with rare poor outcomes. The consensus statement’s lack of agreement on 28 items reflects uncertainty, not a settled answer. This article draws on the full ABM statement and the AAP news summary, and abstracts of the Cochrane review, the AAP clinical report, the consensus statement and the trends paper. This article does not cover older children, sleep-disordered breathing or speech outcomes, where evidence is separate.

The bottom line

Tongue-tie can contribute to nipple pain and feeding trouble, and frenotomy can help some families, but it is neither a universal explanation nor a guaranteed fix. The trials show short-term pain relief and no consistent feeding improvement, and professional guidance asks for skilled assessment, a team approach and conservative help first. A doula’s best contribution is comfort, careful observation and a timely referral, without promising or discouraging a procedure.

Birth & Baby University’s For Doulas page brings together its postpartum doula training, recertification and mentorship for professionals who support feeding families. Confirm that any program meets your certifier’s, employer’s or state’s requirements before you enroll.

This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work. For concerns about a baby’s health, contact a pediatric provider or emergency services.

Sources and further reading

• O’Shea JE, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews (2017). Read the source
• LeFort Y, et al.; Academy of Breastfeeding Medicine. Position statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine (2021). Read the source
• Thomas J, et al. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics (2024). Read the source
• American Academy of Pediatrics. AAP report addresses rise in tongue-tie diagnoses for breastfeeding concerns (HealthyChildren.org, 2024). Read the source
• Messner AH, et al. Clinical consensus statement: ankyloglossia in children. Otolaryngology-Head and Neck Surgery (2020). Read the source
• Wei EX, et al. Ankyloglossia: update on trends in diagnosis and management in the United States, 2012-2016. Otolaryngology-Head and Neck Surgery (2020). Read the source

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