Health Professionals Concerned About Over-Treatment Of Ties

Health Professionals Concerned About Over-Treatment Of Ties

If you’re a new parent who spends time in Facebook breastfeeding groups, no doubt you’ve come across the topic of ties.

Perhaps you are experiencing breastfeeding challenges and you’ve asked such groups for help.

Subsequently, it might have been suggested your baby has ties, and you should see someone who is ‘tie-savvy’ from the group’s provider list.

There is a problem, however, which is dividing professionals and parents alike.

When it comes to tie releases, Dr. David McIntosh, a paediatric ENT surgeon, believes that too many inappropriate ones and not enough appropriate ones are being done.

So, what now?

What Are Ties?

‘Ties’ is a collective term used to describe tongue-ties, upper lip-ties and buccal ties. All of these are related to connective tissue that restricts movement in the mouth and causes functional problems.

Definitions of tongue-tie vary, but it’s generally agreed a tongue-tie exists when the lingual frenulum (the connective tissue under the tongue) restricts tongue movement in a way that negatively affects function.

Upper lip-ties occur when the frenulum underneath the upper lip, known as the labial frenulum, is deemed to have caused a functional problem.

Buccal ties occur when frenula underneath the cheek are deemed to have caused a functional problem.

The prevalence of tongue-tie appears to fall between 4% and 10%. Inconsistencies in diagnostic criteria most likely contribute to variation in estimates.

Broadly and simply speaking, some tongue-ties are obvious – where the frenulum attaches close to the tip of the tongue. These are referred to as ‘classic’ or ‘anterior’ tongue-ties.

Other possible tongue-ties are less obvious, and can be referred to as ‘posterior’ tongue-ties.

Few would argue against there being genuine indications for releasing a tongue-tie. When a tongue-tie causes a functional problem, releasing it can help improve function. A tongue-tie release is a surgical procedure, performed either by scissors or laser.

The question is this: are too many supposed tongue-ties and other ties being released?

Health Professionals Concerned About Over-Treatment Of Ties

Many health professionals are concerned that too many ties are being released; that is, some professionals are performing too many unnecessary surgical procedures on babies.

Karen Palmer, a neonatal nurse (for 10 years), midwife (for 22 years) and an International Board Certified Lactation Consultant (IBCLC) for 23 years, indicates she “fought hard 10 years ago to get simple tongue-ties simply cut, to allow more effective, pain free feeding where necessary”.

She adds, “A few years back we had never heard of these things and other ways were found to manage breastfeeding issues and support mothers. Now, surgery has become the default position. The wide variation of IBCLC practice with no discernible improvement in breastfeeding rates tells a story”.

Heather Harris, a midwife (for 46 years) and an IBCLC (for 25 years) is also concerned tongue-ties, upper lip-ties and buccal ties “appear to have become a mainstream intervention for any breastfeeding or perceived breastfeeding problem.” According to her, “Surgical intervention seems to be the first ‘go to’ option whenever there is a breastfeeding issue”.

Anne Cullen, is another IBCLC who is concerned about the number of ties being released. She says, “I have huge concerns that there are some professionals that release far too many tongues. The increase I have seen in lip and buccal releases over the past two years has me very worried”.

Holly Tickner, a speech pathologist who has specialised in the area of paediatric feeding difficulties for over a decade, believes “the pendulum has swung too far in each direction. Probably fifteen or twenty years ago tongue-ties were being missed and not being diagnosed. The science behind breastfeeding and tongue-tie has come a long way in recent years and we know a lot more about it now than back then. But at the moment the pendulum is swinging a little too far to the other end”.

Holly is concerned about “the current trend of having surgery for oral ties without a functional assessment first. A functional assessment takes into account what the tongue and mouth look like, as well as how they work”.

In Holly’s opinion, it’s not enough “just to have a physical examination of the mouth”. Holly meets “far too many older babies and children who have had oral surgery done first before trying anything else, and often the parent has been led to believe that it will provide a quick fix, and instead the parents have seen no changes (or worse yet, the surgery has caused new problems)”.

There is also a concern some parents are obtaining inaccurate information related to ties from tongue-tie and breastfeeding peer support groups on Facebook.

The Research On Breastfeeding And Ties

A tongue-tie can negatively affect breastfeeding. For example, a tongue-tie might reduce how well a baby can remove milk from the breast and it might increase the risk of nipple pain and damage.

The latest systematic review on the topic of tongue-ties and breastfeeding concluded:

“Frenotomy [the name of the surgical procedure to release a tongue-tie] reduced breastfeeding mothers’ nipple pain in the short term. Investigators did not find a consistent positive effect on infant breastfeeding. Researchers reported no serious complications, but the total number of infants studied was small. The small number of trials, along with methodological shortcomings, limits the certainty of these findings. Further randomised controlled trials of high methodological quality are necessary to determine the effects of frenotomy”.

There have been no systematic reviews undertaken about any possible effect upper lip-ties or buccal ties might have on breastfeeding, due to significant lack of evidence.

There is negligible evidence with regard to breastfeeding and upper lip-tie, and zero evidence with regard to breastfeeding and buccal ties.

Karen thinks anterior tongue-ties “can negatively impact breastfeeding and the effects can be seen in the early days and weeks”. However, she feels “posterior tongue-tie diagnosis can be subjective”. In Karen’s opinion, upper lip or buccal ties don’t affect breastfeeding at all.

Similarly, Heather believes “anterior tongue-ties can (but do not always) impact negatively on breastfeeding, as the tethered tongue may not be able to draw the breast far enough into the mouth to effectively extract milk, resulting in poor milk transfer and potential nipple trauma”.

However, Heather feels the “upper lip frenulum is a normal part of infant oral anatomy and should never be interfered with at this age – if ever”.

She continues: “The belief that the top lip needs to be flanged to enable a good latch is erroneous and demonstrates a poor understanding of normal breastfeeding attachment”. Furthermore she believes that buccal ties have nothing to do with breastfeeding.

Anne says she has “personally never seen a lip-tie or buccal tie that needs releasing due to a breastfeeding problem”.

What Should You Do If You Believe Ties Are Affecting Breastfeeding?

If parents are concerned about whether ties might be affecting breastfeeding, Karen suggests they first contact their primary practitioner (nurse, midwife or GP) for a holistic assessment of their baby.

From there, Karen suggests a referral to an IBCLC for further assessment if necessary. She feels “IBCLCs definitely need to be part of that team, to sit and observe a feed first and foremost, but other factors from pregnancy, birth and the neonatal time need to be taken into account”.

Karen indicates she is “always aware that many medical issues present first as feeding problems so therefore a thorough assessment is required before a specific road is gone down”.

If Heather believes a tongue-tie is interfering with breastfeeding, she feels the most appropriate line of referral is to a medical practitioner who has extensive experience in, assessment of, and safe division of anterior tongue-ties.

She adds she “would never refer to a dentist or speech pathologist or ‘body worker’ for such an issue at this early age”. She adds that with regard to upper lip-ties there’s “no such thing, so I would never refer anywhere; same with buccal ties”.

According to Anne, if parents are concerned their baby has a tie, “Mothers should always consult an IBCLC first to work on latching and positioning”.

In terms of diagnosing ties, Anne says she prefers “a team approach – I’d like to see a certified lactation consultant working in conjunction with an ENT or other paediatric medical specialist”.

She thinks “any feeding problem needs to be looked at holistically so that we can identify the root of the feeding problem. Feeding problems can even be related to a mother’s state of wellbeing and the support around her; they are often not problems that can just be solved with a ‘quick fix’ tie release”.

Heather, Karen and Anne all agree that if a tongue-tie isn’t obviously contributing to any current functional problem, it shouldn’t be released pre-emptively.

Karen says, “A baby has a lot of growing and developing to happen first. There is no harm in a ‘wait and see’ approach.”

Likewise, Heather says, “If there are no obvious problems I can see no advantage in a surgical intervention. Ain’t broke, don’t fix it”.

Anne says “There is never any justification for performing a preventative release on a baby.”

There is certainly a lot of confusion, speculation and conjecture surrounding the topic of ties. For parents who are concerned about their baby possibly having a tie, it can be very difficult to try to navigate their way through it, and make sense of it all.

The truth is we don’t fully understand the topic of ties. More quality research is needed, but this will take time.

If you’re worried your child might have a tie, it’s best to seek advice from the appropriate health professional – e.g. lactation consultant for breastfeeding issues, speech pathologist for speech issues, specialist paediatric dentist for dental issues, and ENT surgeon for breathing issues etc.

Ultimately, if you’re having problems with breastfeeding, please do seek help from a qualified lactation consultant. Get second or third opinions if you need or want to.

Just don’t suffer in silence.


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Renee Kam is a mother of two daughters, an International Board Certified Lactation Consultant (IBCLC), a physiotherapist, author of 'The Newborn Baby Manual' and an Australian Breastfeeding Association Counsellor. In her spare time, Renee enjoys spending time with family and friends, horse riding, running and reading.


  1. I’ve successfully nursed two babies and when my third was born nursing hurt and he was very colicky and was diagnosed with reflux. His doctor prescribed him anti reflux medicine. A friend suggested my little one may be tongue tied. I found a preferred provider and she performed a laser frenectomy. By the end of the the first day he was a different baby. No more colicky and reflux was gone. Now after lots of research I think providers are completely not informed on ties and breastfeeding. I also feel that many providers are performing the procedure who are clueless. Many oral aversions are happening not due to stretches but due to the fact the ties weren’t diagnosed when mom first had symptoms early on.

  2. As someone who has personally dealt with a tongue-tie, I can easily say that it affected my breast feeding journey. I was told that he had a tongue at birth but was told to wait it out, so I did. And was in pain until we got it revised at 3.5 months.
    My son wasn’t even in the 1st percentile and we had multiple weight checks at 2 months.
    Even the ENT we went to said his tie was minimum and he didn’t think it would make a difference. But I went with my gut feeling and had it clipped anyway.

    Best. Decision. Ever.

    I’m no longer in pain and my son has jumped to the 15th percentile.
    9 months in and we are still going strong.
    I just wish I had done it sooner.

  3. Are you KIDDING me? It’s clear you are woefully uninformed on this topic – you have no idea what you’re talking about. I can only hope your wildly inaccurate “reporting” on this topic doesn’t reach any new mothers who are struggling with tongue-tied babies. You should be ashamed of yourself for this poorly written, uninformed piece – there’s a very good chance you are causing actual harm with this.

    -A Tongue-Tied Adult who has STRUGGLED

    1. Hi Allison! I didn’t write the article, but I just wanted to comment that pretty much all of the professionals are in agreement that it’s not being done often enough in those who need it, and being done too often in those who don’t need it. I’ve highlighted that in the posts to make it more clear that we feel sometimes it is necessary, and sometimes you may need to seek second or third opinions if you’re not happy with the solutions you’re being offered. And ultimately, if you are suffering from breastfeeding issues, to please seek help.

  4. I am the mother of a 24 month old little girl. She is still nursing. I can tell you personally, as can many other mom’s that I personally know, that a restrictive upper lip tie can be devastating to the breastfeeding relationship. The top lip, when not tied, should be positioned neutral while nursing, not flanged out, and not rolled under. A baby with a very restrictive upper lip tie will have a top lip that rolls under. This prevents a good latch, allows air in, creates reflux problem, absolutely wrecks the mother’s nipples, and just flat out ruins the breastfeeding relationship. A baby with an upper lip tie will nurse even more frequently than an untied baby, and often times will fall asleep nursing, because they are working so hard to remove the milk that they want but have so much difficulty. They live on the letdown. And when your body gets you around the three month mark and starts to regulate your supply, your supply tanks, because your baby’s shadow latch and ineffective suck don’t simulate the milk. My daughter’s upper lip tie was revised at six weeks and it was an instant relief!! I looked at my husband and our doctor and said “so this is what nursing is supposed to feel like”. I cried! Tears of joy! It was absolutely life changing!!! So, yes, there are restrictive upper lip ties, and those should be considered for revision. The only reason my daughter is still nursing now is because of her upper lip tie release!

  5. My daughter was born healthy at 7 pounds 13 oz. feedings took 1-1.5hrs and she would often fall asleep, she choked during every feeding and milk would spill out of her milk.. breastfeeding and bottle didn’t work. She started losing weight or not gaining at 2 months she was 11 pounds 5 oz (normal) at 4 months she was 11 pounds 6oz (not normal) at four months she had her revision went from 18opd to 30opd 1hr feedings to 15 minutes and now she’s finally coming back up the weight chart at nearly 8 months old she’s 15 pounds. I knew it was toes and no one would listen. They said it was her sick swallow breathe reflex we saw 2 pediatricians , ENT, lactation, 2 feeding therapists , and finally a pediatric dentist .. I believe the term you are looking for is under diagnosed

  6. There are not enough providers out there who are skilled in diagnosing and treating ties! They are severely UNdiagnosed BECAUSE medical professionals don’t understand what they are dealing with!! And FYI, I’m a speech therapist and posterior ties MAJORLY affect speech and feeding! It restricts the ability for the back of the tongue to lift- when does the back of the tongue lift? When saying certain sounds, and when SWALLOWING FOOD!! And while breastfeeding, the BACK of the tongue compresses on the breast to get milk flowing. So yes an undiagnosed posterior tongue tie can horribly affect not only the breastfeeding relationship but also future ability to say certain sounds and cause feeding difficulties. Where there is a lip tie, you will in MOST cases find a tongue tie. Usually posterior tongue tie.

  7. Due to decades of formula use doctors and medical professionals are inept at dealing with breastfeeding problems. We’re also in a new time where people can mass share information and troubleshoot their problems online. I’ve had two tongue tied babies, their limited tongue movement prevented the milk let down leading quickly to suppply issues, Without ‘the snip’ breastfeeding would’ve been disastrous. All cases are different of course and what we want is the whole medical community pushing for quality studies into this. Some of the professionals quotes above irritate as they seem to put the onus back onto the mother who is desperately trying to solve a problem real or perceived. It’s the medical community that should be solving this and offering fact based solutions not adding unhelpful statements based on their opinion.

  8. Articles like these while acknowledging the benefits tend to really shame others into thinking that tongue ties are more of a trend and that’s not what I’m seeing with those who do get their ties cut. And from everything that I have read, the earlier its done the better.

    What needs to happen is child health nurses, gp’s and other professionals should be trained to identify this and consider it the cause of issues.

    The problem isn’t a growing trend. It’s a health condition that gp’s, paediatricians, and even child health nurses and some lactation consultants don’t have enough knowledge on it.

  9. As a mother of 2 tongue tied babies I actually feel it is not diagnosed enough. I had my son checked several times before his tie was found and snipped. I had vasospasms from his tie and he wouldn’t go longer than 1hour between feeds, he also suffered severe colic. Once his tie was snipped (25% posterior tie snipped) his colic went and he started going 2-3 hours between feeds. We went on to feed for 16 months. Then I had my daughter and her tie was snipped at 3 days old but I was still in excruciating pain. I saw so many breastfeeding counsellors and Lactation consultants worked on her latch endlessly and ended up with the top of one nipple missing and the other with a hole so big I could put the tip of my little finger in it. Eventually she was diagnosed with still being tongue tied. It was 10% posterior tie so tiny! I though our breastfeeding journey was over as I was dreading every feed and we were both distressed but one snip changed everything at 5 weeks. My nipples started healing and she started latching better. The size or location of the tie does not matter! Until her tie was snipped my daughter wouldn’t bottle feed or cup feed so the only way o could feed was breastfeeding. Once it was done my life and hers changed dramatically and again we fed for 16 months when she self weaned. All those consultants who didn’t count a tie as less than 25% and didn’t spot it almost ruined my chances of breastfeeding and if I hadn’t had steely determination to continue we wouldn’t have had that journey. Some of the research used in this article has not used very good sample sizes and so is not fully informed. As a mother being made to feel it is a latch issue when it wasn’t was totally unhelpful.

    1. Thanks for your comment Rachael. What research are you referring to when you say ‘Some of the research used in this article has not used very good sample sizes and so it not fully informed’?

  10. I think this article is a very balanced and well written prècis of the complexity around this issue, and I agree with many of sentiments of the Lactation professionals who are dealing with this issue every day. The vehement commenters that disagree with the article say the ‘sample sizes are small’ yet quote their own breastfeeding experience as evidence, where presumably n=1. The one thing we can all agree on is a need for independent research into this matter, for the benefit of all concerned.

  11. Karen’s statement about upper lip tie is totally incorrect!! If a baby can’t flange the lips and get a good deal then bf won’t happen.
    Best decision ever to get lip tie lasered and posterior tongue tie clipped at 4 weeks old for us.
    I’m also a speech pathologist and work with children with speech difficulties due to ties not being dealt with- not ideal and very tricky from a. Therapist point of view.

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