Serena Francis was unable to breastfeed her first baby, so when her second came along in October last year, she was desperate to try.
‘Ludo was premature and feeding him was complicated, so I was really keen to breastfeed Juna,’ says Serena, 33, an estate agent. ‘But when I was struggling to get her to latch on in hospital, an NHS midwife said she thought she had tongue-tie.’
Tongue-tie is where the frenulum — a strip of tissue connecting the tongue to the bottom of the mouth — is shorter or tighter than usual.
The procedure may be suggested by midwives or health visitors when there are problems with breastfeeding, because a tie is thought to restrict tongue movement (to breastfeed, a baby must be able to extend their tongue and pull the breast into their mouth; bottle feeding requires less effort).
Serena says: ‘At home, we consulted a breastfeeding expert privately who didn’t agree it was tongue-tie. She helped Juna feed successfully, but I struggled to get her to latch on my own.’
Serena Francis, 33, with second child Juno who she was really keen to breastfeed as she was unable to do so with her first baby
The health visitor also thought Juna had tongue-tie and recommended cutting the tight tissue under the tongue, a remedy known as a frenectomy, frenotomy or frenulectomy.
‘She said: ‘It’s severe, we’ll add her to the NHS list to get it cut’,’ recalls Serena, who lives in London with her husband Toby, 33, who works in insurance, and their children Ludo, three, and Juna, nine months.
‘But the waiting list was long —several months — and my husband’s parents offered to pay to get it done quickly.
‘A friend recommended a tongue-tie practitioner who other friends had used. She came the same day, confirmed it was a ‘really bad’ tongue-tie and snipped it with scissors on the kitchen table, at a cost of £300.
‘There was no pain relief, it bled a little and Juna cried briefly. I think she was here for about 12 minutes and we didn’t see her again.
‘But sadly, it didn’t work. Juna still couldn’t latch and a few weeks’ later I gave up and switched to formula, which was a shame because I really wanted to breastfeed.’
Serena’s experience captures the bewildering lack of consistency as to what constitutes a tongue-tie and if and when it should be cut.
What’s more, there is evidence that tongue-tie is being over-diagnosed, fuelled by false information on social media about how undiagnosed tongue-tie can have serious behavioural consequences for children in later life — even when there are no newborn feeding issues.
Last week, a report from The American Academy of Pediatrics warned that tongue-tie may be over diagnosed in the US and often treated with unnecessary surgery.
Dentists use state-of-the-art laser machines to perform tongue-tie procedures in the US — and business is booming: Frenotomies rocketed tenfold in 15 years, from 1,200 in 1997 to 12,400 in 2012.
Serena pictured with newborn baby Juno who was diagnosed with tongue-tie – where the frenulum – a strip of tissue connecting the tongue to the bottom of the mouth – is shorter or tighter than usual
The report said the procedures can cause pain and sore mouths, potentially deterring babies from trying to breastfeed — and encouraged medical professionals to consider non-surgical options to address breastfeeding problems.
Overdiagnosis is a worry in the UK, too. But as no one in the private sector (where many frenotomies are being done), is collecting data, the true figures are impossible to know. Yet even in the NHS the number of these procedures is soaring.
In 2022-23, 18,729 frenectomies were performed in NHS outpatient departments — up from 2,550 in 2016, and just 31 in 2004, according to NHS Digital. As it isn’t mandatory to record procedure codes, these figures can only be estimates. But they suggest a staggering rise, set against a dearth of consistent information — and no mandatory standardised training.
Dr Rose Scott, a GP in South London, is one of those concerned about the number of new mothers worried their baby had tongue-tie, known medically as ankyloglossia.
‘You hardly ever see a genuine tongue-tie — it’s extremely rare,’ she says. ‘Yet I’ve seen more and more babies in clinic with perfectly normal anatomy whose parents were convinced they had tongue-tie and wanted them cut.
‘Mums worry the baby will never talk properly or be able to eat solids without treatment, which is nonsense,’ says Dr Scott.
‘When I had my first child three years’ ago and joined mothers’ social media groups in my area, I realised that what we are seeing in the medical world is just the tip of the iceberg.’
She says she’s come across extreme examples, such as one mum who said she had all four of her babies’ frenulums snipped (including a set of twins) hours after arriving home from hospital, ‘as a precaution’. Another mum warned that doctors and nurses ‘know very little about the serious repercussions of tongue-tie, which include behavioural and emotional problems’, says Dr Scott.
Frenotomy is sometimes promoted as a cure-all for sleep apnoea or reflux, and to prevent speech, language and behavioural difficulties in later life – yet there is no evidence of a link with behavioural issues in later life.
While some frenotomies are done in NHS clinics, many are done at home by private lactation consultants, often midwives who have done extra training, hired to provide breastfeeding support – at a cost of about £200-£300.
It is normally done with a pair of sterile, surgical scissors without anaesthetic. (Current National Institute for Health and Care Excellence NICE guidelines recommend that anaesthetic is generally only required after the first few months of infancy.)
According to the women who spoke to Good Health, many procedures are happening on kitchen tables – with no follow-up care and no record they took place.
‘Very often a lactation consultant tells a mum that a tongue-tie is definitely present and the cause of problems like poor latch and sore nipples,’ says Dr Scott.
‘The vast majority of these procedures never appear in babies’ medical notes. Babies’ GPs are not notified so we have no way of knowing exactly how many are happening across the UK.’
The Hazelbaker Assessment Tool for Lingual Frenulum Function [HATLFF] is a globally accepted method of assessing the frenulum and tongue for tongue-tie.
Most paediatricians, speech therapists and lactation consultants, whether private or within the NHS use this method. Yet there are often conflicting opinions as to whether a tie is the cause of feeding problems. To add to the confusion, there is little evidence that cutting them improves breastfeeding long term.
Dr Alison Hazelbaker, a lactation consultant and craniosacral therapist from Ohio in the US, whose 1993 research on tongue-tie, informed practice all over the world — and who the tongue-tie assessment scale is named after — believes we may be in the midst an ‘an epidemic of misdiagnosis’.
Serena’s experience captures the bewildering lack of consistency as to what constitutes a tongue-tie and if and when it should be cut
‘The scientific literature, which is mostly poor quality, reports a 3-5 per cent rate of occurrence of tongue-tie; in my experience it’s nearer 1-1.5 per cent,’ she says.
‘In my 40-year career, I can count the number of true tongue-ties I’ve seen on two hands.
‘People are over-diagnosing tongue-tie, because they don’t understand what the real problems could be,’ she continues.
‘For instance, a forceps or C-section delivery or an epidural can all cause tensions in a baby’s neck and this can affect ability to suck, swallow and breathe — necessary to breastfeed.
‘Until practitioners understand all the ways that breastfeeding can be compromised they are going to use this catch-all diagnosis.
‘They think they have improved the situation through surgical intervention, but there are always better ways to solve the real problems with feeding than by cutting a baby’s mouth.’
Clare Byam-Cook, a former midwife and leading breastfeeding specialist based in London, has also seen a huge rise in tongue-tie misdiagnosis over the past ten years.
‘I used to see one or two babies a year who had a genuine tongue-tie, but now approximately eight in ten mothers has been told their baby has or might have a tongue-tie.
‘While I do recognise that some babies have a tongue-tie that needs to be cut, it’s now being used as the ‘go to’ reason for all breastfeeding problems,’ she says.
She believes the reason many mothers struggle to latch the baby on or experience pain is because midwives and health visitors are not showing them how to do it successfully – and instead blame a medical problem like tongue-tie.
The NICE guidelines on tongue-tie were last updated in 2005, acknowledging the ‘controversy regarding the significance of tongue-tie in relation to breastfeeding difficulties’ and ‘the appropriate management of the condition’.
The controversy is far from new. In the Middle Ages competition was fierce between midwives – who charged to cut the frenulum with a fingernail – and surgeons who used instruments.
Yet it doesn’t always achieve what it’s intended to do.
‘None of the published literature has demonstrated that frenulectomy results in a greater duration of breastfeeding,’ says Stephen Borowitz, a professor of paediatrics and public health sciences at the University of Virginia Children’s Hospital in the US.
He reviewed all the available global research on tongue-tie and frenectomy to date, publishing his findings in the journal Frontiers in Pediatrics in 2023. What’s more, most babies who have a tie don’t have any symptoms, ‘so the assumption that it is the tongue-tie that is causing breastfeeding problems is questionable’, says Professor Borowitz.
‘Particularly since the vast majority of infants with breast-feeding problems attributed to tongue-tie are firstborns suggesting that there are maternal and social factors at play.’
Nonetheless, says Alison Hazelbaker, ‘cutting has caught on and, with the help of social media, spread like wildfire’.
Charlotte Green, 32, and her husband Keiran, 33, who live in Hertfordshire and both work in IT, saw a tongue-tie specialist for their daughter Maya, now six months. They were concerned that she often vomited after a feed.
‘She told me Maya had a very severe tongue-tie’ says Charlotte. She charged them £180 to treat Maya saying it would help.
‘Maya cried, but there was no blood. It wasn’t that traumatic,’ recalls Charlotte. ‘But neither was it the answer,’ she admits.
‘The vomiting stopped eventually. But in hindsight, I think she was just little and I had a lot of milk.
‘I feel embarrassed about how much we spent – but if you look online you’ll see tongue-tie connected to things like speech and language difficulties,’ says Charlotte. ‘It was frightening.’
Such stories concern Alison Hazelbaker because they highlight the vulnerability of new mothers who feel huge pressure to breastfeed – and the size of the industry that’s grown up around them.
‘You should exhaust every other avenue before you decide to perform surgery on a baby, even if that surgery is minor,’ she says.
‘The literature is now reporting the harms of doing unnecessary surgery – particularly by laser.’
Professor Borowitz agrees: ‘Based on the available evidence, and potential risk of harm, I do not believe the dramatic increase in frenulectomy is justified.’
Luci Lishman, a lactation consultant and chair of the Association of Tongue-Tie Practitioners, says: ‘It is possible that frenotomy can be seen as a quick-fix when perhaps other causes of feeding issues haven’t been explored first.
‘We do not support frenotomy in babies under 12 months being carried out to prevent future difficulties or for issues that don’t relate to feeding.’
The organisation is working on standardised training for its 204 members, which include nurses, midwives, doctors and dentists.
Luci Lishman says: ‘As there is a risk of over or under-diagnosis, it is vital that babies are assessed by tongue-tie practitioners who specialise in infant feeding – ideally an international board-certified lactation consultant, the gold standard qualification. In many cases adjustments to feeding techniques are enough to help resolve feeding issues.’
As for whose advice to trust, Alison Hazelbaker says: ‘If your baby is having problems breastfeeding, see a skilled lactation consultant who doesn’t advocate frenetomy – or market themselves on that basis – and a physiotherapist or an osteopath. Most of the time, no surgery is required. and stay off social media.’
