Tongue Tie and Frenectomy: Evidence-Based Guide for SLPs

Written by Sarah Keller, Last Updated: November 20, 2025

Whether you’re working in the NICU with newborns struggling to feed or helping older kids with swallowing or speech, the issue of tongue ties will come up sooner or later. This is the one area in SLP practice where you’re likely to encounter strong opinions from parents and practitioners, so it’s essential to be well-versed in the debate and prepared with an evidence-based response.

We aren’t taking a neutral position simply because it’s safest. We feel it’s essential to present scientific evidence and clinical experience on both sides of the debate so that parents and practitioners can reach informed conclusions.

When mother and nurse practitioner Katy S. saw her first child, Hudson, drop from the 89th percentile to the 1st percentile and was labeled failure to thrive, no one mentioned examining his tongue. Now, she wonders if this simple step could have saved her family from an agonizing start to parenthood.

“Spending a few weeks with your child in the NICU is not an experience you forget,” Katy says.

When Katy’s second child, Harper, also lost a dramatic amount of weight within the first week of life, it felt like her worst nightmare on repeat.

This time, Katy took the advice of a family member and a friend and brought Harper in for a tongue-tie evaluation by a pediatric dentist.

“Once her tongue tie was lasered, she gained a pound a week for the next two weeks,” Katy says.

Katy shared this success with her pediatrician and the SLP working with her oldest, Hudson, on his speech. “They both were pretty astounded by the fact that she (Harper) had gained so much so quickly.”

This experience sparked questions for Katy, both as a mother and medical practitioner: Did her son have a tongue tie? (Yes, she discovered after a recent dental appointment.) Could they have been spared the trauma of his dramatic weight loss and time in the NICU? (Possibly.) Could this tongue tie be a factor in his current slow progress with speech therapy? (Depends on which professional you ask.)

What Is Tongue Tie (Ankyloglossia)?

Tongue tie (ankyloglossia) is a condition where the lingual frenulum restricts tongue movement. The frenulum is the thick band of tissue stretching between the tongue and the floor of the mouth. When this tissue limits the tongue’s ability to function correctly, it can affect feeding, eating, and potentially speech development.

According to a 2020 systematic review and meta-analysis in Pediatric Research, the overall prevalence of tongue tie in children under 1 year is 8% (95% CI 6-10%), with higher rates in males (7%) than females (4%).

Types of Tongue Tie

Anterior Tongue Ties are visible flaps of tissue attaching the tip, middle, or base of the tongue to the floor of the mouth. These are the classic forms of ankyloglossia and are generally easier to identify.

Posterior Tongue Ties (PTT) are “hidden” ties, generally beneath the mucous membrane, and need to be felt during examination to be diagnosed. Sometimes a child is observed to have a “short tongue” when, in fact, there is a posterior tongue tie. The diagnosis of posterior tongue tie remains controversial, with some practitioners questioning whether this represents actual restriction or normal anatomical variation.

Lip Ties occur when the flap of tissue from the upper lip to the gums appears to restrict proper flanging for breast and spoon-feeding. Some babies present with both tongue and lip ties.

Seeing a tie doesn’t necessarily indicate a child will automatically face difficulties, as not all ties significantly restrict movement. The 2020 American Academy of Otolaryngology clinical consensus statement emphasizes that practitioners should focus on function rather than form when evaluating tongue-tie.

The Tongue Tie Controversy

It’s these questions that have Katy, and many parents like her, navigating the ongoing tongue tie debate. From the prevalence of ties to their impact on swallowing and speech, practitioners offer varying opinions, often with limited evidence to support their positions.

Parents are left to make decisions based on conflicting information:

• Should I subject my tiny newborn to an uncomfortable, albeit minor, laser surgery, or focus on therapeutic modalities such as lactation support and oral motor interventions?
• If I don’t opt for tongue-tie revision, will my child experience increased swallowing issues when we start solids? What about speech development?
• What about my older child who struggles to make certain sounds? Would a tongue tie revision help, or should my therapist focus on compensatory methods?

You, the practitioner, can equip parents to make informed decisions they’re less likely to regret by providing a clear explanation of current evidence, clinical experience, and acknowledged research gaps.

Tongue Tie and Infant Breastfeeding

As a pediatric SLP, you may be called on to support mothers like Katy, whose infants present with extreme, inexplicable weight loss in the first weeks of life.

Evidence for Frenectomy in Breastfeeding

The most substantial evidence for tongue-tie intervention comes from infant breastfeeding. A 2014 study of 264 mother/baby pairs by Dollberg, Marom, and Botzer found “favorable effects of frenotomy on breastfeeding.”

Additional AAP-endorsed studies showed immediate, significant improvement that could not be attributed to a placebo. In one randomized controlled trial, 78% of babies showed immediate improvement after frenotomy, compared to 47% in the sham procedure group. By three months, 92% reported improved feeding.

SLP and IBCLC Nina Isaac notes that tongue ties can lead to numerous issues, including:

• Nipple pain and damaged nipples
• Poor milk transfer
• Low milk supply
• Early cessation of breastfeeding
• Failure to thrive
• Dysphagia
• Difficulty transitioning to solids
• Dental issues

Recent Research Findings

A 2024 American Academy of Pediatrics clinical report titled “Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants” 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.

A large 2023 randomized controlled trial (the FROSTTIE study) found no difference between frenotomy and observation for breastfeeding outcomes at three months. This high-quality study added important data but highlighted that many questions remain unanswered.

A 2025 study from the University of California, San Francisco, examined 1,454 patients using a multidisciplinary model that prioritized clinical swallow evaluations by speech-language pathologists and lactation consultants before surgical referral. The model reduced frenotomy rates while improving breastfeeding outcomes and health equity for publicly insured patients.

Current Consensus

While some professionals continue to express doubts about the effectiveness of frenectomies in infants, a larger percentage agree that, in certain circumstances—particularly severe anterior tongue tie with documented feeding difficulties—a revision can be an essential intervention. The controversy tends to center on:

• Which cases truly require surgery versus lactation support
• Whether posterior tongue ties exist as a distinct entity
• The role of maternal factors versus infant anatomy
• Whether current rates reflect medical necessity or over-treatment

Tongue Tie and Feeding in Toddlers and Older Children

In her ASHA Leader Blog post, Melanie Potock, MA, CCC-SLP, notes that she has observed indicators of tongue-tie among children referred to her practice for feeding difficulties. Some indications include:

• Inadequate caloric intake due to inefficiency and fatigue
• Tactile oral sensitivity secondary to limited stimulation/mobility of the tongue
• Difficulty progressing from “munching” to a more lateral, mature chewing pattern
• Affected swallowing patterns and compensatory motor movements
• Picky eating because certain foods are challenging
• Gagging and vomiting when food gets “stuck” on the tongue

In an anecdote published in the ASHA Leader Blog, Robyn Merkel-Walsh (MA, CCC-SLP) writes that a 34-month-old child, Bobby, developed food aversions and couldn’t properly use his tongue to move food around his mouth to swallow. After a series of treatments, including surgery, Bobby continued to struggle. Ultimately, an aggressive tongue-tie revision led to successful eating.

The Evidence Gap

While these anecdotes appear compelling, comprehensive research on the link between tongue ties and feeding difficulties with solids is lacking. In an interview about overtreatment of ties, Australian SLP Holly Tickner says, “Many children have trouble learning to eat and they have no oral ties at all.” She’s concerned that older babies are sometimes referred for frenectomies before practitioners explore other possible physiological issues.

Tickner isn’t alone in her assessment. Research on tongue ties and swallowing stirs up a confusing mix of professionals who strongly support and firmly deny the connection between tongue ties and difficulties with solids. Most opinions on either side are based on clinical experience, as so little research is available.

Tongue Tie and Speech Development

Katy learned that her own brother and mother had ties released at ages 5 and 7, respectively, to improve speech problems. She shares that both family members showed significant improvement after the procedure.

SLP Dawn Moore has also observed impressive improvement in some of her patients following a tongue-tie release.

“So many SLPs have struggled with children not making progress and wondered why they could not correct their errors,” she writes. It’s these children she suspects may be affected by tongue-tie. For those with doubts, she offers audio clips demonstrating the child’s speech before and after revision.

Research on Speech Outcomes

A 2024 systematic review and meta-analysis in the Annals of Otology, Rhinology & Laryngology examined speech outcomes following frenectomy for tongue-tie release. The review found that evidence for speech-related benefits of frenectomy is inconclusive, due to low-quality or mixed evidence, with most studies exhibiting methodological limitations.

A 2024 randomized controlled trial by Zhao et al. examined the efficacy of infant tongue tie release on speech articulation. However, the study faced the common challenge that speech assessments occurred months after the procedure. During that time, children also received speech therapy, making it difficult to isolate the effect of the frenectomy alone.

One small study of 30 children aged 1-12 concluded that “tongue mobility and speech improve significantly after frenuloplasty in children with ankyloglossia who have articulation problems.” However, critics point out that in most related studies, pre- and post-operative assessments could be months apart, sometimes with additional therapy in the interim, making causation difficult to determine.

Clinical Reality

Experts note that most speech delays are likely multifactorial and not solely caused by ankyloglossia. Some patients may benefit from frenotomy, while others with severe tongue restriction show no articulation issues. Conversely, some children with significant speech delays have little or no tongue-tie restriction.

Dr. Kristina Rosbe, professor and chief of pediatric otolaryngology at UCSF, evaluates claims linking tongue tie to speech delays “very suspiciously,” noting that “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.

So again, you as the SLP find yourself with no definitive answers—only a mix of limited data, clinical experience, and anecdotal evidence to present to parents making difficult decisions.

Over-Diagnosis vs. Under-Diagnosis: The Great Debate

Much discussion in the tongue-tie conversation focuses on the question of over- or underdiagnosis.

Historical Context

While it’s true that tongue tie seems to have “suddenly” surfaced in the past 10-20 years, mentions of tongue tie can be found as far back as biblical times. In medieval times, midwives kept one fingernail long specifically to slit the frenulum directly after birth. In the 1900s, with the advent of formula and bottle-feeding, tongue ties were much less likely to affect infant growth, so they fell out of the modern birth conversation.

With the recent emphasis on breastfeeding in Western countries, the question of tongue ties has resurfaced as a surprising number of mothers discover breastfeeding difficulties.

Rising Rates Without Rising Evidence

A 2025 systematic review published in Otolaryngology–Head and Neck Surgery examined 462 articles on tongue tie published from 2017 to 2024. The review found an exponential rise in publications on ankyloglossia and lingual frenotomy, yet no corresponding increase in high-quality evidence to clarify the controversies surrounding these critical topics.

Of the 462 articles, cohort studies were most common (38.7%), while randomized controlled trials—the gold standard for evidence—comprised only 2.8%. The authors concluded that future studies should be quality RCTs with meaningful outcome measures.

The Over-Treatment Question

The increase in diagnoses may reflect changing times and increased awareness. It’s also likely that, as practitioners have become more aware of tongue ties, they’ve inadvertently become over-focused on them, leading to over-diagnosis.

In an interview with IBCLC Renee Kam, pediatric ENT surgeon Dr. David McIntosh says that regarding tongue-tie releases, “too many inappropriate ones and not enough appropriate ones” are being performed.

Dr. Edward Harley, an otolaryngologist, has seen a drop in tongue tie surgeries in his practice since 2023, which may correspond to when he stopped using a laser. “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. 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.”

The Team Approach

In her ASHA Leader Blog post, SLP Melanie Potock explains that the SLP’s role is to screen, not diagnose, and then refer concerns to an ENT, pediatric surgeon, or pediatric dentist trained in recognizing tongue ties. This team approach helps to avoid missing or over-diagnosing ties.

Current Research and Evidence Gaps

One thing all professionals appear to agree on is the need for more research.

“Much is being talked about in this area and there is a lot of controversy, yet no one is systematically studying this,” says David Francis (M.D., MS), author of a report examining the existing literature on tongue tie release.

As ENT Dr. Christopher Chang points out, “Just because quality data is lacking does not mean tongue tie release should not be performed.”

What We Know (As of 2025)

Assessment Tools

A 2025 systematic review in the International Journal of Pediatric Otorhinolaryngology examined assessment tools for diagnosing ankyloglossia in infants. The review identified nine assessment tools with varying parameters and inconsistent reporting of reliability and validity.

The Lingual Frenulum Protocol for Infants (LFPI) had the most reported reliability and validity and is the most comprehensive tool. However, few studies used a measure of feeding function as a diagnostic feature, highlighting the ongoing challenge of standardized assessment.

Standard assessment tools include:

• Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) – Assesses both anatomy and function
• Bristol Tongue Assessment Tool (BTAT) – Screening tool based on tongue appearance and movement
• Kotlow Classification – Based on measurement of free tongue length
• Coryllos Classification – Based on the location of the frenulum attachment
• Lingual Frenulum Protocol for Infants (LFPI) – Most comprehensive for infant assessment

The SLP’s Role in Tongue Tie Management

As an SLP, your role in tongue tie management involves several key responsibilities:

Screening and Referral

SLPs screen for potential tongue tie but do not diagnose. When you identify restricted tongue movement that may be impacting feeding or speech, refer to specialists qualified to diagnose:

• Pediatric ENT (otolaryngologist)
• Pediatric dentist with tongue tie training
• Pediatric surgeon
• Lactation consultant (IBCLC) for infant feeding assessment

Providing Balanced Information

Help parents understand both what research shows and what it doesn’t. Be honest about:

• Strong evidence for severe anterior tongue tie affecting infant breastfeeding
• Limited evidence for posterior ties, lip ties, and older children
• The multifactorial nature of speech and feeding difficulties
• Alternative interventions that may help (lactation support, compensatory strategies)

Collaborative Care

Work as part of a multidisciplinary team, including:

• Pediatricians for overall health monitoring
• Lactation consultants for breastfeeding support
• ENTs or dentists for surgical evaluation if indicated
• Occupational therapists for feeding therapy

Documentation and Functional Assessment

Focus your assessment on function over form:

• Can the tongue elevate to the alveolar ridge?
• Can the tongue lateralize to move food?
• Can the tongue extend past the lower lip?
• Does restricted movement correlate with the presenting problem?
• Are there compensatory patterns developing?

Post-Surgical Support

If a frenotomy is performed, SLPs often provide:

• Pre-surgical counseling about expectations
• Post-surgical exercises to prevent reattachment
• Continued feeding or speech therapy as needed
• Monitoring for functional improvement

Frequently Asked Questions

Sarah Keller

Sarah M. Keller, MS, CCC-SLP, is a licensed speech-language pathologist with 15 years of experience in pediatric clinics and university training programs. She earned her master’s in speech-language pathology from a CAHPS-accredited program in the Midwest and supervised clinical practicums for online and hybrid SLP cohorts. Sarah now advises students on graduate school applications, clinical fellowships, and state licensure. She lives in Colorado with her family and golden retriever.

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