We are concerned by the emerging industry of private practitioners offering “posterior tongue tie” or “lip tie” division to newborns with feeding difficulties despite a paucity of evidence in this area.
A tongue tie (or ankyloglossia) occurs when the frenulum of the tongue is abnormally short or tight and is estimated to occur in 4-11% of newborns.  Although not always problematic, it can, in some newborns interfere with the ability to latch and in extreme cases contribute to feeding difficulties, weight loss, and maternal mastitis. Diagnosis is subjective, on the basis that the lingual frenulum is seen to be short or tight and causing restriction of tongue movement.
Although the evidence base for ankyloglossia division is generally quite weak, standard practice in the UK would be to offer to divide the visibly tight frenulum in those babies who are struggling with feeding. Division of a tongue tie is a fairly well-established and safe procedure and involves division of the visible frenulum using sharp dissection scissors, usually in an ENT outpatient setting.  A Cochrane review from 2017 suggested a reduction in maternal nipple pain, but recommended further randomised controlled trials of high methodological quality to investigate further the impact on infant breastfeeding.  A recent Canadian review suggested that tongue-tie division likely has a positive impact on maternally reported or perceived breastfeeding effectiveness in the short-term, but that benefit is less clear for long-term outcomes and objective measurements of breastfeeding effectiveness. 
Over recent years the concept of “posterior” tongue tie as a reason for feeding difficulties in newborns appears to have gained popularity, particularly among various online parenting forums and breastfeeding support networks. Definition varies, but the concept is generally thought to represent a tight non-visible submucosal band of tissue at the very base of the ventral tongue that is palpated rather than seen. This is very different from the classically reported “anterior” tongue tie which is usually easily visible and simple to divide. As yet, there is no definitive anatomical study or robust definition within the literature, nor evidence to prove a causal relationship of posterior tongue tie with feeding difficulties in affected babies. For this reason, posterior tongue tie is generally not recognised or treated currently by professionals within the NHS setting.
Despite this, there appears to be a large industry of private practitioners in the UK that have emerged who offer to deal with the ailment, usually for a fee of several hundreds of pounds. A quick online search uncovers scores of private practitioners willing to travel to assess and treat newborns for posterior tongue tie, offering hope to struggling mothers desperately researching online for ways to help their baby feed better. Proponents advocate division of the non-visible band, using deep submucosal dissection at the base of the lingual frenulum with scissors or laser. This is a much more invasive dissection than the traditional anterior tongue tie division offered at NHS clinics. Without good evidence to back up treatment decisions, we believe that such practitioners are not practicing ethically and are potentially exploiting a vulnerable population group who would be willing to try (or pay) anything to help their newborn baby feed better. It is our opinion that offering posterior tongue tie as an explanation for these feeding difficulties has no role in current evidence based medical practice.
Babies can struggle to feed well for a multitude of reasons, yet “getting checked out for a posterior tongue tie” is becoming increasingly popular. We have noticed a dramatic increase in the number of babies referred to our ENT services with concern over posterior tongue tie, driving up waiting times which often then leads struggling parents to seek a quicker opinion from the private sector. The ambiguity surrounding the condition and its rather vague features only seems to fuel parental concern and encourages activity within the industry that has arisen to deal with it.
A similar phenomenon has been observed with the concept of “lip-tie”, where the frenulum of the upper lip is felt to be tight by some practitioners and therefore restrictive to feeding (again, without any robust definition or evidence of a link to feeding). There are an increasing number of mothers enquiring about these conditions at NHS clinics and via health visitors, GPs and midwives, many of whom are unsure themselves about the condition, what it means, and what to do with it. Expectation management, given the wealth of information available to mothers online, remains challenging.
We remain concerned that practitioners who are incising into the submucosa of the ventral tongue for “posterior tongue ties” are potentially exposing that baby to the risks of infection, bleeding, and also potentially longer term scarring, nerve or ductal damage without any quality evidence to support the procedure. Should a complication arise, we propose it would be hard to defend medicolegally. We would argue that until a robust definition of posterior tongue or lip tie is developed and there exists evidence to prove an impact on feeding, then blind surgical dissection within the submucosa of the tongue base in babies should be avoided. Until such times, parents should be offered intensive support with feeding techniques. 
Lyndsay Fraser, Consultant ENT Surgeon, Crosshouse Hospital, Kilmarnock.
Stuart Benzie, Staff Grade ENT Surgeon, Crosshouse Hospital, Kilmarnock.
Jenny Montgomery, Consultant ENT Surgeon, Queen Elizabeth University Hospital, Glasgow.
Competing interests: None declared.
Not commissioned, peer reviewed.
- Division of ankyloglossia (tongue tie) for breastfeeding. Interventional procedures guidance. NICE, Dec 2005. www.nice.org.uk/guidance/ipg14
- O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, Davis PG. Frenotomy for tongue-tie in newborn infants.
Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD011065.
- Frenectomy for the correction of ankyloglossia: a review of clinical effectiveness and guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Jun. CADTH Rapid Response Reports.
- Unicef Baby Friendly Initiative https://www.unicef.org.uk/babyfriendly/