How is a tongue-tie release performed in infants?

A referral for tongue-tie release can leave families with a surprising number of questions: Is one method safer? Will it help feeding? What happens afterwards? Conversations about frenulotomy methods in infants should begin with the feeding relationship, the infant’s oral function and the family’s experience - not with an instrument. Anatomy provides information. Function provides context.

In UK practice, the procedure to divide a restrictive lingual frenulum in an infant is called a frenulotomy. It may be considered when a skilled assessment identifies a restrictive frenulum alongside feeding difficulties that have not improved with appropriate, individualised support. Not every visible frenulum causes feeding difficulty, and not every feeding difficulty is caused by tongue-tie.

A method is only one part of clinical decision-making

A frenulotomy is a small procedure, but it is not a stand-alone answer to a complex feeding concern. Breastfeeding, chestfeeding, bottle feeding and combination feeding can be affected by positioning, attachment, milk supply, flow preference, prematurity, birth experiences, infant health, oral-motor coordination and parental comfort, among other factors.

A careful assessment therefore considers more than appearance. It brings together the history, the infant’s feeding behaviour, observed milk transfer or bottle feeding, parental symptoms, growth where relevant, oral anatomy and tongue function. It should also allow space for what matters to the family, including whether they wish to continue with feeding support, consider a frenulotomy, or take time before making a decision.

The Academy of Breastfeeding Medicine (ABM) advises that the presence of a sublingual frenulum alone is not an indication for surgery. A decision to offer frenulotomy should be based on a functional diagnosis and shared decision-making (Academy of Breastfeeding Medicine, 2021).

What does the evidence say about frenulotomy methods in infants?

The strongest research question is often not whether one instrument is preferable, but whether frenulotomy is appropriate for a particular infant and feeding dyad. Randomised trials included in a Cochrane review found that frenulotomy may reduce maternal nipple pain in the short term. However, the trials were small, outcomes were inconsistent, and evidence for sustained improvement in infant breastfeeding was less certain (O’Shea et al., 2017).

This matters when discussing expectations. Some families notice a meaningful change after a release; others need time, skilled feeding support or further assessment of contributory factors. Some may not experience the improvement they had hoped for. A thoughtful consent conversation should make room for all of these possibilities.

Evidence comparing instruments and techniques is limited. The American Academy of Pediatrics states that there is no evidence that laser is superior to other approaches for infant frenotomy procedures (American Academy of Pediatrics, 2024). Similarly, the ABM notes that comparative evidence is insufficient to establish that one method is consistently better than another for breastfeeding outcomes, pain, healing or complications (Academy of Breastfeeding Medicine, 2021).

For this reason, it is not clinically helpful to frame a choice of method as a simple ranking of “best” versus “worst”. The practitioner’s training, clinical governance, ability to assess feeding function, consent process, infection-control arrangements, emergency preparedness and follow-up provision all deserve close attention.

The methods that may be discussed

In infant practice, clinicians may use sterile scissors or a thermal device, such as laser or electrosurgery, depending on their setting, training, professional scope and local governance. These approaches differ in how tissue is divided and in the equipment required. They may also involve different practical arrangements around consent, comfort measures, aftercare and review.

Families may hear claims that one approach causes less bleeding, less discomfort or quicker healing. Such claims should be approached carefully. The available evidence does not allow reliable promises about an individual infant’s experience or feeding outcome. A clinician should explain the method they use in clear, non-technical language, including known risks, uncertainties and what support is available afterwards.

The setting is also relevant. A safe service has clear eligibility criteria, appropriate clinical records, informed consent, infection prevention processes, a plan for managing complications and arrangements for post-procedure contact. These measures are not extras around a procedure - they are part of safe, family-centred care.

Comfort and analgesia

Comfort during a frenulotomy is an understandable concern. Approaches vary between services and may depend on the infant’s age, medical history, the clinical setting and the method used. Families should be told in advance what their clinician recommends and why, as well as how feeding and soothing will be supported immediately afterwards.

It is reasonable to ask how your baby will be comforted, whether you can remain present, when a feed may be offered, and whom to contact if you are worried once home. Clear answers can reduce uncertainty without minimising the emotions that may accompany the decision.

Choosing care: questions that support informed consent

A family does not need to become an expert in surgical devices to make an informed decision. More useful questions focus on the assessment and the care around the procedure. For example: what functional feeding concerns have been identified; what non-surgical support has been tried or remains available; what benefit is realistically anticipated; what are the risks; and how will feeding be reviewed afterwards?

It is also appropriate to ask about the clinician’s infant feeding expertise, their experience within their professional role, governance arrangements and how complications are managed. For healthcare professionals referring families, a detailed feeding history and observation can help ensure that a referral is based on function rather than appearance alone.

Conservative management is a valid pathway. It may include skilled support with positioning and attachment, paced and responsive bottle feeding, support with expressing where needed, and review of maternal or infant factors affecting feeding. Choosing to wait, or deciding against a frenulotomy, should be respected and accompanied by a plan for review if concerns continue.

Risks, aftercare and realistic expectations

Frenulotomy is generally described as a minor procedure, but minor does not mean risk-free. Potential complications include bleeding, pain, infection, oral aversion, scarring and the need for further assessment or treatment. Serious complications appear uncommon in the published trials, but those studies were small and may not detect rare events reliably (O’Shea et al., 2017). Good consent explains both the low frequency of serious harm and the limits of the evidence.

Aftercare should focus on the infant and feeding, rather than the wound alone. Families benefit from knowing what is expected in their particular service, when feeding support is available, and which changes require prompt clinical advice. Ongoing bleeding, breathing difficulty, marked lethargy, fever, poor feeding or a parent’s sense that their baby is unwell warrant timely assessment.

Routine exercises intended to repeatedly open or disrupt a healing wound are not supported by evidence and may cause distress. The AAP advises against recommending post-frenotomy stretching exercises for this purpose (American Academy of Pediatrics, 2024). Any oral activities discussed by a suitably qualified practitioner should have a clear functional rationale, be responsive to the infant’s cues and never replace appropriate medical review.

Feeding support after a frenulotomy remains important. An infant may be learning a different pattern of movement, while a parent may be recovering from pain, protecting milk supply or building confidence. Follow-up can identify whether feeding is improving, whether other factors need attention, and whether the family needs additional support without assuming that every concern is related to the frenulum.

For professionals: hold uncertainty with care

For clinicians, this area calls for clinical reasoning rather than protocol-led assumptions. Assessment tools can support documentation and communication, but no tool should replace a skilled feeding assessment or be used as the sole basis for surgery. The ABM stresses that tools vary in purpose and reliability, and should not independently determine whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021).

Language matters, too. Families deserve accurate explanations that neither dismiss their feeding difficulties nor imply that release will resolve every concern. A balanced conversation can acknowledge uncertainty while still offering a clear plan: optimise feeding support, assess function, consider the potential role of frenulotomy where indicated, and provide continuity whichever route the family chooses.

References

Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281.

American Academy of Pediatrics (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2024067605.

National Institute for Health and Care Excellence (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE.

O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065.

A final thought

The most reassuring next step is rarely a particular instrument. It is being heard, having feeding assessed with care, and making a decision that feels informed, supported and right for your baby and family.