Literature review
Is frenotomy effective in improving
breastfeeding in newborn babies
with tongue-tie? A literature review
Abstract
Aim: This literature review explores whether frenotomy can result in
more successful breastfeeding of newborn infants with ankyloglossia.
Method: A systematic literature search was carried out. Nine pieces of
research were chosen and appraised using two critical appraisal tools.
Findings: Three main themes emerged: the mother’s experiences of
breastfeeding; duration of breastfeeding; and latch. The majority of
studies found that frenotomy could improve latch and alleviate nipple
pain. However, there is little information available about outcomes for
babies with ankyloglossia who do not undergo the frenotomy procedure.
Conclusion: Frenotomy is a procedure that can benefit breastfeeding
mothers and babies, but the cultural and social background of families is
not addressed in much of the research, nor is the risk of distress to the
infant and parents.
Keywords: Ankyloglossia, Tongue-tie, Frenotomy, Breastfeeding, Newborn
W
ith the increasingly persuasive
evidence that breastfeeding provides
infants and mothers with significant
health benefits (Oddy et al, 1999; Kull et al,
2002; UNICEF, 2010), midwives and other health
professionals should be doing everything possible
to support women to initiate and continue
breastfeeding. In some cases, ankyloglossia (or
tongue-tie) is considered to inhibit breastfeeding,
and current National Institute for Health and
Care Excellence (NICE, 2005) guidelines support
frenotomy—division of the tongue-tie—as
an intervention to rectify this. However, the
guidelines recognise that there is limited evidence
to justify this; in addition, the guidelines are now
dated, which makes the subject of this literature
Sally Burrows review highly topical. The literature available
Midwife on frenotomy for tongue-tie is controversial
Homerton University (McBride, 2005; Edmunds et al, 2012) and lacks
Hospital NHS reliable, objective primary research studies (Hall
Foundation Trust and Renfrew, 2005).
There is no uniform definition, diagnostic
Rosemary Lanlehin criteria or classification system for ankyloglossia
Neonatal Lecturer (Ricke et al, 2005; Mettias et al, 2013). It is described
City University London as a congenital anomaly whereby the baby is
born with an abnormally short lingual frenulum
790
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(Glasson, 1998; NICE, 2005). Current NHS advice
states that the condition affects 4–11% of babies
and is more common in boys than girls (Ricke et
al, 2005). The condition can bind the tongue to
the floor of the mouth (Glasson, 1998) or restrict
the movement of the tongue (NICE, 2005). As a
consequence, the baby may not be able to draw
the breast deeply into his or her mouth, which is
a requirement of successful breastfeeding (Inch,
2009). Breastfeeding, and sometimes bottle-
feeding, can become problematic. Problems
may include inefficient milk intake and weight
gain, poor latch and pain for the mother during
breastfeeding (Griffiths, 2004; Hall and Renfrew,
2005; Edmunds et al, 2011). However, not all
babies born with ankyloglossia experience feeding
problems; estimates suggest that 25–60% of babies
will present with difficulties (Association of
Tongue-tie Practitioners, 2013; Mettias et al, 2013).
Frenotomy, or frenulotomy, is a procedure
whereby the lingual frenulum is divided using
sharp, blunt-ended scissors (Griffiths, 2004; NICE,
2005). During the procedure, the infant is usually
swaddled, his or her head is stabilised, and rarely is
any anaesthetic used (Griffiths, 2004; NICE, 2005).
Many authors argue that the procedure is simple
and associated with little or no bleeding (Hogan et
al, 2005; NICE, 2005; Dollberg et al, 2006; Mettias
et al, 2013; Emond et al, 2014).
Aim
The aim of this literature review is to improve
breastfeeding outcomes by exploring whether
frenotomy can result in more successful
breastfeeding in newborn babies with
ankyloglossia. The review critically appraises
a number of research articles in order to shed
light on this issue. It also examines whether the
procedure can alleviate the mother’s pain when
breastfeeding and improve latch in breastfeeding
babies. Additionally, this paper investigates the
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confounding factors and additional issues that
may be associated with the procedure, and its
effect on successful breastfeeding and duration of
breastfeeding.
British Journal of Midwifery • November 2015 • Vol 23, No 11

Methodology
Two databases were searched, EBSCOhost and
Ovid Online, ensuring that the most relevant
research articles could be located from a wide
range of sources (Rees, 2011). The Population,
Intervention, Comparison and Outcome (PICO)
framework (Akobeng, 2005) was employed to
define the search terms and related keywords
for the question. Boolean logic was applied,
enabling the search to be widened and focused
appropriately (Aveyard, 2007). The critical
appraisal tool CASP (Critical Appraisal Skills
Programme) (2013) was then used to review the
three randomised controlled trials (RCTs), and
the British Medical Journal’s (2015) appraisal tool
was used to review the six questionnaire studies.
Table  1 provides a summary of the research
articles reviewed.
Findings
A number of themes recur throughout the research
literature; the themes are presented in Figure 1.
Mothers’ experiences of breastfeeding
All of the research articles focused, to some degree,
on the mothers’ experiences of breastfeeding.
The questionnaire studies were more likely to
place weight on mothers’ judgement of whether
frenotomy had improved their breastfeeding.
Emond et al’s (2014) RCT incorporated
a breastfeeding self-efficacy assessment.
Interestingly, the authors found that the frenotomy
procedure did improve the maternal breastfeeding
self-efficacy assessment, but did not improve
more objective breastfeeding scores. The authors
included transcripts from interviews carried out
with mothers. These tended to be related to the
mother’s experience of pain, and her frustration at
painful breastfeeding.
Alongside Emond et al (2014), all other studies
used the mother’s experience of breastfeeding as
an indicator as to whether frenotomy had been
successful in improving breastfeeding, albeit
using different methods. Dollberg et al (2014)
pointed out that their study sample consisted
of highly motivated mothers, which may have
introduced some bias. The research articles
critically appraised tend to address the mother’s
experience in relation to pain and breastfeeding
efficiency, rather than focusing on her experience
of, and feelings towards, the frenotomy itself
and breastfeeding. However, Ridgers et al (2009)
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address the complex issue of bonding and its
effect on feeding, acknowledging that, in some
cases, tongue-tie may not be the only cause of
feeding difficulties.
British Journal of Midwifery • November 2015 • Vol 23, No 11
Literature review
Duration of breastfeeding
The majority of the studies focused on whether
frenotomy affected how long the participants
continued to breastfeed their infants. Emond et
al (2014) followed up their participants at 8 weeks
and found that 80% of both the intervention and
control groups were still breastfeeding. Griffiths
(2004) found that 64% of participants breastfed
for at least 3  months after frenotomy. O’Callahan
et al (2013) found that their participants breastfed
for a mean duration of 14 months, regardless of the
classification of ankyloglossia diagnosis. Dollberg
et al (2014) found that 56% of their participants
were breastfeeding after 6  months. Hogan et
al (2005) followed-up participants at 8  months,
finding that the 60% continued to breastfeed
until 4  months and that, by this point, 56 out of
57 infants randomised had undergone frenotomy.
This last observation helps identify a key
problem affecting this type of research: that it
is almost impossible to compare the duration of
breastfeeding between groups that did and did
not undergo frenotomy as part of the intervention.
The majority of participants in control groups
decided to opt for frenotomy eventually, and the
two groups then become more similar. The study
by Steehler et al (2012) was the only one to reveal
a genuine difference between infants who did and
did not undergo frenotomy. They found that 83%
Is frenotomy effective in improving breastfeeding in
newborn babies with ankyloglossia?
Latch
Mothers’ Latch
experiences of Emotion
breastfeeding Cracked
Nipple
nipples
Attitude
Efficacy Pain
Duration of breastfeeding
Efficacy Weight gain
Figure 1. Themes and subthemes emerging from the research articles
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 792
Table 1. Summary of research articles
Author, title Year, location Design Methods, sample size, measures used Key findings and recommendations for practice
Emond A et al 2014 Randomised 107 infants randomised into immediate ll Intention-to-treat analyses showed no difference
Randomised Bristol, UK controlled (n=55) or delayed (n=52) frenotomy. in primary outcome LATCH score. Frenotomy did
controlled trial of trial Researchers blinded as to intervention improve the breastfeeding self-efficacy assessment.
early frenotomy status. Difficulty in breastfeeding judged 15% increase in bottle-feeding in comparison group
in breastfed by LATCH score (Jensen et al, 1994). compared to 8% in intervention group
infants with Primary outcome of breastfeeding at 5 days, ll After 5 days, 44 of comparison group opted for frenotomy
mild–moderate secondary outcome of breastfeeding self- ll Early frenotomy did not result in improvement in
tongue-tie efficacy and pain scores. Final assessment at breastfeeding at day 5, but fewer of these mothers
Literature review

8 weeks switched to bottle-feeding

ll Further research needed to assess breastfeeding and
tongue-tie
Dollberg S et al 2006 Randomised 25 mothers of healthy infants with ll Significant decrease in pain score after frenotomy
Immediate Tel Aviv, Israel controlled tongue-tie, referred due to sore nipples. compared to sham. Also improvement in latch after
nipple pain relief trial Randomised into: (1) frenotomy, frenotomy
after frenotomy breastfeeding, sham, breastfeeding (n=14) ll Authors assert that tongue-tie plays a significant role in
in breast-fed or 2) sham, breastfeeding, frenotomy, breastfeeding, and that frenotomy is effective
infants with breastfeeding (n=11). Researchers and
ankyloglossia: mothers blinded. Latch and pain score
a randomized, obtained from mother after each sham or
prospective study frenotomy procedure
Hogan M et al 2005 Randomised 57 infants with tongue-tie and breastfeeding ll In the control group, one infant (3%) improved and
Randomized, Southampton, controlled problems randomised, both breastfeeding breastfed for 8 months, 28 did not. After 48 hours,
controlled trial UK trial and bottle-feeding: 20 breastfed and eight the remaining 28 were offered frenotomy; all mothers
of division of bottle-fed infants put into immediate accepted, then 27 improved and fed normally
tongue-tie in frenotomy group; 20 breastfed and nine ll Of the 28 infants that had immediate frenotomy,
infants with bottle-fed infants put into 48 hours of 27 improved and fed normally, one remained on a nipple
feeding problems intensive lactation consultant support. shield. Frenotomy resulted in improved feeding in 95%
Mothers gauged any changes to the original of infants
feeding problems. Telephone follow-up ll Authors assert that frenotomy is safe, successful and
carried out at 24 hours, 4 weeks and improves feeding more than lactation support
after 4 months; mother was only judge of
breastfeeding changes
Mettias B et al 2013 Questionnaire 63 infants who had tongue-tie division ll All preoperative problems were resolved in 98%
Division of Wales, UK study as outpatients. Guardians contacted by ll Authors assert that frenotomy is a simple procedure
tongue tie as telephone to complete a survey prepared with minimal complications. They argue that timely
an outpatient from National Institute for Health and Care diagnosis and referral for frenotomy can improve
procedure. Excellence guidelines; 67% of these had breastfeeding and weight gain
Technique, difficulties breastfeeding, 11% had poor
efficacy and safety growth, 22% had limited tongue movement
and 28% of mothers had breast problems.
No control group and study does not focus
solely on breastfeeding

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Table 1 (continued). Summary of research articles

Author, title Year, location Design Methods, sample size, measures used Key findings and recommendations for practice
Steehler MW et al 2012 Questionnaire 302 infants underwent assessment ll 80% of mothers strongly believed the procedure
A retrospective USA study for tongue-tie; 91 mothers agreed to increased the infant’s ability to breastfeed. 82.9% were
review of participate in follow-up survey. Of these, able to initiate or resume breastfeeding following the
frenotomy in 82 infants underwent frenotomy and nine procedure
neonates and received no intervention ll Women whose infants had the procedure in the first
infants with feeding week of life were more likely to believe that the
difficulties procedure significantly increased infant’s ability to
breastfeed (86%) than those who had the procedure
carried out after the first week of life (74%)
Griffiths D 2004 Questionnaire 215 infants who had major problems ll Within 24 hours, 80% of infants were feeding better;
Do tongue Southampton, study breastfeeding despite professional 64% breastfed for at least 3 months
ties affect UK support. Feeding was assessed by the ll Author asserts that initial assessment, diagnosis

British Journal of Midwifery • November 2015 • Vol 23, No 11

breastfeeding? mother 24 hours and then 3 months after and help, alongside division and subsequent support,
frenotomy. No control group may mean more mother–infant dyads benefit from
breastfeeding
O’Callahan C et al 2013 Questionnaire 299 mothers of infants who underwent a ll 92% breastfed exclusively post-intervention. Mean
The effects of USA study frenotomy over a 5-year period completed duration of breastfeeding (14 months) did not differ
office-based a web-based survey about breastfeeding significantly by ankyloglossia classification
frenotomy difficulties before and after the procedure ll Infant latching significantly improved and nipple pain
for anterior decreased
and posterior ll Authors assert that frenotomy can improve
ankyloglossia on breastfeeding in most cases and assessment and
breastfeeding treatment should be a basic competency for primary
care providers
Dollberg S et al 2014 Questionnaire 264 mother–infant dyads that underwent ll 89% still breastfeeding 2 weeks later. Three-quarters
Lingual frenotomy Israel study frenotomy for breastfeeding difficulties. reported improvements in breastfeeding but 3%
for breastfeeding Followed up at 2 weeks, 3 months and reported that it had worsened. 68% still breastfeeding
difficulties: a 6 months to answer questionnaire 3 months later. 56% still breastfeeding 6 months later
prospective ll Authors assert there are favourable long-term effects
follow-up study of frenotomy and, because it is a minor procedure, it
should be considered to help alleviate breastfeeding
problems. Although it does not always improve
breastfeeding problems, it rarely worsens them
Ridgers I et al 2009 Questionnaire 220 infants underwent frenotomy for ll Feeding problems were fully resolved in 67% of cases,
A tongue-tie clinic Surrey, study feeding difficulties. The mothers were and improved in 47%; 5% of mothers reported nothing
and service UK contacted 4 weeks later to take part in a had changed
structured interview to assess changes in ll Authors conclude that the procedure was effective
feeding and their overall experience not only in improving feeding, but also in alleviating
parents’ anxieties
ll Authors address possible distress and also that
several factors, such as bonding, can contribute to
feeding issues
Literature review

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Literature review
of their frenotomy group continued to breastfeed
for an average of 7.09  months. In comparison,
67% of the babies who received no intervention
continued to breastfeed for 6.28 months.
Latch
The majority of studies focused on the infant’s
ability to latch successfully onto the breast before
and after frenotomy. Emond et al (2014) use
a scoring system called LATCH (Jensen et al,
1994), designed to measure the effectiveness of
breastfeeding, in which mothers score on :
ll Latch (L)
ll Audible swallowing (A)
ll Nipple type (T)
ll Comfort (C)
ll Hold (H).
Interestingly, Emond et al (2014) found no difference
in LATCH scores between their two groups at
8 weeks. Dollberg et al (2006) found a statistically
significant improvement in mothers’ pain scores
after frenotomy (P<0.001). Mettias et al (2013) found
that following frenotomy, 98% of preoperative
problems were resolved. These problems included
poor growth and cracked and sore nipples, which
could be attributed to poor latch.
Griffiths (2004) found that 88% of his
participants’ babies had difficulty latching onto
the breast before frenotomy, and 80% of his sample
had improved at 24 hours. O’Callahan et al (2013)
found that, following frenotomy, infant latching
significantly improved among their participants
(P<0.001), as did nipple pain (P<0.001). In Dollberg
et al’s (2014) sample, 83% of the mothers reported
nipple soreness, and 55% reported latching
difficulties. Following frenotomy, 75% of mothers
reported an improvement in breastfeeding
difficulties. Furthermore, 50% of the mothers
who had reported nipple wounds said that they
had disappeared 4 days following frenotomy. This
study did not include a control group.
Arguably, infant latching, nipple pain and
soreness are difficult parameters to measure as
they can be subjective. A ‘normal’ latch can vary in
different infants. However, the majority of studies
included in this review found that frenotomy could
be found to improve latch and alleviate nipple pain.
Discussion
What happens to babies with ankyloglossia
who do not undergo frenotomy?
The majority of research articles found that
frenotomy can improve breastfeeding and have a
positive effect on alleviating unwanted symptoms
associated with breastfeeding. This argument is
backed up in the wider literature (Edmunds et
794
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al, 2011). However, there is a distinct lack of
representation from a control group in which
infants did not undergo frenotomy—in the three
RCTs, the majority of mothers in the control
groups eventually decided to opt for frenotomy.
In the remaining six questionnaire studies, only
one study (Steehler et al, 2012) included a control
group (nine mother–infant dyads) who opted for
no frenotomy. The fact that most mothers included
in the control groups decided to opt for frenotomy
eventually indicates that they were likely to still be
experiencing breastfeeding problems. Therefore,
among the studies subject to critical appraisal,
there was little opportunity to follow-up the long-
term outcomes of mothers who decided for their
infants not to undergo frenotomy, because most
mothers ultimately did choose the procedure.
Mothers’ culture, background and previous
experiences of breastfeeding
Several studies have indicated that a woman’s
motivation to breastfeed and ideas about how long
she would like to breastfeed for are directly related
to other issues such as her culture, background and
experiences of feeding previous children (Bonuck
et al, 2005; Simmie, 2006; Bai et al, 2015). It is
arguable that long-term outcomes of infants with
ankyloglossia are likely to be related to these
factors. Few of the studies in this review identify
these issues. They do not address whether the
mother had breastfed a previous child or whether
she herself had been breastfed. In such research, it
is problematic to regard the link between frenotomy
and successful breastfeeding in isolation.
Risks or stress associated with frenotomy
The literature that focuses on frenotomy states
that it is a simple procedure that rarely carries
complications (Hogan et al, 2005; NICE, 2005;
Dollberg et al, 2006; Mettias et al, 2013; Emond
et al, 2014). Other authors also assert that the
procedure is painless (Inch, 2009). However, few
of the studies subjected to critical appraisal here
consider the psychological impact, distress or
trauma that frenotomy may cause the infant, or
the stress that parents may experience. McBride
(2005) touches on this issue, explaining that,
although frenotomy is currently thought to be
a safe and painless procedure for the infant that
carries no need for anaesthetic, the same was
believed about circumcision in infants a generation
ago. He speculates whether the current approach
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to frenotomy without anaesthetic may be modified
in the coming years. This suggests further research
may be needed into whether anaesthetic should be
used during the procedure—and, if so, what type.
British Journal of Midwifery • November 2015 • Vol 23, No 11

Ridgers et al (2009) discuss the levels of distress
experienced by the infants in their study, and touch
on pain scores used to detect infant pain. They
conclude that infants are unlikely to find the actual
procedure painful or stressful, but they are irritated
about having a finger inserted into their mouths.
It could also be argued that the frenotomy
procedure could be traumatic to the infant’s
psychological development. In Freudian theory,
a child works his or her way through a variety
of psychosexual stages, the oral stage being the
primary phase whereby the child explores and
gains pleasure through the mouth (Freud, 1905).
In developmental psychology, the infant’s early
experiences and any traumas experienced are
classed as hugely important (Tyson and Tyson,
1990). Following this school of thought, despite
being medically uncomplicated and carrying few
clinical risks, the frenotomy procedure could pose
significant disruptions to the child’s normal early
psychological development. More research is
required to explore this possibility.
The value of breastfeeding support
It is important to consider whether it is the
frenotomy procedure itself or breastfeeding
support that causes improvements in unwanted
breastfeeding symptoms. With effective
breastfeeding support provided to the mother,
many infants with ankyloglossia can successfully
latch onto the breast, but often cannot replicate
this latch when they return home (Edmunds et
al, 2012). When mothers decide to consent for
frenotomy, they are often provided with intensive
support before and after the procedure. This
can be beneficial, and may be likely to increase
confidence in mothers who may have previously
been feeling anxious with regard to breastfeeding.
In the RCTs assessed during this review, the
control groups were provided with intensive
support from lactation consultants or other
breastfeeding specialists. However, among the
questionnaire studies—where there is lack of a
control group—it is difficult to know whether
breastfeeding improved as a result of the
frenotomy procedure or the extra time, support,
and attention the women were likely to have
experienced in conjunction with the procedure.
Implications for practice, education,
management and research
Practice
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The studies appraised, along with supporting
literature, indicate that there is currently no
uniform guidance regarding the diagnosis, grading
and treatment of ankyloglossia (McBride, 2005;
British Journal of Midwifery • November 2015 • Vol 23, No 11
Literature review
Ricke et al, 2005). The current NICE (2005)
guidelines are dated and somewhat ambiguous.
Edmunds et al (2011) reported a similar situation in
the USA and Australia, noting the lack of published
position statements by the large professional
bodies. In the UK, Finigan (2009) experienced
resistance to the development of a frenotomy
service and discusses the controversy over the
procedure. Perhaps it is this controversy that can
cause anxiety in mothers and health professionals.
Few would dispute that there are inconsistent
approaches to assessment and management of
ankyloglossia, where some midwives are more
likely to check for tongue-tie than others. Following
this, the advice then given to mothers may differ
and cause confusion.
Several of the research articles appraised in this
review make recommendations for infants to be
assessed for tongue-tie by trained professionals,
followed by timely referral to appropriate
professionals (Griffiths, 2004; Hogan et al, 2005;
Mettias et al, 2013; O’Callahan et al, 2013). This
is a valuable recommendation for practice in
midwifery and related fields. Building on this,
midwives should be encouraged to be aware of the
woman’s social and cultural background and her
previous experiences of breastfeeding, and how
these factors may have an impact on her intentions
regarding how to feed her infant (Nursing and
Midwifery Council, 2009).
There is a question over whether improved
breastfeeding is due to the frenotomy procedure
itself, or to the extra breastfeeding support that
women experience alongside the procedure, or
indeed a combination of both. The implication
for practice is that mother–infant dyads are likely
to benefit from long-term access to breastfeeding
support from midwives, breastfeeding specialists
and lactation consultants, both in the hospital
and the community, regardless of their decision
regarding frenotomy. This could improve outcomes
and prolong duration of breastfeeding through
practical support, alleviating anxieties and
increasing women’s confidence. There is currently
24-hour access to breastfeeding support through
La Leche League (2015) and other organisations
such as the National Childbirth Trust (NCT,
2012) and the Breastfeeding Network (2014). It is
important that women are regularly informed of
how to access this type of support in the postnatal
period and beyond.
Education and training for midwives
It is essential that midwives and midwifery
students are provided with adequate training in
how to look for ankyloglossia and subsequently
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Literature review
Key points
ll Ankyloglossia (tongue-tie) can cause problems for breastfeeding
ll Evaluating the impact of frenotomy can be challenging. Evidence from
randomised controlled trials suggests that the majority of mothers in
the control groups eventually opt for the procedure
ll While frenotomy does offer benefits for breastfeeding in babies with
ankyloglossia, the evidence is inconclusive
ll The absence of uniform guidance regarding the diagnosis and
treatment of ankyloglossia means that there are inconsistencies in the
way health professionals approach the issue
ll More uniformity and better outcomes could be achieved by improving
training and education for health professionals and standardising
local policies
ll Mother–infant dyads are likely to benefit from long-term access to
breastfeeding support, regardless of their decision regarding frenotomy
support feeding in a way that reassures women
and empowers them to continue to breastfeed,
regardless of whether they decide to opt for
frenotomy. It would be beneficial for this to be
incorporated into training for student midwives
and also during mandatory training for registered
midwives. Clearly, the lack of a standardised
definition and classification of ankyloglossia
(McBride, 2005; Ricke et al, 2005) makes this
difficult to achieve.
While assessment for tongue-tie should be
an essential competency for health professionals
involved in the care of women and babies
(O’Callahan et al, 2013), it is important that
these professionals are aware of the fact that
ankyloglossia does not always cause breastfeeding
problems (UNICEF, 2010; Mettias et al, 2013). This
information should be emphasised to professionals
and mothers to reduce needless anxiety, and
also to prevent unnecessary frenotomy taking
place. Education should include how to judge
whether the ankyloglossia is causing unwanted
breastfeeding symptoms.
Management
Local NHS Trusts would benefit from
implementing a standard policy in relation to
assessment for ankyloglossia and the subsequent
options for management of the condition, should
mothers and/or infants be symptomatic. This
information should then be disseminated to
the relevant health professionals to apply in
their practice.
Research
The current literature on ankyloglossia and
frenotomy is varied or, as McBride (2005:  242)
has described it, ‘long on opinion but short on
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fact’. There were three RCTs included in this
review, only one of which blinded mothers to the
treatment group (Hogan et al, 2005; Dollberg et
al, 2006; Emond et al, 2014). There is a need for
more blinded RCTs that involve larger sample
sizes. Also useful would be long-term follow-up of
breastfeeding outcomes in mother–infant dyads
that decide not to opt for frenotomy, investigating
questions such as: how long did they breastfeed
for, and did breastfeeding remain problematic
or painful?
Future research on the effectiveness of
frenotomy for ankyloglossia would benefit from
addressing cultural and social issues as well as
personal attitudes to breastfeeding, as these can
be confounding factors and affect the validity of
research. Furthermore, research focusing on the
possible distress caused by frenotomy and the
need for anaesthetic is needed.
Future research into effective and standardised
ways to assess and classify ankyloglossia—and
to grade the effect that it has on breastfeeding—
could warrant knock-on implications for practice,
education and management in the NHS.
Conclusion
The research under review demonstrates that
frenotomy can be effective for reducing nipple pain
and improving a baby’s latch onto the breast, thus
alleviating unwanted breastfeeding symptoms.
However, the research fails to address issues such
as the woman’s motivation to breastfeed, her social
and cultural background, and how these are related.
It is, therefore, difficult to attribute improvements
in breastfeeding to the frenotomy itself, or the
extra support received with breastfeeding.
The majority of research focused on the
mother’s experience of breastfeeding before and
after a frenotomy procedure, to ascertain whether
the procedure had been successful. There is a lack
of representation from a control group who do
not undergo frenotomy. The scarcity of follow-up
with any control groups means it is difficult to
determine whether the procedure can lead to
prolonged breastfeeding.
Few of the studies appraised address the
psychological impact of frenotomy on the infant
or the parents. Despite being medically deemed
as uncomplicated and safe, it may be that the
procedure has an impact on the child’s early
experience and development. More research is
required in this area.
© 2015 MA Healthcare Ltd
The current lack of uniform guidance
regarding the diagnosis, grading and treatment
of ankyloglossia is likely to contribute to
inconsistencies in the way midwives and other
British Journal of Midwifery • November 2015 • Vol 23, No 11

health professionals address this issue. Those
working with newborns and mothers should
be educated and trained in how to assess for
ankyloglossia, and make a judgement on whether
it is causing breastfeeding problems (bearing in
mind that the condition does not always cause
problems) following locally agreed policies.  BJM
Association of Tongue-tie Practitioners (2013) What is
a Tongue-Tie? www.tongue-tie.org.uk/tongue-tie-
information.html (accessed 2 October 2015)
Akobeng AK (2005) Principles of evidence based medicine.
Arch Dis Child 90(8): 837–40
Aveyard H (2007) Doing a Literature Review in Health and
Social Care: A Practical Guide. Open University Press,
Maidenhead
Bai DL, Fong DY, Tarrant M (2015) Previous breastfeeding
experience and duration of any and exclusive
breastfeeding among multiparous mothers. Birth 42(1):
70–7. doi: 10.1111/birt.12152
Bonuck KA, Freeman K, Trombley M (2005) Country of
origin and race/ethnicity: impact on breastfeeding
intentions. J Hum Lact 21(3): 320–6
British Medical Journal (2015) Table E. Critical appraisal
checklist for a questionnaire study. www.bmj.com/
content/suppl/2004/05/27/328.7451.1312.DC1 (accessed
2 October 2015)
Critical Appraisal Skills Programme (2013) 11 Articles to
help you make sense of a trial. http://tinyurl.com/
q8o5awx (accessed 2 October 2015)
Dollberg S, Botzer E, Grunis E, Mimouni FB (2006)
Immediate nipple pain relief after frenotomy in
breast-fed infants with ankyloglossia: a randomized,
prospective study. J Pediatr Surg 41(9): 1598–600
Dollberg S, Marom R, Botzer E (2014) Lingual frenotomy for
breastfeeding difficulties: a prospective follow-up study.
Breastfeed Med 9(6): 286–9. doi: 10.1089/bfm.2014.0010
Edmunds J, Miles SC, Fulbrook P (2011) Tongue-tie and
breastfeeding: a review of the literature. Breastfeed Rev
19(1): 19–26
Edmunds J, Hazelbaker A, Murphy JG, Phillip B (2012) Tongue
Tie. J Hum Lact 25(1): 14–17. doi: 10.1177/0890334411428588
Emond A, Ingram J, Johnson D et al (2014) Randomised
controlled trial of early frenotomy in breastfed
infants with mild-moderate tongue-tie. Arch Dis
Child Fetal Neonatal Ed 99(3): 189–95. doi: 10.1136/
archdischild-2013-305031
Finigan V (2009) ‘It’s on the tip of my tongue’: Evaluation
of a new frenulotomy service in Northern England.
MIDIRS 19(3): 396–400
Freud S (1905) Three Essays on the Theory of Sexuality.
Basic Books, New York
Glasson M (1998) Foreword. In: Fernadez C. Tongue-Tie
– From Confusion to Clarity: A Guide to the Diagnosis
and Treatment of Ankyloglossia. Australian Print Group,
Maryborough, VIC
© 2015 MA Healthcare Ltd
Griffiths DM (2004) Do tongue ties affect breastfeeding?
J Hum Lact 20(4): 409–14
Hall DMB, Renfrew MJ (2005) Tongue tie: Common
problem or old wives tale? Arch Dis Child 90(12): 1211–15.
doi: 10.1136/adc.2005.077065
British Journal of Midwifery • November 2015 • Vol 23, No 11
Literature review
Hogan M, Westcott C, Griffiths M (2005) Randomized,
controlled trial of division of tongue-tie in infants with
feeding problems. J Paediatr Child Health 41(5–6): 246–50
Inch S (2009) Infant Feeding. In: Fraser DM, Cooper MA,
eds. Myles Textbook for Midwives. 15th edn. Elsevier,
London: 785–816
Jensen D, Wallace S, Kelsay P (1994) LATCH: a
breastfeeding charting system and documentation tool.
J Obstet Gynecol Neonatal Nurs 23(1): 27–32
Kull I, Wickman M, Lilja G, Nordvall SL, Pershagen G (2002)
Breast feeding and allergic diseases in infants-a prospective
birth cohort study. Arch Dis Child 87(6): 478–81
La Leche League GB (2015) Telephone Helpline. www.
laleche.org.uk/content/telephone-helpline (accessed
2 October 2015)
McBride C (2005) Tongue-tie. J Paediatr Child Health
41(5–6): 242
Mettias B, O’Brien R, Abo Khatwa MM, Nasrallah L,
Doddi M (2013) Division of tongue tie as an outpatient
procedure. Technique, efficacy and safety. Int J
Pediatr Otorhinolaryngol 77(4): 550–2. doi: 10.1016/j.
ijporl.2013.01.003
National Childbirth Trust (2012) One-to-One Support.
www.nct.org.uk/about-nct/contact-us/one-one-support
(accessed 2 October 2015)
National Institute for Health and Care Excellence (2005)
Division of ankyloglossia (tongue-tie) for breastfeeding.
http://tinyurl.com/NICEipg149 (accessed 2 October 2015)
Nursing and Midwifery Council (2009) Standards for
pre-registration midwifery education. NMC, London
O’Callahan C, Macary S, Clemente S (2013) The
effects of office-based frenotomy for anterior and
posterior ankyloglossia on breastfeeding. Int J
Pediatr Otorhinolaryngol 77(5): 827–32. doi: 10.1016/j.
ijporl.2013.02.022
Oddy WH, Holt PG, Sly PD et al (1999) Association between
breast feeding and asthma in 6 year old children: findings
of a prospective birth cohort study. BMJ 319(7213): 815–9
Rees C (2011) Introduction to Research for Midwives.
Elsevier, London
Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA (2005)
Newborn tongue-tie: prevalence and effect on breast-
feeding. J Am Board Fam Pract 18(1): 1–7
Ridgers I, McCombe K, McCombe A (2009) A tongue-tie
clinic and service. British Journal of Midwifery 17(4):
230–3. doi: 10.12968/bjom.2009.17.4.41671
Simmie E (2006) Breastfeeding: different ethnic background,
different perceptions? British Journal of Midwifery 14(1):
20–6. doi: 10.12968/bjom.2006.14.1.20256
Steehler MW, Steehler MK, Harley EH (2012) A
retrospective review of frenotomy in neonates
and infants with feeding difficulties. Int J Pediatr
Otorhinolaryngol 76(9): 1236–40. doi: 10.1016/j.
ijporl.2012.05.009
The Breastfeeding Network (2014) Independent,
confidential, mother-centred, non-judgemental
breastfeeding support and information. www.
nationalbreastfeedinghelpline.org.uk (accessed
2 October 2015)
Tyson P, Tyson R (1990) The Psychoanalytic Theories of
Development: An Integration. Yale University Press,
London
UNICEF (2010) Baby Friendly Initiative. http://tinyurl.com/
q7gqkhp (accessed 2 October 2015)
797
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