Response to RCPI Faculty of Paediatrics: Assessment of Tongue Tie in Newborns and Infants (2025)

From: Dr Justin Roche MB ChB, FRCPCH, FRCPI (Paeds), IBCLC and Kate Roche BSc, MISCP, MCSP, IBCLC
Directors, National Tongue Tie Centre, Ireland 

 Introduction

We appreciate the comprehensive work undertaken by the RCPI Faculty of Paediatrics in developing guidance on ankyloglossia assessment and management. As clinicians with extensive international recognition and over two decades of experience in this specialised field, we offer the following observations regarding the recommendations. We recognise that significant gaps remain in published research; however, clinical experience from specialists worldwide provides valuable insights that should inform evidence-based practice.

Response to Recommendations

Recommendation 1: Assessment and Diagnosis

RCPI Position: Ankyloglossia, in the absence of breastfeeding difficulties or symptoms, does not need any intervention as it is estimated that the majority of infants with ankyloglossia will breastfeed successfully.

Our Response:

We note a critical omission: there is no mention of feeding difficulties for bottle-feeding infants. The source statistic derives from Hogan et al. (2005), which actually reports that 88 of 201 babies with tongue tie (44%) experienced feeding problems. Importantly, 30% of that cohort were bottle feeding. Many families in our practice have had their infant's feeding difficulties dismissed solely because they were bottle feeding - this represents a significant gap in clinical education.

Furthermore, the appearance of the lingual frenulum alone should not determine the diagnosis of ankyloglossia. Professional organisations including ICAP and IATP recognise that functional impairment is crucial to diagnosis. This includes identifying dysfunctional compensatory patterns that achieve sufficient milk transfer despite abnormal feeding biomechanics.

Recommendation 2: Posterior Tongue Tie

RCPI Position: The term "posterior tongue tie" lacks anatomical precision and should not be used as a reason for frenotomy.

Our Response:

While we agree the term is often misinterpreted, "posterior tongue tie" refers to restriction of the posterior component of the frenulum, not the posterior tongue itself. The terminology is widely understood within specialist circles, though perhaps misunderstood more broadly. Assessment of functional impact is the vital part to distinguish a normal frenulum from ankyloglossia. To dismiss this entity with the phrase “posterior tongue tie is not a thing”, as has been rolled out in HSE training on ankyloglossia, means some infants who could benefit from timely intervention are not being considered.

Published evidence supports treating posterior ankyloglossia. Ghaheri et al. (2022) demonstrated in a randomized controlled trial that frenotomy for posterior tongue-tie resulted in statistically significant improvements in 11 objectively measured feeding metrics, including faster tongue speed, more rhythmic and coordinated sucking, and improved adaptability to feeding demands. Additionally, 78% of infants in Ghaheri's 2017 prospective cohort study had isolated posterior tongue tie, with significant improvements in breastfeeding outcomes post-intervention. 

Recommendation 3: Multidisciplinary Assessment

Our Response:

We wholeheartedly agree with the importance of comprehensive assessment. However, we emphasise that distinguishing normal oromotor biomechanics from compensatory movements is critical. This expertise requires specialised training and experience.

Recommendation 4: Support Services

Our Response:

We completely agree with the importance of multidisciplinary team involvement. However, this should apply to ALL infants regardless of feeding modality, not just breastfed infants. This will have training implications as, in our experience, normal feeding biomechanics for bottle feeding infants is not widely appreciated.

Recommendation 5: Feeding Method and Intervention

RCPI Position: Frenotomy should be considered primarily for breastfeeding difficulties.

Our Response:

The need for frenotomy should be based on functional assessment, not feeding method. Bottle-feeding infants with ankyloglossia experience feeding difficulties and can benefit from frenotomy when ankyloglossia is the likely cause. Limiting intervention to breastfed infants creates an inequity based on feeding modality.

Recommendation 6: Risks and Benefits

Our Response:

We agree that all surgical procedures carry risks. In our extensive experience, complications are rare when performed by experienced practitioners:

• Reattachment: <1% (From our clinic data)
• Significant bleeding: 1:1000

The term "symptomatic ankyloglossia" adds terminology rather than clarity. We have observed cases with significant tongue restriction but minimal feeding symptoms initially, who later presented with difficulties transitioning to solids or speech development - these symptoms resolved following functional frenuloplasty ( therapy plus surgery).

Bleeding risk, though small, typically relates to anatomical variation (aberrant midline veins) rather than technique. This underscores why frenotomy should be performed in clinical settings with appropriate support.

Recommendation 7: Service Provision

Our Response:

We agree regarding equitable access but emphasise this should be regardless of feeding technique. For infants, we would suggest that frenotomy plus appropriate supporting interventions should be available within 2 weeks of suspected ankyloglossia to prevent establishment of compensatory patterns.

Recommendation 8: Laser Use

RCPI Position: Insufficient evidence exists for laser superiority.

Our Response:

Whilst there are no studies specifically looking at lingual frenotomy there are multiple published studies which demonstrate the benefits of laser, particularly Er:YAG and CO2, for oral mucosal procedures:

• Fisher et al. (1983) demonstrated superior wound healing with CO2 laser versus conventional surgery
• Monteiro et al. (2019) showed minimal margin damage with both CO2 and Er:YAG lasers
• Multiple studies demonstrate reduced postoperative pain, improved hemostasis, and enhanced healing with laser techniques

Recommendation 9: Training Standards

Our Response:

We strongly support standardised training and competency requirements and would be happy to contribute our experience and knowledge to this.

Recommendation 10: Follow-up Care

Our Response:

Follow-up is essential for all team members to assess outcomes and support families during the transition to normal feeding biomechanics.

Recommendation 11: Aftercare Protocols

Our Response:

Aftercare remains contentious with limited published evidence. Frenotomy uniquely leaves an intentionally open wound. Maintenance of tongue mobility gained through performing the procedure is crucial. Our clinical observations suggest many infants also hold tension in the neck and orofacial complex impacting feeding function - addressing this tension facilitates establishment of normal functional patterns. We have observed these patterns persisting into adulthood when left untreated.

Recommendation 12: Long-term Outcomes

Our Response:

Evidence demonstrates frenotomy can improve speech outcomes in children with ankyloglossia. Baxter et al. (2020) found 89% improvement in speech, with 50% of speech-delayed children saying new words post-procedure (p=0.008). Meta-analysis shows overall improvement in speech articulation (0.78; 95% CI: 0.64-0.87; P<0.01).

From our own clinic audit, of 281 children who had speech difficulties, 92.5% reported an improvement in speech following lingual functional frenuloplasty.

Additionally, low resting tongue posture is associated with:

• High-arched narrow palate development
• Increased risk of obstructive sleep apnea
• Suboptimal craniofacial growth

Multiple studies demonstrate these associations, unfortunately long-term prospective studies comparing intervention versus watchful waiting are lacking.

Recommendation 13: Research Priorities

Our Response:

We agree completely but emphasise equity of access regardless of feeding modality.

Recommendation 14: Upper Lip Tie

Our Response:

Limited published data warrants caution. However, some significantly restrictive upper labial frenula may warrant consideration for frenotomy. Studies to record the natural history are needed, as appearance often changes during childhood, frequently through traumatic rupture.

Recommendation 15: Quality Improvement

Our Response:

We wholeheartedly support national data collection with long-term outcome monitoring throughout childhood. Many families report needing additional lactation support beyond current HSE provision - further resourcing of this is essential. Equity of access must be regardless of feeding method.

Additional Considerations

Some observed clinical changes are difficult to measure quantitatively, creating challenges for publishing research. This does not negate their clinical significance. The complexity of oral function and its long-term impacts on development require both rigorous research and recognition of expert clinical observation.

Conclusion

As internationally recognised experts with over two decades of clinical experience treating ankyloglossia across the lifespan, we appreciate the RCPI's efforts to standardise care. However, we encourage consideration of the broader evidence base, including functional assessment regardless of feeding method, recognition of posterior tongue tie as a clinical entity, and the established benefits of laser techniques in experienced hands.

We remain committed to evidence-based, family-centered care and welcome ongoing dialogue to optimise outcomes for all infants and families affected by ankyloglossia.

Dr Justin Roche
Consultant Paediatrician, Medical Director, International Board Certified Lactation Consultant
MB ChB, FRCPCH, FRCPI (Paeds), IBCLC

Kate Roche
Chartered Physiotherapist, Clinical Director, International Board Certified Lactation Consultant
BSc, MISCP, MCSP, IBCLC

National Tongue Tie Centre
Clonmel, Tipperary | Naas, Kildare
www.nationaltongutiecentre.ie

Link to Irish Medical Times Article: https://www.imt.ie/news/dismissal-of-form-of-tongue-tie-risks-leaving-infants-without-appropriate-care-20-02-2026/

Key References

1. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005;41(5-6):246-250.
2. Ghaheri BA, Lincoln D, Mai TNT, Mace JC. Objective Improvement After Frenotomy for Posterior Tongue-Tie: A Prospective Randomized Trial. Otolaryngol Head Neck Surg. 2022;166(5):976-984.
3. Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 2017;127(5):1217-1223.
4. Baxter R, Merkel-Walsh R, Baxter BS, Lashley A, Rendell NR. Functional Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release: A Prospective Cohort Study. Clin Pediatr. 2020;59(9-10):885-892.
5. Fisher SE, Frame JW, Browne RM, Tranter RMD. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch Oral Biol. 1983;28(4):287-291.
6. Monteiro L, Delgado ML, Garcês F, et al. A histological evaluation of the surgical margins from human oral fibrous-epithelial lesions excised with CO2 laser, Diode laser, Er:YAG laser, Nd:YAG laser, electrosurgical scalpel and cold scalpel. Med Oral Patol Oral Cir Bucal. 2019;24(2):e271-e280.
7. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016;2(3):00043-2016.
8. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional-morphological study. Orthod Craniofac Res. 2017;20(4):237-244.
9. International Consortium of Ankyloglossia Professionals (ICAP). Consensus statements on ankyloglossia assessment and management. 2018-2024.
10. International Association of Tongue Tie Practitioners (IATP). Clinical practice guidelines for assessment and management of ankyloglossia. 2016-2024.