Letter to the Editor

Dear Editor,

I am writing in regard to your recent article “Why So Many Babies Are Getting Their Tongues Clipped” by Rachel Morgan Cautero on March 12, 2019. I have some concerns regarding this article and the influence it may have on mothers and their children.

As the co-author of Functional Assessment and Remediation of Tethered Oral Tissues (TOTs) and international lecturer on the topics of tongue-tie, TOTS, feeding disorders, oral motor disorders and orofacial myology, I feel this article is a one-sided opinion of a mother who perhaps did not have proper medical or therapeutic care during her infant’s tongue-tie journey. While I sympathize with Ms. Cautero, her specific case study and opinions are not reflective of the latest research on this topic, or many patients who have greatly benefited from a tongue-tie release. In fact the current research mainly focuses on breastfeeding infants with positive correlation that breastfeeding does improve post-frenectomy (see reference list). 

First and foremost the article contains interviews with physicians from well-respected facilities, but not necessarily physicians who specialize in this condition. I am a speech-language pathologist and it is within my license and scope to treat stuttering at my facility, but I do not because I have not been trained in stuttering for almost twenty years. Ms. Cautero had access to many preferred providers in the tri-state area who are published on TOTs, yet she only interviewed those who shared her opinion. An article which can affect the medical care of infants and children needs to be well-rounded and provide all pertinent information. I have no issue with presenting an opposing view, as TOTs is a controversial topic, but when a widespread publication chooses to report on a medical condition it is their obligation to provide all sides of the story. 

While I agree functional impact is the key to determining frenectomy, the article was also not clear on what functional impact means and focused only on breastfeeding. TOTs can impact a person across the life span and cause issues with: body alignment and posture (such as torticollis), reflux, dental malocclusion, palatal development, oral resting posture, TMJ, sleep, speech clarity and feeding. 

What the author failed to mention is that these skills need to be assessed by a licensed and TOTs trained speech-language pathologist (SLP), registered dental hygienist (RDH), chiropractor, occupational therapist (OT), physical therapist (PT) and /or lactation consultant (IBCLC) prior to a revision dependent on symptoms and age of the patient. In addition, the patient requires pre- and post-operative therapy/neuromuscular re-education in order for functional changes to occur. Most of the cases we see that do not improve are those who do not follow this advice, or were under the care of a provider who does not share this information. In other words, the surgery is one piece of the TOTs puzzle. We need all the pieces to fit to complete the picture.

The article makes it seem that these situations are black and white and does not explain the ideal scenario that will result in the best outcomes. Of course TOTs should not be surgically released by appearance alone, but the author is overgeneralizing her experience and this could cause harm to infants, children and adults that need medical attention for this condition. Ideally TOTs care follows the following flow chart:   

Clearly the author also did not do a thorough evidence based literature review. There are two recent texts on this topic easily accessed via Amazon: 1) Tongue-Tied by Dr. Richard Baxter (and associates) and 2) Functional Assessment and Remediation of TOTs by Robyn Merkel-Walsh and Lori Overland, both rich with citations and leads to more literature. The risks she describes are very low and out of a two year research project of international publications on the topic, my co-author and I only found three case studies on acute surgical complication all of which were caused by underlying conditions that the surgeon was unaware of at the time of the procedure (see references). This misinformation could also cause a patient to be frightened by addressing a tongue-tie, and suffer unjustly with functional problems. 

I know I am not the only TOTs subject matter expert deeply concerned by this article. It has basically gone viral and the exposure is dangerous because it is not well-rounded article. I suggest in good faith, and for public safety, you review the attached evidence based practice references and explore the links I am providing. Please consider an opposing editorial to explore more factual information on this important topic.


Robyn Merkel-Walsh MA, CCC-SLP/COM®

Licensed Speech Pathologist NJL#41S00305300

Certified Orofacial Myologist®
Certified Talk Tools Therapist & Instructor
PROMPT Trained / Beckman Trained
Orofacial Myofunctional, Feeding and Oral Motor Therapy

Board Chair, Oral Motor Institute


Attached: Evidence Based References and Links

American Academy of Breastfeeding Medicine (AABM). (2016). Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad.

American Academy of Pediatric Dentistry (AAPD) Council on Clinical Affairs (2015). Guidelines on management considerations for pediatric oral surgery and oral pathology. Clinical Practice Guidelines, 279-288.

Amir, L.H., James, J.P. & Donath, S.M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function. International Breastfeeding Journal, 1(3).

Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development! Arlington, TX: Sensory World. 

Baxter, R. (2018). Tongue Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. Alabama, GA: Alabama Tongue-Tie Center.

Baxter, R. & Hughes, L. (2018). Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. International Journal of Clinical Pediatrics, 7(3), 29-35.

Boshart, C. (2015). Demystifying the tongue tie: methods to confidently analyze and treat a tethered tongue. Ellijay, GA: Speech Dynamics Inc.

Burkhart, N.W. (2015). Ankyloglossia: Are You Paying Attention?

Chauney, K.K., Arora, V.K., Thakur, R. & Narula, I.S. (2011). Perio-esthetic surgery: Using LPF with frenectomy for prevention of scar. Journal of Indian Soc Periodontics, 15(3): 265-269.

Chu, M.W. & Bloom, D.C. (2009). Posterior ankyloglossia: a case report. International Journal of Pediatric Otorhinolayryngology, 73(6):881-3.

Cioffi Izu, S., Harumi Itamoto, C., Pradella Hallinan, M., Ulson Pizarro, G., Tufik, S., Pignatori, S. & Raimundo Fujita, R. (2010). Obstructive sleep apnea syndrome (OSAS) in mouth breathing in children. Brazil Journal of Otorhinolayringology, 75(5).

Coryllos, E., Genna, C.W. & Salloum, A.C. (2004). Congenital tongue-tie and its impact on breastfeeding. American Academy of Pediatrics.

de Castro Rodrigues,R.L., Marchesan,I.Q., Gusmao,R.J. de Castro Rodriguez, A. & Berretin-Felix, G. (2014). Characteristics of altered human frenulum. International Journal of Pediatrics and Child Health Care, 2, 5-9.

Daggumati S., Cohn, J.E., Brennan, M.J., Evarts, M., McKinnon, B.J. & Terl, A.R. (2019).  Speech and language outcomes in patients with ankyloglossia undergoing frenulectomy: a retrospective pilot Study. OTO Open, 3, 1,1:1-4.doi:10.1177/2473974×19826943. 

Devishree, Kumar-Gujjari, S. & Shubhashini, P.V. (2012) Frenectomy: a review with the reports of surgical techniques. Journal of Clinical Diagnosis and Research, 6(9):1587-1592.

Elad, D., Kozlovsky, P., Blum, O., Laine, A. F., Po, M.J., Botzer, E.& Sira, L. B. (2014). Biomechanics of milk extraction during breast-feeding. Proceedings of the National Academy of Sciences, 111(14), 5230-5235.

Emanuel, M. (2017). Developing considerations with TOTs: tummy time. Presented at: Connecting the Dots in TOTs. New York, N.Y.

Emanuel, M. (2016). Oral restrictions.

Fernando, C. (1998). Tongue tie – from confusion to clarity: a guide to the diagnosis and treatment of ankyloglossia. Sydney, Australia: Tandem Publications.

Ferret-Amat, E., Pastor-Vera, T., Ferres-Amat, E., Mareque-Bueno, J., Prats-Armengol. J. & Ferres-Padro, E. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Journal of Oral Medicine and Pathology, 1:21 (1):39-47.

Fisher, S.E., Frame, J.W., Browne, R.M., et al. (1983) A comparative histological study of wound healing following CO2 laser and conventional excision of canine buccal mucosa. Arch Oral Biol, 28, 287-291.

Forienza, G., Paradise-Black, N.M., McNamara, E.G, & Sullivan, S.E. (2010). Ankyloglossia: exclusive breastfeeding and failure to thrive. Pediatrics, 125 (6); e1500-e1504.

Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., Krishnaswami, S., Sathe, N. & McPhetters, M. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip tie. Effective Healthcare Program: Comparative Effectiveness Review, US Department of Health  

Geddes, D.T., Kent, J.C., Mitoulas, L.R. & Hartmann, P.E. (2008). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84(7): 471-7.

Genna, C.W. (2016). Supporting sucking in infant breast feeding infants. (2nd Ed.) Burlington, MA: Jones and Bartlett Learning.

Genna, C.W. (2002). Tongue tie and breastfeeding. Leaven, 38(2): 27-29.

Genna, C.W. & Coryllos, E.V. (2009) Classification of Ankyloglossia.

Genther, D. J., Skinner, M. L., Bailey, P. J., Capone, R. B., & Byrne, P. J. (2015). Airway obstruction after lingual frenulectomy in two infants with Pierre-Robin Sequence. International journal of pediatric otorhinolaryngology, 79(9), 1592-1594.

Ghaheri, B. (2017). Aftercare.

Ghaheri, B, (2015). The importance of active wound management following frenectomy.

Ghaheri, B. (2014a). Diagnosing tongue-tie in baby is not a fad.

Ghaheri, (2014b). Rethinking tongue-tie: anterior vs. posterior is irrelevant.

Ghaheri, B. (2014c). How to assess a baby for tongue-tie or lip-tie.

Hari Iyer, V. & Sudarson, S. (2015). A comprehensive treatment protocol for lingual frenectomy with combination of laser and speech therapy. International Journal of Laser Dentistry, 5(1): 12-21.

Hazelbaker, A. (2010). Tongue-tie: Morphogenesis, Impact, Assessment and Treatment. Columbus, OH: Aidan and Eva Press.

Horton C.E., Crawford H.H., Adamson J.E., Ashbell T.S. (1969). Tongue-tie. The Cleft Palate Journal, 6: 8–23. PMID 5251442.

Huang, Y.,Quo, S., Berkowski, J.A. & Guilleminault, C.S. (2015). Short lingual frenulum and obstructive sleep apnea in children International Journal of Pediatric Research, 1:1, ISSN: 2469-5769.

International Affiliation of Tongue-Tie Professionals (2011). Classification.

International Lactation Consultant Association (ILCA). (2011). Position paper on the role of IBCLC. Morrisville, NC: ILCA.

Ito, Y., Shimizu, T., Nakamura, T. & Takatama, C. (2014). Effectiveness of tongue-tie division for speech disorders in children. Pediatrics International, 57:2, 1442-200.

Kassing, (2008). Breastfeeding and craniosacral therapy: when it can help. Low Milk Supply. 

Khaimar, M., Pawar, B. & Khaimar, D. (2014). A novel pre-surgical technique for the management of ankyloglossia. Journal of Surgical Technique Case Reports, 6(2): 49-54. 

Kotlow, L. (2001). Infant reflux and aerophagia associated with maxillary lip-tie and ankyloglossia. Clinical Lactation, Vol. 2-4, 25-29.

Kotlow, L. (2014). Lasers in Pediatric Dentistry. Dental Clinics of North America. 48:4.

Kotlow,L. (2015). TOTS-tethered oral tissues: the assessment and diagnosis of the tongue and upper lip ties in breastfeeding. Oral Health

Kummer, A. (2016). To clip or not to clip? That’s the question. Presented at the annual convention of The American Speech and Hearing Association, Philadelphia, PA.

Kummer, A. (2005). To clip or not to clip? That’s the question. The ASHA Leader, 10:6-30.

Kupietzky, A. & Botzer, E. (2005) Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatric Dentistry, 27:1, 40-46.

Levine, R. Vitruk, P. (2015b). Enhanced hemostasis and improved healing in CO2 laser assisted soft tissue oral surgeries. Implant Practice US 8(3). 34-37.

Mayo Clinic (2016). Diseases and conditions: tongue-tie (Ankyloglossia).

Marchesan, I.Q. (2012). Lingual Frenulum Protocol. International Journal of Orofacial Myology, 38, 89-104.

Marchesan, Irene Queiroz. Lingual Frenulum: Classification and Speech Interference. International Journal of Orofacial Myology, Nov. 2014,

Martinelli, R.C.C., Marchesan, I.Q., Honório, H.M., & Berretin-Felix, G. (2018). Tendency of tongue positioning during crying in infants with and without lingual frenulum alteration. International Journal of Developmental Research, 8, 14672.

Martinelli, R.L.C., Marchesan, I.Q., & Berretin-Felix, G. (2012). Lingual Frenulum Protocol with Scores for Infants. International Journal of Orofacial Myology, 38, 104-113.

Meaux, A., Savage, M., & Gonsoulin, C. (2016). Tongue ties and speech sound disorders: what are we overlooking? Presented poster at the Annual ASHA Convention, Philadelphia, PA.

Messner, A.H. & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54(2):123-31.

Merdad H. & Mascarenhas, A,K. (2013). Ankyloglossia may cause breastfeeding, tongue mobility, and speech difficulties, with inconclusive results on treatment choices. Journal of Evidence-Based Dental Practice, 10(3):152-3.

Merkel-Walsh & Overland, L.L. (2017). TOTs: the functional impact on feeding and speech (joint lecture).
Presented at: Connecting the Dots in TOTs. New York, N.Y.

Merkel-Walsh, R. & Overland, L.L. (2017) Functional assessment of feeding challenges in children with ankyloglossia. Poster presentation at the American Speech Language and Hearing Association, Los Angeles, CA.

Merkel-Walsh , R. & Jahn, A. (2014). Teaming up to correct tongue-tie. The ASHA Leader,19.

Merkel-Walsh , R. & Overland, L. (2018). SLP’s Role in Post-Frenectomy Care for Children Who Present with Feeding Challenges. Poster presentation at the American Speech Language and Hearing Association, Boston, MA.

Merkel-Walsh, R. (2011) Systematic Intervention for Lingual Elevation (SMILE). Charleston, SC: TalkTools.

Mills, N., Pransky, S.M., Geddes, D.T. & Mirjalili, S.A. (2019) What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clin Anat. Retrieved from: https://onlinelibrary.wiley.com/doi/full/10.1002/ca.23343

Northcutt, M. (2009). The lingual frenum. The Journal of Clinical Orthodontics, 43(9):557-565.

O’Callahan, C., Macary, S., & Clemente, S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International journal of pediatric otorhinolaryngology, 77(5), 827-832.

Opara, P., Gabriel-Job, N. & OPara, K.O. (2012). Neonates presenting with severe complications of frenotomy: a case series. Journal of Case Reports, 6, 77.

Ostapiuk, B. (2006). Tongue mobility in ankyloglossia with regards to articulation. Ann Acad Med Stetin. 2006;52 Suppl 3:37-47 

Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

Paladino, L. (2017). IBCLC as a team leader for the assessment and management of the nursing infant with lip and tongue tie. Presented at: Connecting the Dots in TOTs. New York, N.Y.

Price-Emanuel, M. (2017). Benefits of bodywork.

Priyanka, M., Sruthi, R., Ramakrishnan, T., Emmadi, P., & Ambalavanan, N. (2013). An overview of frenal attachments. Journal of Indian Society of Periodontology, 17(1), 12–15. http://doi.org/10.4103/0972-124X.107467

Raghevendra-Reddy, N., Marudhappan, Y., Devi, R. & Narang, S. (2014). Clipping the (tongue) tie. Journal of Indian Soc Periodontal, 18 (3); 395-398.

Ricke, L.A., Baker, N.J., Madlon-Kay, D.J. & DeFor, T.A. (2005). Newborn tongue-tie: Prevalence and effect on breast feeding. Journal of American Board of Family Practice, 18(1), 1-7 

Schuster, J.L. (2014). ‘Just a snip,” I was told, but that was just the start of my troubles. Health Affairs: Washington Post.

Segal, L. M., Stephenson, R., Dawes, M., & Feldman, P. (2007). Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Canadian Family Physician, 53(6), 1027–1033.

Sethi N., Smith D., Kortequee S., Ward V.M. & Clarke S. (2013). Benefits of frenulotomy in infants with ankyloglossia. Int J Pediatr Otorhinolaryngol, 77(5): 762-5.

Siegel, S.A. (2017) Advancements in diagnosis and laser surgery of ankyloglossia from infancy to adulthood: impacts on breast feeding, feeding, speech and airway. Presented at Connecting the Dots in TOTs. New York, N.Y.

Siegel, S.A., (2016). Aerophagia induced reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenulu (Tongue and Lip Tie). International Journal of Clinical Pediatrics, 5(1):6-8.

Srinivasan, A., Al Khoury, A., Puzhko, S., et al. (2018). Frenectomy in infants with tongue-tie and breastfeeding problems. Journal of Human Lactation

Taylor, P. (2011) Benefits and drawbacks of frenectomy. Retrieved from: https://www.speechpathology.com/ask-the-experts/benefits-and-drawbacks-frenectomy-1557  

Vallone, S. (2014). Chiropractic care for the breastfeeding dyad. Leaven, 39(6): 126-127.

Vitruk, P. et al. (2017). Oral soft tissue laser ablation and coagulation physics. Color Atlas of Infant Tongue-Tie and Lip-Tie Laser Frenectomy. Pan Sophia Press.

Walsh F. & Kelly D. (1995). Partial airway obstruction after lingual frenotomy. Anesth Analg, 80;1066-1067

Wigdor, H., Walsh, J., Featherstone, J.D.B., et. al. (1995). Lasers in dentistry. Lasers Surg Med, 16, 103-133.

Wilson, J. M. (Ed.) (1978) Oral-motor function and dysfunction in children. Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.

Yang, H.M., Woo, Y.J., Won, S.Y., Kim, D.H., Hu, K.S. & Kim H.J. (2009) Course and distribution of the lingual nerve in the ventral tongue region: anatomical considerations for frenectomy. Journal of Craniofacial Surgery, 20(5):1359-63.

Yousefi, J., Tabrizian Namani,F., Raisolsadat,S.M.A., Gillies,R., Ashkesari, A. & Meara, J.G. (2015). Tongue-tie repair: z-plasty vs. simple release. Iranian Journal of Otorhinolaryngology, 27(79):127-135.

Talktool admin 18 Dec 19