This review concluded that tongue-tie division for ankyloglossia was well tolerated, and provided objective and subjective benefits for breastfeeding, but the evidence was limited. There were no significant data to suggest that ankyloglossia was a cause of speech articulation problems. These conclusions were appropriately cautious, but may be overly positive given the severe limitations of the included evidence.

To systematically review the outcomes of tongue-tie division procedures for patients with ankyloglossia (tongue tie).

MEDLINE, EMBASE, and The Cochrane Library were searched for relevant publications from 1966 to June 2012. Search terms were reported and reference lists of retrieved articles were handsearched for further relevant publications. No language restrictions were applied.

Two reviewers independently selected studies that reported measures of breastfeeding, speech, or adverse events, for patients who had undergone tongue-tie release. Case series (with at least five patients), case-control studies, cohort studies, and randomised controlled trials were eligible for inclusion.

Participants in the included studies were aged from one day to 23 years and underwent frenotomy (frenectomy; removal of the frenulum – tongue-tie tissue) or frenuloplasty (alteration of the frenulum), following a clinical diagnosis of ankyloglossia or breastfeeding problems.

Where authors disagreed on study selection, a third reviewer was consulted.

Study quality was assessed on seven criteria: inclusion and exclusion criteria clearly stated; validated assessment method; appropriate comparison group (within-patient or control group); blinded observers; adequate sample size or power analysis; well-defined, consecutive sample; and less than 5% of participants lost at follow-up.

The authors did not state how many reviewers performed this assessment.

The data were extracted on study characteristics, with mean or median values, standard deviations, confidence intervals or probabilities, or several of these measures, extracted for quantitative outcomes.

The authors did not state how many reviewers extracted the data.

The study results were combined in a narrative synthesis.

Twenty studies (15 observational and five randomised controlled trials) with 1,012 participants were included. Studies met between two and six of the quality criteria.

Tongue-tie division provided statistically significant objective improvements in Latch, Audible swallowing, Type of nipple, Comfort, and Hold (LATCH) scores (two studies), the Short Form McGill Pain Questionnaire (two studies), the Infant Breastfeeding Assessment Tool (one study), milk production and feeding characteristics (three studies), and infant weight gain (one study). Subjective improvements were reported for maternal perception of breastfeeding (14 studies) and maternal pain (four studies).

No significant improvements in speech function were reported (four studies). Adverse events were infrequently reported, the most serious being the need for a repeat procedure.

Tongue-tie division was well tolerated and provided objective and subjective benefits for breastfeeding, but there was little high-quality evidence. There were no significant data to suggest that ankyloglossia was a cause of speech articulation problems.

This review attempted to identify evidence to address a broadly defined research question. Attempts were made to minimise bias and errors in the selection of studies, but it was not clear if such measures were taken for other processes. The diversity of the included studies suggests that a narrative synthesis was appropriate, but few details of the included studies were given.

The authors' conclusions follow from the results found, but this evidence might be biased due to small samples, selected participant groups, subjective outcome measures, lack of blinding, and the absence of comparators. The discussion section of the review appeared to suggest that the largest (and highest quality) randomised study found no significant effect on LATCH score, but this study did not appear in the summary tables, nor in the narrative synthesis of results.

Given the limitations of the primary evidence and the lack of clarity in some aspects of reporting, the authors' conclusions on the efficacy of tongue-tie division were appropriately cautious, but may be overly positive.

Practice: The authors stated that tongue-tie division should only be performed by a trained healthcare professional, on newborns with significant ankyloglossia and associated breastfeeding problems, who had failed to respond to conservative management; it should not be used to prevent articulation problems.

Research: The authors stated that long-term studies were needed and they should use validated measures of ankyloglossia severity and breastfeeding outcomes.

No external funding received.