Tongue-Tie and Breastfeeding, Infant Weight Gain: Presentation of the Raol et al. Study (Pediatrics, 2026)

Context: Probable over-medicalization of ankyloglossia

The question of tongue-tie (ankyloglossia) and frenotomy is today one of the most controversial in the breastfeeding world.

On one side: a global explosion in diagnoses and surgical interventions.
On the other side: families drawn into long, costly, and emotionally exhausting care pathways: oromyofacial therapies to prevent frenotomies, repeated intra-oral massages (methods whose efficacy remains very poorly proven), multiple frenotomies.

In this context, the study by Raol et al., published in Pediatrics in January 2026, provides interesting data on the topic of

"Tongue-tie and Breastfeeding".

1. The Tongue-Tie and Breastfeeding Study in Brief: Presentation and Methodology

Design and Population

This is an explanatory sequential mixed-methods study (quantitative then qualitative), conducted in a hospital in India between October and December 2023. 476 mother-infant dyads were recruited within 48 hours of birth.

Diagnostic tool used: the Bristol Tongue Assessment Tool (BTAT), scored 0 to 8. Any score below 8 was considered ankyloglossia. 110 infants (23.1%) were included in the tongue-tie group (TT), 366 (76.9%) in the no tongue-tie group (No-TT).
Primary and secondary objectives

• Primary objective: compare exclusive breastfeeding (EBF) rates at 6 months

• Secondary objective: compare weight gain velocity between the two groups

• Qualitative component: explore reasons for early EBF cessation via semi-structured interviews with 36 mothers

Follow-up and data collection

Mothers were contacted at 3 key moments: 2–4 weeks, 3 months, and 6 months post-birth. Lactation counseling was offered to struggling dyads from the hospital phase onward.

Notable fact: mothers were not informed of their baby's tongue-tie status, in order to limit decision bias.

2. Key Results

No significant difference in EBF rates

This is the central finding of the study: there are no statistically significant differences in breastfeeding rates between infants with and without ankyloglossia in this study.

Exclusive breastfeeding rates by follow-up point: 2–4 weeks: No-TT 88.5% vs TT 92.6% (p=0.39) | 3 months: No-TT 84.6% vs TT 77.7% (p=0.18) | 6 months: No-TT 81.4% vs TT 78.6% (p=0.60)

No difference in weight gain velocity

Similarly, there is no statistically significant difference in weight gain between the two groups:

0–3 months: 26.3 g/day (No-TT) vs 26 g/day (TT), p=0.86
3–6 months: 19.3 g/day vs 20.4 g/day, p=0.49

The predictive factor for early EBF cessation: maternal concern about milk supply

The only factor significantly associated with a higher risk of early EBF cessation at 6 months was maternal concern about insufficient milk production, reported as early as the 2–4 week follow-up call (OR = 0.22; 95% CI: 0.083–0.58; p=0.003).

Tongue-tie, nipple pain, mode of delivery, maternal age: none of these factors were statistically associated with exclusive breastfeeding cessation.

Qualitative component: the real reasons for cessation

36 mothers were interviewed. Main themes identified in both groups who stopped early:

• Perceived insufficient supply: 8/9 mothers in the TT group and 9/9 in the No-TT group cited this as the main reason

• Formula recommendation by a physician without prior lactation counseling: 6/9 (TT) and 7/9 (No-TT)

• Inappropriate family advice: major influence of female figures (mother, mother-in-law)

• Latching difficulties or pain cited by only 2/9 mothers in each group

Note: Work or household constraints were not cited as reasons for cessation in this stay-at-home mother population.

3. Strengths of the Study

Mixed design and longitudinal follow-up: the combination of quantitative data and qualitative interviews is a true methodological strength, rare in this field.
6-month follow-up is longer than most existing tongue-tie studies, which often stop at a few weeks.
Control group without ankyloglossia: most frenotomy studies are before/after studies without a control group, making it impossible to know whether improvement after frenotomy would have occurred anyway with time or lactation support. Raol et al. partially fill this gap by comparing dyads with and without tongue-tie, all followed in the same way, and WITHOUT FRENOTOMY.

4. Limitations of the Study

Single-center study conducted in India: limits generalizability to Western contexts (different breastfeeding cultures, healthcare systems, lactation support access).
Use of the BTAT as the sole diagnostic tool: the BTAT was not designed as a screening tool and has limited sensitivity for severe tongue-ties. The absence of a clinical breastfeeding assessment at inclusion (LATCH score, presence of pain, weight loss) is a significant gap.
No differentiation by tongue-tie severity: a score of 7/8 and a score of 2/8 are both classified as "TT", which may mask subgroup effects.
Lactation support provided to all dyads in difficulty: this is good practice, but it also reduces the effect of tongue-tie by providing active support. In contexts without this support, results might differ.
No frenotomy performed: we cannot conclude from this study that frenotomy is ineffective. The study evaluates the natural course with support, not the effect of the intervention.
Outcome measured: EBF rates and weight gain, but not maternal pain, transfer efficiency, or infant satisfaction — factors central to the clinical reality of tongue-tie.

5. What to Retain for Practice

This study does not call into question the existence of clinically significant tongue-tie, but it invites caution about systematic frenotomy without prior lactation support. It strongly supports the idea that maternal concern about milk supply ,more than tongue-tie itself , is the main driver of early breastfeeding cessation.

In practice, this means: before any frenotomy, thorough lactation support addressing perceived insufficient supply, family pressures, and access to qualified professionals is essential.

Bibliography

Raol et al. (2026). Tongue-tie and breastfeeding, infant weight gain. Pediatrics.