As an exhausted first-time mum, Galen Elliott says she felt "like her world exploded" when she was told there was a potential problem with her newborn.
Despite her years of work as a Brisbane midwife, it was a different story when it involved her own baby.
Ms Elliott was seeing a lactation consultant who pinpointed the issue — Elke had a minor tongue-tie.
"I work with postnatal mums, but [it is different] to actually be in the experience of being completely sleep deprived … and wanting to do everything right," she says.
A tongue-tie is when the tissue under the tongue restricts its movements and functions.
In young babies it can impact their latch and ability to suck when breastfeeding, which may lead to low weight gain, according to Queensland Health.
A GP can suggest a frenotomy, which is a surgical procedure where the lingual frenulum under the tongue — the tie — is released so that the tongue can move more easily.
In Ms Elliot's case, in addition to working with her lactation consultant, she was referred to a chiropractor who offered exercise options to help release some of the tightness the tie was causing, eliminating the need for a procedure.
But for many parents, navigating what the best option is for their family can be daunting.
"I think everybody would have a story around [tongue-ties] and it is a controversial topic," Ms Elliott says.
Medicare data shows increase in claims related to tongue-tie releases
Brisbane-based GP and researcher Pamela Douglas believes there is a "serious problem with overdiagnosis and overtreatment" of tongue-ties in Australia.
Research, which Dr Douglas was involved in, found the rate of claims for Medicare frenotomy items increased from 1.22 per 1,000 people in 2006 to 6.35 per 1,000 in 2016 for children aged zero to four-years-old.
She's concerned parents are being "frightened" by warnings from health professionals that their baby will suffer a range of consequences,including orthodontic problems, snoring and sleep disturbance,if a tongue-tie is not released.
"It's very often the case that parents get this kind of well-meaning, but quite frightening advice that if they don't follow through, their baby will be negatively impacted," Dr Douglas says.
However, an Australian study, published last year, foundthat — while there was an increase in referrals for tongue-ties between 2014 and 2018 — there was no evidence of a significant increase in the number of releases.
Medicare data shows the number of claims for frenotomy items rose from 1,487 in 1995 to 9,720 in 2023.
The most claims were made in 2017 with 11,304.
Dr Douglas says the increase over time is "not consistent with any sort of meaningful increase in congenital abnormality".
"The reason why we've moved into such overdiagnosis and overtreatment, I think, is because clinical breastfeeding support still remains a research frontier," she says.
Tongue-tie releases in public hospitals, or those done privately by dentists, are not captured in the Medicare data.
Putting mums 'in the driver's seat'
There is currently no formal accreditation for health professionals performing tongue-tie releases.
When a baby has a tongue-tie, breastfeeding mothers may experience nipple pain, low milk supply, blocked ducts, mastitis or notice the nipple looks pinched when the baby comes off.
As a private-practice lactation consultant in Brisbane, Rebecca Cavallaro sees herself as a "breastfeeding detective".
When a mother comes to her, suspecting their baby may have a tongue-tie, Ms Cavallaro says the first thing she does is assess their tongue function to determine whether surgical intervention is necessary.
Lactation consultants do not have the ability to diagnose a tongue-tie, but can help address breastfeeding difficulties.
She says some parents may be looking for a "quick fix".
"The truth is, for a lot of understandably desperate and frustrated parents, they're looking for a solution," Ms Cavallaro says.
"I try my very best to make sure that mum is in the driver's seat of that decision-making."
Mihiri Silva, who is a paediatric dentistry lecturer at the University of Melbourne, says there's currently no evidence a frenotomy helps in avoiding any future issues a child may face.
This was addressed in a consensus statement by a multidisciplinary panel of health professionals, chaired by Dr Silva.
The statement, published by the Australian Dental Association (ADA) in 2020, states surgery should only be considered after failure of non-surgical management.
"We wanted to show that, just because it looks like a child might have a short tongue, looking at a tongue isn't enough to say that they've got a tongue-tie," she says.
"There's actually got to be a process to look for a functional problem."
The consensus statement notes individuals must not advertise themselves as registered specialists in ankyloglossia or tongue-tie management specifically.
Dr Silva says if there's uncertainty over what a tongue-tie is and how to diagnose it, there's a risk of over or incorrect diagnosis.
"That's something that we really tried to help," she says.
"In terms of how much it is overdiagnosed, it's impossible to say.
"I think part of it is practitioners are looking to help families."
Dr Silva says there's a gap in evidence when it comes to tongue-ties, which is important to address.
The other side of the debate
Enhance Dentistry, which does tongue and lip tie release procedures in Brisbane, issued a rebuttal to ADA's statement, in which it raised concerns that committee members did not declare conflicts of interest and that the literature review was "grossly incomplete".
"These attempts have the potential of denying mothers and infants the care and assistance they need to overcome the very real challenges they face, to sustain that most significant and life-giving practice of providing sustenance to their infants," the statement said.
Tongue Tie Institute founder Dr Marjan Jones is the principal dentist at Enhance Dentistry, and co-signed the rebuttal statement. The Tongue Tie institute, which seeks to support health professionals to develop their understanding of oral restrictions, declined the ABC's request for comment.
Speech Pathology Australia's Jane Delaney says if the tongue is restricted, speech and sound development can be impacted, but like any presentation it needs to be assessed on a case-by-case basis.
The organisation acknowledged research published in 2020, which found "no significant difference in measures of speech outcomes between groups of children with treated and untreated tongue-ties".
"Appropriately trained or experienced speech pathologists play an important role in assessing and evaluating the functional impact of a tongue-tie," Ms Delaney says.
She says the first port of call would be to look at non-surgical interventions — if a child is not benefiting from speech pathology, further investigation might be required.
In its practice guidelines released this year, the International Consortium of Ankylofrenula Professionals (ICAP) — which is an organisation of tongue-tie professionals — stated multidisciplinary collaboration involving dentists, medical, lactation and allied health professionals was crucial before surgical intervention was considered.
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"Surgical procedures require careful consideration of risks and benefits, with post-operative monitoring essential for optimal outcomes," ICAP said.
The group acknowledged there was a need for further research in various areas including the short and long-term outcomes of surgical investigations, optimal surgical techniques, and assessment of the social and psychological implication of living with an untreated tie.
'Follow your intuition'
Ms Cavallaro says when women voice their concerns over their baby's ability to breastfeed, they are often dismissed if the infant is still putting on weight.
"No-one's talking about breastfeeding trauma. I see it all day, every day," she says.
Ms Cavallaro says continuity of postnatal care is not normalised.
"If we had that, we would know the dark side of breastfeeding is pretty serious when we parallel it to birth trauma," she says.
"But we just haven't got a system to even acknowledge it."
After her experience with Elke, Ms Elliott's advice to other mums is to "follow your intuition".
"You're working with your baby," she says.
"You see all the things all the time, at 2am, and you get to know your baby."
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