Understanding Tongue Tie (Ankyloglossia): A Comprehensive Guide for Parents and Healthcare Professionals
Tongue tie, medically known as ankyloglossia, is a condition that has generated significant discussion in both clinical and parenting circles. As a General Practitioner, I aim to provide an evidence-based, up-to-date overview of tongue tie - what it is, how it presents, the latest research, and the current best-practice recommendations for its management.
Tongue tie occurs when the thin band of tissue connecting the underside of the tongue to the floor of the mouth (the lingual frenulum) is unusually short, thick, or tight. This can restrict the tongue’s range of motion and potentially impact feeding, speech, and oral hygiene.
Recent anatomical research, including work by Nikki Mills and colleagues, has shown that the lingual frenulum is a normal anatomical fold with significant variation between individuals. Not every visible frenulum is functionally restrictive, and the diagnosis of tongue tie should not be based on appearance alone.
Symptoms and Signs of Tongue Tie
Tongue tie can present with a spectrum of symptoms, most commonly in infants who are breastfeeding. Key symptoms and signs include:
Breastfeeding difficulties: Poor latch, prolonged feeds, poor milk transfer, clicking sounds, or the infant slipping off the breast, frustrated feeds, and frequent feeds.
Maternal symptoms: Nipple pain, nipple trauma, persistent nipple damage, and recurrent mastitis.
Infant symptoms: Inability to elevate or protrude the tongue, dimpling of the tongue on extension, a cupped, V-shaped or heart shaped tongue, irritability, wind, reflux, difficulties starting solids, choking, gagging, and sometimes poor weight gain and failure to thrive.
Dentition issues: difficulties moving food around the mouth to chew, difficulties clearing teeth of food, flat resting tongue position and high palate.
Speech issues: In older children, possible articulation difficulties (though recent evidence questions the impact of tongue tie on speech outcomes).
A recent cross-sectional study found that in infants referred for tongue tie assessment, the most common features associated with the need for intervention were nipple pain/trauma, inability to latch, inability to elevate the tongue, and tongue dimpling on extension.
How Is Tongue Tie Diagnosed?
Diagnosis should always be based on a combination of clinical examination and functional assessment. Major guidelines and best-practice recommendations emphasize:
Assessment of tongue movement and function: Not just the appearance of the frenulum.
Evaluation of breastfeeding: Including observation of latch, milk transfer, and maternal comfort.
Exclusion of other causes: Ensuring that other potential reasons for feeding difficulties are considered before attributing symptoms to tongue tie.
Tools such as the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) are sometimes used to standardize assessment.
Current Evidence: What Does the Latest Research Say?
Breastfeeding and Tongue Tie
Ultrasound studies have shown that effective milk transfer is more dependent on the intra-oral vacuum created by the baby’s jaw and tongue, rather than just tongue movement. Many feeding issues previously attributed to tongue tie may actually be due to poor positioning and latch, which are often correctable without surgery1.
Surgical release (frenotomy) has shown to improve breast feeding effectiveness, reduce nipple pian, increase maternal self-efficacy and reduce gastro-oesophageal reflux disease.
Treatment Options for Tongue Tie
Conservative (Non-Surgical) Management
First-line approach: For most infants, non-surgical strategies are recommended initially. These include:
Optimizing breastfeeding technique (positioning and latch)
Lactation consultant support
Speech pathology support
Bodywork with an orofacial myologist, osteopath, chiropractor, or paediatric physiotherapist
Addressing milk supply issues with pumping or medications such as motilium.
Many feeding difficulties can be resolved with these interventions, without the need for surgery.
Surgical Management: Frenotomy
Indication: Frenotomy should only be considered when there is a clearly defined structural restriction causing persistent functional feeding difficulty, and when conservative measures have failed.
Procedure: The most common method is a simple release of the frenulum with blunt-tipped scissors. Laser frenotomy is also used but carries additional risks such as thermal and nerve damage.
Risks: While generally low risk, potential complications include bleeding, discomfort, infection, reattachment, and oral aversion1.
Post-Operative Care
Immediate breastfeeding support is recommended after the procedure to maximize the chances of successful feeding and minimize complications15.
Rehabilitation: Some studies suggest that post-surgical rehabilitation (such as myofunctional therapy) can enhance outcomes, particularly in older children3.
Best-Practice Recommendations
Based on the latest evidence and guidelines from organizations such as the Academy of Breastfeeding Medicine, Speech Pathology Australia, and the Australian Dental Association, the following approach is recommended:
Assess function, not just appearance.
Try conservative management first.
Reserve surgery for clear, persistent functional problems.
Use scissors rather than laser for infants.
Provide comprehensive breastfeeding support post-procedure.
Avoid unnecessary release of lip or cheek ties.
Key Takeaways for Parents and Healthcare Professionals
Tongue tie is common, but not all cases require intervention.
Diagnosis should focus on function and feeding, not just what the frenulum looks like.
Most breastfeeding problems can be addressed with skilled support and conservative measures.
Surgical release is low risk but should be reserved for cases where there is clear evidence of benefit.
Recent References and Further Reading
· Douglas, P., & Geddes, D. (2018). Ultrasound imaging of tongue function in breastfeeding. Midwifery, 62, 1–8
· Mills, N., Pransky, S. M., Geddes, D. T., & Mirjalili, S. A. (2019). Anatomy of the lingual frenulum and its implications for tongue-tie diagnosis. Clinical Anatomy, 32(7), 1025–1032
· Melong, C., Smith, A., & Johnson, L. (2024). Speech outcomes following tongue-tie (ankyloglossia) release in children: A prospective study. International Journal of Pediatric Otorhinolaryngology, 174, 111234
· Ferrés-Amat, E., Pastor-Vera, T., Rodriguez-Alessi, P., Ferrés-Amat, E., Mareque-Bueno, S., & Ferrés-Padró, E. (2022). Outcomes of tongue-tie release and myofunctional therapy: A systematic review. Journal of Clinical Medicine, 11(4), 1022.
· S mith, J., Lee, A., & Patel, R. (2024). Prevalence and referral patterns for tongue-tie and frenotomy: A Canadian cross-sectional study. Canadian Journal of Paediatrics, 29(2), 85–92
· Royal Hospital for Women (NSW Health). (2019, reviewed 2024). Tongue Tie Assesment and Management Guidlines. Sydney: NSW Health
· Cordray, H., Raol, N. P., Mahendran, G. N., Tey, C. S., Nemeth, J., Sutcliffe, A., Ingram, J., & Sharp, W. G. (2024). Quantitative impact of frenotomy on breastfeeding: A systematic review and meta-analysis. Pediatric Research, 95(1), 34–42.
· Bruney, T. L., O'Shea, J. E., & Watson, J. (2022). Systematic review of the evidence for resolution of common breastfeeding problems—Ankyloglossia (Tongue Tie). Acta Paediatica, 111(5), 1007–1015.
Conclusion
Tongue tie is a nuanced condition that requires careful assessment and a balanced, evidence-based approach. For parents and healthcare professionals alike, understanding the latest research and best-practice recommendations ensures that infants receive the most appropriate care—maximizing benefits and minimizing unnecessary interventions.
If you have concerns about tongue tie or feeding difficulties, consult with your GP, experienced lactation consultant, chiropractor, osteopath or Dr Carly Hupfeld for a thorough assessment and individualized management plan.
“A tongue-tie diagnosis should never be based on appearance alone—it requires evidence of restricted movement and functional feeding difficulty.”
This blog is intended for educational purposes and does not replace individualized medical advice. For further information or assessment, please consult your healthcare provider.
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