Tongue Tie Explained — Causes, Symptoms, and Treatment

Dr Helen Fung

What is a tongue tie?

The medical name for tongue tie is ankyloglossia. It is caused by a short membrane, or frenulum, that restricts tongue movement. Reported rates vary a great deal between studies — from under 2% to around 11% of newborns. That spread exists because there is no single agreed way of identifying a tongue tie, and different studies have used different criteria.

The presence of a frenulum is normal. Its appearance can vary significantly between babies, ranging from a thin web to a thick and wide belt. The length can also vary, and may extend from the edge of the tongue to the lower front teeth, or may be so short it tethers the tongue tightly to the floor of the mouth. Diagnosis is not made on appearance alone. The 2020 Australian consensus statement on ankyloglossia is clear that two things must both be present: an anatomically restricted frenulum, and a real functional limitation such as difficulty feeding. Where there is no functional limitation, the frenulum is considered normal.

Many babies with tongue tie can be breast and bottle fed successfully, but some tongue ties can cause pain for the breastfeeding mother, or interfere with a baby’s ability to breast and bottle feed. In these cases, tongue tie release, or frenotomy, can provide a significant help for both mother and the baby.

A restricted lingual frenulum. The frenulum tethers the tongue to the floor of the mouth, and the tongue tip is drawn into a notch when it lifts.

How does tongue tie develop?

During embryonic development, the frenulum guides the growth of oral structures. The tongue begins to form at about fourth week of pregnancy, and the frenulum guides the forward growth of the tongue. As the embryo continues developing, the frenulum retracts or dissolves away from the tip of the tongue to increase the tongue’s mobility. After birth, the tip of the tongue continues to elongate forward, giving the impression that the frenulum continues retracting. Sometimes, the frenulum does not dissolve enough, which restricts the tongue movement, and a tongue tie results.

What are the signs and symptoms of a tongue tie?

For the baby, symptoms may include:

Difficulty latching or maintaining attachment to the breast
Gumming or chomping at the breast, rather than sucking
Increased swallowing of air
Prolonged feeding, including continuous snacking
Clicking on feeding

The maternal experience of breastfeeding a tongue tied baby may include:

Pain, damage, bleeding, blanching or distortion of the nipples
Mastitis, nipple thrush or blocked ducts
Severe pain with latch or losing latch
Sleep deprivation caused by the baby being unsettled
Reduction or loss of milk supply

What about “posterior tongue tie” and “lip tie”?

Parents often arrive having been told their baby has a “posterior tongue tie” or a “lip tie”. The 2020 Australian consensus statement — developed by the Australian Dental Association with paediatric dentists, lactation consultants, midwives, speech pathologists and surgeons — is direct about both.

On “posterior tongue tie”: there is a lack of evidence from dissection studies to support it as an entity, and using the term can result in a normal frenulum being classified as abnormal. The statement says it should not be used as a medical diagnosis.

On the upper lip and cheek: there is no evidence that these frena cause problems with feeding or speech, and insufficient evidence to support releasing them in infants for feeding, speech or orthodontic reasons, including closing a gap between the front teeth.

If you have been told your baby has one of these, that is worth knowing before anything is released. It does not mean your feeding problem is imaginary — it means the feeding itself deserves a proper assessment.

What are the consequences of a tongue tie?

Breastfeeding problems

Breastfeeding requires a baby to be able to protrude the tongue beyond the lower gumline and elevate the tongue towards the palate to be able to transfer the milk from the breast effectively. If there is inadequate movement, or difficulty keeping the tongue in the correct position, the baby may chew instead of suck on the nipple, resulting in nipple pain and inefficient feeding.

Inability to breastfeed successfully in the presence of a tongue tie can cause a variety of challenges for the infant, the mother and the family. A strong bond is built between the mother and baby when a calm and satisfied baby can interact with the mother. Repeated difficulties during breastfeeding can interrupt or delay this bonding. Sleep deprivation affects both mother and baby; unsuccessful suckling will tire the baby, who will fall asleep on the breast and wake unsatisfied, which prolongs the feeding time without fully satisfying the hunger.

Ultimately, sleep deprivation and inadequate nutrition may lead to poor weight gain, or even failure to thrive.

Speech difficulties

The tongue has the ability to elevate, retract, protrude, and move to the sides. The presence of a tongue tie can mean that the tongue might be unable to move into the correct position to produce certain sounds, such as “D”, “T”, “L”, “TH”, etc. This has been put forward as a cause of delayed speech, though the evidence for that link is weak.

It is worth being plain about the evidence here. The Australian consensus statement found no available evidence of a causative association between tongue tie and speech articulation problems, and no way of predicting which infants will go on to have speech difficulties. A release should not be carried out on the basis of a speech problem a child does not yet have. Where a frenotomy is performed in an older child who already has a speech disorder, improvement may be limited, as the child has already developed their own ways of producing those sounds.

Oral hygiene

The tongue helps clear the teeth of food debris and spread saliva, and restricted movement can make eating messier, with more gagging or spitting out of food. The link to dental problems is easily overstated, though. The Australian consensus statement is clear that decay, gum recession and bite problems cannot be predicted from the appearance of a frenulum in a baby or young child, so none of them is a reason on its own to release one.

Challenges with other oral activities

A tongue tie can interfere with many oral activities such as licking ice cream, playing wind instruments, or participating in plays and games involving tongue movements and gestures. It may also contribute to persistence of dribbling.

What are the management options for tongue tie?

If a baby or mother is experiencing symptoms such as breastfeeding problems, difficulty sucking, poor weight gain, or pain for the mother, help is needed. Not all breastfeeding problems are caused by a tongue tie, so a proper assessment comes first.

Current Australian guidance puts non-surgical support ahead of surgery. That means working on positioning and latch, feed frequency, supporting milk supply, and tools such as nipple shields, alongside an IBCLC, midwife or child health nurse. For many families this resolves the problem and no procedure is needed. Surgery is considered only where a tongue tie has been properly diagnosed, that support has not resolved the functional problem, and the family has given fully informed consent. It is not undertaken on the basis of appearance, or of problems a child might have in the future.

Frenotomy

Frenotomy, often referred to as tongue tie release, may be considered for a baby whose tongue restriction is genuinely affecting feeding. It is a brief procedure carried out in our rooms. A parent is welcome to stay in the same room throughout, and feeding can be offered afterwards. Dr Helen will explain what is involved and what to expect beforehand, and nothing needs to be decided on the spot. A release on its own does not restore function — the tongue has to learn to use the movement it has gained — so the support that helps afterwards is discussed as part of the plan, and may involve your lactation consultant or a myofunctional therapist.

A frenotomy can also be performed with a laser. The Australian consensus statement recommends cold steel — that is, scissors — for newborns, with laser or cold steel being appropriate in older infants, and it notes risks particular to laser including eye exposure and inhalation of plume. Laser also requires the parent to be separated from the baby for safety reasons, which a scissors release does not.

Regardless of the method, the earlier the problem is identified and the frenotomy is performed, the less time it will take for the baby to breastfeed effectively and comfortably after the procedure. Therefore looking for help as early as possible is strongly recommended.

Frenectomy

A frenectomy is a more extensive procedure, involving removal of tissue, generally under general anaesthesia. In older children the age of the child influences the approach and anaesthesia used. It is reserved for the small number of cases with a clear justification, and is not recommended otherwise.

Is it safe to treat a tongue tie?

Serious complications are uncommon, but this is not a procedure without risk, and you should hear that plainly. The Australian consensus statement lists bleeding, swelling, ulceration, oral aversion, injury to the salivary ducts, scarring, recurrence and airway compromise among reported complications, and records rare cases of significant blood loss in newborns. It also states that a release carries no guarantee the feeding problem will resolve, and that problems can occasionally be made worse. That is precisely why a release is only considered where there is a genuine functional problem that feeding support has not fixed.

Where there is no functional problem, there is nothing to treat, and watching is the right answer. Where feeding genuinely is not working, getting help early does matter — difficulties that drag on for weeks are more likely to end in breastfeeding stopping altogether — but early means early assessment and early feeding support, not an early procedure.

Views in the literature differ on how to weigh that. The Australian paediatric surgeon Dr Martin Glasson has described it as “an operation which is simple, brief and virtually devoid of complications”, and NICE guidance in the UK states that “current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue tie)”. Both of those sit alongside the complications above, and both can be true at once: serious problems are rare, and they are not impossible. What follows from that is not that the procedure is trivial, but that it should be done for a clear reason.

If you feel that your baby is experiencing breastfeeding difficulties due to a tongue tie, contact us right away! We can usually offer you an appointment within just a couple of days.