5.2 Ankyloglossia
Ankyloglossia (tongue tie)
The lingual frenulum is a mucous membrane that attaches to the floor of the mouth under the tongue and stabilizes it. Ankyloglossia is a congenital anomaly characterized by an abnormally short lingual frenulum due to an excess of residual embryonic tissue. During fetal development, the tongue is fused to the floor of the mouth. During the process of apoptosis, the tongue detaches and becomes mobile. If there is incomplete detachment, this is called ankyloglossia. Since there is no consensus on diagnostic criteria across studies and the definition is not standardized, the incidence of ankyloglossia can vary from 4% to 11%.

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.
© Carole Dobrich
A short or tight lingual frenulum can restrict tongue mobility to varying degrees and may prevent the infant from extending the tongue fully over the bottom gum line or elevating the tongue (both essential actions for breastfeeding).
Ultrasound imagery has demonstrated that in order to breastfeed effectively and comfortably, the tongue must use complex movements to create the necessary movement to extract milk without causing friction on the nipple and breast. In addition to discomfort and/or pain at the breast, other problems can be associated with tongue tie:
- inadequate latching
- incomplete drainage of the breast, which can lead to ductal blockages or mastitis
- long and ineffective feedings, irritability of the baby at the breast, dissatisfaction of the baby after feedings
- nipple injuries or infections, a feeling that the baby is biting during feeding
- decreased milk production, and inadequate weight gain in the baby
- early weaning from breastfeeding in the mother
While tongue tie can sometimes be assessed visually (as in the photo above), the point of attachment is not necessarily indicative of the degree to which breastfeeding is affected.
Recommendations
According to the Canadian Paediatric Society recommendations, a frenotomy is not routinely recommended in all cases of ankyloglossia. A frenotomy may be recommended when there is a clear association between a restrictive tongue-tie and major breastfeeding problems. The Academy of Breastfeeding Medicine suggests that a frenotomy should be considered when there are persistent breastfeeding problems (such as nipple pain or inadequate latch) that are not resolved with timely conservative management. Frenotomy should always be a shared decision between the health care professional and the parents.

© Carole Dobrich

© Dale Hansson

© Carole Dobrich

© Carole Dobrich
As you can see in the photos above, tongue tie can present in multiple ways and assessment must always include an oral exam and a full observation of feeding (preferably by an experienced practitioner) before making any recommendations.
Treatment
Frenotomy
Even though frenotomy is a simple surgical procedure to release the restriction, providing greater tongue movement and an improved breastfeeding outcome, parents need to be provided with evidence-based information to be able to make that informed decision. This is part of the informed consent.
The following outcomes of frenotomy have been described:
- Reduced maternal nipple pain
- Improved milk transfer
- Reduced length of feeding times
- Improved infant weight gain
- Improved maternal breastfeeding self‐efficacy
- Improved breastfeeding outcomes
Supportive team care
While frenotomy will correct the anatomy, breastfeeding difficulties associated with tongue tie also involve behavioural and physical adaptations that the infant (and parent) have developed while the tongue tie was restricted. Offering a team approach of trained IBCLCS, physiotherapists, and other bodyworkers will help the dyad return to a state of full functionality and comfort.
When tongue-tie is noted ...
And in the presence of breastfeeding difficulties
- Refer the mother/lactating parent and their infant to a health professional who has experience assessing tongue ties and performing frenotomy.
Unfortunately, even when obvious breastfeeding difficulties are affecting both mother/lactating parent and baby related to tongue tie, some health professionals may still refuse to treat ankyloglossia.

What should I remember?
- Not always necessary to treat
- Many infants with tongue-tie will not need an intervention
- It is important to fully assess the infant and observe and evaluate a complete feeding
- Look at the tongue function and not just at the anatomy
- Always start with good basic breastfeeding guidance (skin-to-skin and self-latching)
- Provide positive lactation support
- Try conservative methods first
- It is still controversial
- It is an intervention
- Further education is needed
- More research is needed
- Ask the following questions “Is it causing a breastfeeding problem?”, "have other possible reasons for a breastfeeding problem been ruled out?"
- If yes...what are the risks of not doing the procedure for the breastfeeding dyad?
- Informed consent is essential