and well-being of children and youth
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.
Ankyloglossia (or tongue-tie) is a relatively uncommon congenital anomaly defined by an abnormally short lingual frenulum. Associations between tongue-tie and breastfeeding problems in infants have been inconsistent, and are a longstanding source of controversy in the medical community. Definitions of ankyloglossia vary, and management suggestions are not based on randomized controlled trials. Surgical correction involves cutting the lingual frenulum (frenotomy). Based on current available evidence, frenotomy cannot be recommended. If, however, the association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed necessary, frenotomy should be performed by a clinician experienced with the procedure and with appropriate analgesia. More definitive recommendations regarding the management of tongue-tie in infants await appropriately designed trials.
Key Words: Ankyloglossia; Breastfeeding; Infant
The term “ankyloglossia” comes from the Greek words agkilos for crooked or loop and glossa for tongue . Ankyloglossia (tongue-tie) is a congenital anomaly observed in newborns and children characterized by an abnormally short lingual frenulum. The tight frenulum may result in varying degrees of decreased tongue mobility.
Associations between tongue-tie, lactation problems, speech disorders and other oral motor disorders (eg, problems with swallowing or licking) have been inconsistent, and are a longstanding source of controversy in the medical community -. A survey of otolaryngologists, paediatricians, speech pathologists and lactation consultants done by Messner et al reported significant disparities within and among these groups with respect to their approaches to ankyloglossia and their beliefs regarding its association with feeding, speech and social problems .
This statement focuses specifically on the evidence surrounding the association of ankyloglossia and breastfeeding difficulties. It updates the previous Canadian Paediatric Society document published in 2002 .
There is neither a universally accepted definition nor practical objective criteria for diagnosing ankyloglossia. Historically, definitions have been based on either oral anatomic characteristics (ie, degree of fusion between the tongue and the floor of the mouth), or based on functional impairment (ie, inability to protrude the tongue past the incisal edge of the lower gingiva and other signs of decreased tongue mobility) -. Criteria used to diagnose ankyloglossia vary greatly, and there is no accepted standard. Hazelbaker developed a descriptive assessment tool for lingual frenulum function , but it is complex, lengthy and has not been validated in a controlled manner .
During early development, the tongue is fused to the floor of the mouth. Cell death and resorption free the tongue, with the frenulum left as the only remnant of initial attachment . The lingual frenulum usually becomes less prominent as a natural process of the child’s growth and development, when the alveolar ridge grows in height and the teeth begin to erupt . This process occurs during the first six months to five years of life. Ankyloglossia can be classified based on the degree of fusion remaining between the tongue and the floor of the mouth. 
The role of a short lingual frenulum as a cause of breastfeeding difficulties has been described in multiple anecdotal reports linking partial ankyloglossia to decreased tongue mobility and a potential inability to latch on properly -.
It is important to remember that the swallowing mechanism of the newborn and infant is different from the adult or older child. It has been noted that for successful nursing to occur, the infant must latch on to the mother’s areola with his/her upper gum ridge, buccal fatty pads and tongue. Suckling begins with the forward movement of the jaw and tongue. The tongue helps to make a better seal, but with minimal active action. The anterior edge of the tongue thins, cupping upwards to begin a peristaltic ripple back toward the throat. At the same time, the lower jaw squeezes milk from the ductules. Finally, the posterior part of the tongue depresses to allow milk to collect in the oropharynx before swallowing . It is clear that restriction of the tongue movements must be quite extreme to interfere with sucking and swallowing . It also appears that some mothers may have particular breast/nipple or milk ejection characteristics that allow them to successfully breastfeed an infant with ankyloglossia .
In a prospective study, Messner et al  reported the incidence of ankyloglossia in a well-baby population and studied whether affected patients with this condition experienced breastfeeding difficulties. Only 50 babies of the 1041 newborns that were screened in the well-baby nursery had tongue-tie as defined by their liberal definition. This incidence of 4.8% corresponds with what is reported in the literature -. No cases of complete ankyloglossia were identified. Thirty-six mothers of affected infants were paired with 36 mothers of control infants. All breastfed for a period of two to six months. Thirty (83%) of the 36 infants with ankyloglossia were successfully breastfed during the study period, compared with 33 (92%) of the 36 control infants (P=0.29). Mothers of infants with ankyloglossia reported more breastfeeding difficulties than mothers of controls. However, as stated above, the duration of breastfeeding was similar in both groups .
Hogan et al conducted the only randomized controlled trial studying infants with tongue-tie and feeding problems . The infants were randomized to medical treatment (ie, lactation consultant expertise) or immediate frenotomy. The sample size in this study was small at 57, and used a population of both breastfed and bottle-fed infants. Results show that 27/28 mothers randomized to frenotomy had reduced nipple pain and improved breastfeeding at 1 week, compared to only1/29 mothers randomized to conservative management. Importantly however, this study also showed that 56% of babies with tongue-tie can adequately feed.
A comprehensive review of the literature on the prevalence, diagnosis and treatment of ankyloglossia by Segal et al concluded that: i) standardized and practical diagnostic criteria for ankyloglossia were needed; ii) frenotomy was beneficial in uncontrolled studies to improve nipple pain, latching and continued breastfeeding in some infants with ankyloglossia; and iii) further randomized controlled trials are needed to support frenotomy . The more recent review by Suter et al supports the necessity of developing consistent diagnostic and classification criteria for ankyloglossia, and of undertaking prospective controlled studies regarding its impact on breastfeeding .
Management of tongue-tie is usually conservative, requiring no intervention beyond parental education and reassurance. Infants must be observed closely when a complete fusion of the tongue is found, and frenotomy must be performed . In cases of partial ankyloglossia, it remains controversial which tongue-ties need to be surgically released, and which can be left to observation .
If a tongue-tie release is deemed necessary, a referral to an otolaryngologist, or a physician experienced with the procedure, should be made. Appropriate analgesia should be provided for the procedure. Release of the tongue-tie appears to be a minor procedure, but may cause complications such as bleeding, infection or injury to Wharton’s duct .
A simple incision or ‘snipping’ of a tongue-tie (frenotomy) is the most common procedure performed for partial ankyloglossia. There is a risk that postoperative scarring may limit tongue movement even more, necessitating reoperation . Excision with lengthening of the ventral surface of the tongue or a frenuloplasty release is a more complicated procedure with less postoperative scarring, but has the inherent risks of general anesthesia .
Ankyloglossia is relatively uncommon in the newborn population, but inspection of the tongue and its function should be part of the routine neonatal examination. Most of the time, ankyloglossia is an anatomical finding without significant consequences for the newborn or infant affected by this condition. Current evidence seems to demonstrate that despite ankyloglossia, most newborns are able to breastfeed successfully .
Based on available evidence, frenotomy cannot be recommended. If, however, the association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed necessary, frenotomy should be performed by a clinician experienced with the procedure and with appropriate analgesia.
More definitive recommendations must await precise diagnostic criteria and appropriately designed clinical trials.
Members: Minoli Amit MD (Board Representative); Carl Cummings MD; Sarah Gander MD; Mark Feldman MD (Chair); Barbara Grueger MD; Anne Rowan-Legg MD
Liaison: Peter Nieman MD, Canadian Paediatric Society, Community Paediatrics Section
Consultants: Mia Lang MD; Alan Murdock MD; Hema Patel MD
Principal author: Anne Rowan-Legg MD
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.