Tongue Tie – What’s all the fuss?

What is tongue tie?

Tongue-tie, also known as Neonatal Ankyloglossia, is a congenital anomaly characterised by the thin piece of skin under a baby’s tongue (lingual frenulum) affecting the appearance or function of the tongue. It may be short, less elastic or attach towards the front of the underside of the tongue. The degree of this restriction and its’ effects on function can vary greatly. Tongue tie is said to occur in somewhere between 3-4% of newborns.

What are the signs and symptoms of tongue tie?

Many tongue ties are asymptomatic and may not require treatment, with some improving as a child grows. There is a growing acceptance however, that tongue tie may impact on a baby’s ability to latch at the breast and breastfeed effectively. Significant tongue tie can prevent the infant from being able to extend and elevate the tongue past the gum line, which may result in a shallow latch and limit the normal motion of the tongue during feeding.

Breastfeeding difficulties may include signs that the baby is feeding on the end of the nipple including nipple pain and damage (this means that the nipple is pushed up against the hard palate rather than the soft palate and more likely to suffer trauma); baby losing suction while feeding; baby making clicking sounds when feeding; or signs of poor transfer of milk – baby failing to gain weight well, recurrent mastitis or blocked ducts. It is important to note that you may not have all of these symptoms when feeding a baby with tongue tie, as some babies compensate adequately. There are also many other causes of these breastfeeding difficulties that are unrelated to tongue tie – these should be explored by an International Board Certified Lactation Consultant (IBCLC).

What does this mean?

Given the difficulty confirming the effects of tongue tie, there is understandable controversy in some circles around the treatment options. There are very limited high quality studies around the short and long term consequences of tongue tie. Possible issues that have been suggested include feeding and speech difficulties, as well as oral hygiene issues and orthodontic abnormalities.

It is reasonable to suggest that all newborn infants, whether having feeding difficulties or not, should have an examination of the oral cavity that assesses function of the tongue as well as anatomy.

Diagnosis of tongue tie

Diagnosis for this condition must include adequate assessment of both structure and function. This means that diagnosis cannot be made from a photo alone. Examination includes palpation of the oral cavity as well as assessment of the range of motion of the tongue and length, elasticity and points of insertion of the sublingual frenulum. Commonly used assessment tools include the Assessment Tool for Lingual Frenulum Function (ATLFF) by Alison Hazelbaker or the Frenotomy Decision Tool for Breastfeeding Dyads by Carole Dobrich. Diagnosis may also include the classification of an anterior or posterior tongue tie, both of these have different characteristics. Examination should also include assessment of the cheek and lip cavities for lip and buccal ties.

What about lip ties?

Although we have reasonable evidence to suggest that treating a tongue tie can be a low risk procedure for healthy babies, and potentially have great benefits, we unfortunately don’t have the same evidence for lip and buccal ties. There is often confusion about what a normal maxillary/labial (upper lip) frenulum should look like. In most babies, this frenulum attaches into the gum or palate, and acts as a spacer for baby teeth. This frenulum then slowly moves up the gum line in preparation for adult teeth (which are bigger than baby teeth). For this reason, a midline diastema (gap between the front teeth) is normal in kids up to roughly age 7, and then relatively rare in those over 12. This means we do need more good quality research on lip ties.

Treatment for tongue tie

Treatment may vary from a “watch and wait” approach to a variety of frenotomy procedures that may be performed with scissors or laser. Treatment may depend on the age of the child and severity of symptoms. An initial breastfeeding assessment should always be done by a trained IBCLC in order to rule out other causes of breastfeeding difficulties. Conservative treatment options may include breastfeeding advice from an IBCLC and treatment of musculoskeletal compensations by a trained professional such as an Osteopath. If breastfeeding difficulties are present then frenotomy (division of the frenulum) is often recommended early.

Megan Fraumano, Registered Osteopath & ABA Community Educator BSc, MHSc (Osteo), Cert IV Community Education (Breastfeeding)


References & Resources:


  1. Brodribb W (ed), 2012, Breastfeeding Management in Australia. 4th edn. Australian Breastfeeding Association, Melbourne.
  2. Buryk M, Bloom D, Shope T 2011, Efficacy of neonatal release of ankyloglossia: a randomized trialPediatrics 128(2):280–288.
  3. Francis D O, Krishnaswami S, McPheeters M, 2015, Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics 135(6):e1458–e1466.
  4. Geddes DT, Langton DB, Gollow I, Jacobs LA, HartmannPE, Simmer K 2008, Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 122:e188–e194.
  5. O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, Davis PG, (2017), Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews 3(CD011065):DOI: 10.1002/14651858.CD011065.pub2.
  6. The Royal Women’s Hospital 2015, Tongue-tie: information for families. The Royal Women’s Hospital, Victoria Australia.
  7. Herzhadt-Le Toy, J, et al. J Hum Lact. 2016. Efficacy of an Osteopathic Treatment Couples with Lactation Consultations for Infants Biomechanical Sucking Difficulties
  8. Pizzolorusso, Gianfranco; et al. JAOA: Journal of American Osteopathic Association 2013 Jun; 113(6): 462-467. Osteopathic evaluation of somatic dysfunction and craniosacral strain pattern among preterm and term newborns.
  9. Hayes, Bezilla TA. JAOA; 2006 Oct; 106(10):605-8. Incidence of Iatrogenesis associated with OMT of pediatric patients.
  10. Posadki, Lee MS; Ernst, E. Paediatrics 2013 Jul; 132(1):140-52. Osteopathic manipulatice treatment for pediatric conditions: a systematic review
  11. Cerritelli, Pizzolorusso, et al. BMC Pediatr. 2013 April;13:65. Effect of osteopathic manipulatice treatment on length of stay in a population of preterm infants: a randomized controlled trial
  12. Henry SW, Levin MP, Tsaknis PJ. Histological features of superior labial frenum. J Periodontol 1976;47:25-8.
  13. Taylor JE. Clinical observation relating to the normal and abnormal frenum labii superioris. Am J Orthod Oral Surg 1939;25:646.
babiesEmily Osmond