Tongue Tie and Frenotomy in theBreastfeeding NewbornIsabella Knox, MD, EdM*

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AbstractTongue tie or ankyloglossia has been the subject of much controversy. As defined inthis review, tongue tie occurs when a common minor embryologic tissue remnant—persistence of midline sublingual tissue that usually undergoes apoptosis duringembryonic development—causes restriction of normal tongue movement. Effectivebreastfeeding requires newborns to fine-tune their tongue movements to adapt totheir mothers’ particular nipple and breast anatomy and physiology. In the presence oftongue tie, two categories of signs/symptoms arise: those related to nipple trauma andthose related to ineffective breast emptying and low infant intake. Untreated tonguetie can lead to untimely weaning and its attendant health risks. Frenotomy is a safe andeffective procedure to release tongue tie and improve tongue function and breastfeed-ing outcomes.

Objectives After completing this article, readers should be able to:

1. Recognize the existence of tongue tie as a condition that can potentially cause clinicaldysfunction.

2. Understand the pathophysiologic mechanisms of clinical signs and symptoms oftongue tie in a breastfeeding dyad.

3. Determine when to refer a breastfeeding infant for frenotomy.

IntroductionTongue tie, also known as ankyloglossia, occurs when a persistent lingual frenum restrictstongue movements and interferes with tongue function. True ankyloglossia is classified asa minor congenital anomaly. (1) Controversy has existed for centuries about if and whensublingual frenum tissue is the actual cause of clinical dysfunction. Over the past 3 decades,advances have been made in defining the embryology, pathophysiology, clinical features,and treatment of tongue tie. It is now clear that in some cases sublingual frenum tissuecauses tongue tie because the tissue is restrictive and creates difficulties with breastfeedingand, later in life, other activities that require tongue mobility. The field is still hampered bythe lack of a uniform definition, diagnostic criteria, treatment indications, and outcomesresearch. This review summarizes current knowledge about tongue tie in 2010.

HistoryTongue tie is mentioned in the Bible and other written documents that precede themodern medical literature. (2)(3) For many centuries, it was believed that the sublingualfrenum could impair an infant’s ability to extract milk from the breast and, hence, tosurvive. Frenotomy was widely practiced by midwives and physicians until the mid-20thcentury, coinciding with the period in which few infants in the United States werebreastfed. (4) Tongue tie rarely causes major dysfunction in bottlefeeding infants, and itwas not until the early 1990s, after breastfeeding rates had risen significantly, that tonguetie and frenotomy reappeared in the medical literature. Tongue tie is now confirmed as arelatively common and remediable clinical entity, (5)(6)(7)(8) although many importantclinical questions remain. In 2010, all neonatologists, general pediatricians, and familyphysicians should understand this entity and ensure that resources are available to theirpatients for diagnosis and remediation.

*Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Wash.

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EmbryologyBetween the fourth and seventhweeks of development, the oral cav-ity of the embryo develops from asmooth-walled tube to a more ma-ture structure that has complexanatomy, including a mobile, mus-cular tongue that protrudes freelyfrom the floor of the mouth (Fig.1). The tongue develops from bilat-eral tissue buds that grow from theinner surface of the oral tube, fuseposteriorly-to-anteriorly, and sepa-rate from the floor of the mouth. Aswith many processes in embryo-logic development, the separationoccurs by a combination of tissuegrowth and programmed morpho-logic cell death (apoptosis). Similarto interdigital synechiae seen insoft-tissue syndactyly, (9) the per-sistent lingual frenum is likely aremnant of incomplete apoptosis.(10)(11) This anomaly most com-monly occurs in isolation. Its asso-ciation with cleft palate has been

well characterized, including iden-tification of an underlying TBOXgene abnormality in some kindreds.(12) Other anomalies have beenassociated with tongue tie, mostoften involving craniofacial struc-tures. Maternal cocaine use hasbeen documented as a risk factorfor tongue tie. (13)

EpidemiologyThe incidence of tongue tie is diffi-cult to ascertain because of the lackof a uniform assessment strategy.Studies that rely on visual inspec-tion alone report a rate of persistentlingual tissue of 3% to 10%. (5)(8)Several studies have attempted toassess the risk that the presence ofthis tissue poses for breastfeeding

Figure 1. Embryology of tongue development. A. and B. Scanning electron micrographs ofmouse embryo at days 10 and 12, respectively, approximately equivalent to human weeks5 and 7. Courtesy of K. K. Sulik, all rights reserved. C. and D. Corresponding mid-sagittalanatomy. Drawn by Kelly Ledbetter, © 2010, University of Washington. E. and F.Corresponding coronal sections through the anterior tongue.

TerminologyFrenum

(or frenulum):A membranous fold of skin or mucous membranethat supports or restricts the movement of a part of organ.

Persistent lingualfrenum:

Presence of a frenum between the underside of thetongue and the floor of the mouth; this does notnecessarily cause clinical dysfunction.

Tongue tie: Restriction of tongue movement or function by apersistent lingual frenum. Note that some authors use“tongue tie” to refer to the presence of any sublingualtissue. In this article, a clear distinction is made betweenfrenum tissue, which may be present and in no way interferewith tongue function, and tongue tie, in which the frenumis restrictive.

Ankyloglossia: Synonym for tongue tie.Frenotomy

(or frenulotomy):Surgical procedure in which the frenum is incised.

Frenectomy(or frenulectomy):

Surgical procedure in which frenum tissue is excised.

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difficulties (ie, tongue tie) but are complicated by thelarge numbers needed and the many factors involved inbreastfeeding success. The risk appears to be significant,in the range of 25% to 60%. (14) In most studies, amale:female ratio of about 2:1 has been reported, al-though Knox and O’Callahan recently reported the firstlarge series of posterior tongue ties and found a male:female ratio of 1:1. (15)

PathophysiologyComplex tongue movements are critical for successfulbreastfeeding. Each mother and baby have unique ana-tomic features, and the infant must adapt his or hersucking behavior accordingly. To extract milk success-fully, the tongue must undertake several actions (Fig. 2and Video 1 in data supplement):

1. Protrude over the alveolar ridge both to inhibit thebite reflex (16) and to contribute to an airtight seal onthe areola that allows creation of an intraoral vacuum.

2. Manipulate the nipple and areolar tissue into the

proper relationship with the hard and soft palates, thetongue itself, and the swallowing/breathing apparatus.

3. Produce the intraoral vacuum that results in milkflow from the breast. (17)

Restriction of the tongue’s ability to move freely leads tosuboptimal nursing mechanics. The nipple’s spatial rela-tionship to the infant’s mouth structures and the specificpattern of tongue movements are critical both for effec-tive and efficient milk removal and for protection of thedelicate nipple tissue from trauma. The downstreameffects of tongue tie are related either to ineffective breastemptying or to nipple trauma. All of the common signsand symptoms of tongue tie can be explained by theeffects of abnormal sucking mechanics (Table).

Diagnostic FeaturesIn addition to the clinical signs and symptoms listed inTable, the diagnosis of tongue tie is based on anatomicand functional abnormalities found on physical exami-

nation. The physical examinationmay reveal either a thin anteriormembrane or a thick posterior fi-brous strand in the midline be-tween the underside of the tongueand the floor of the mouth (Fig. 3).The superior attachment of the fre-num to the tongue can occur invarious locations between the tipand the junction with the floor ofthe mouth. On occasion, no abnor-mality is visible. Instead, a tightmidline filament, like a taut fishingline in the soft tissue where thetongue joins the floor of themouth, is palpable. In general, an-terior frena are thin and trans-parent, merely consisting of a re-flection of mucosal tissue, whileposterior frena are thicker, white,and fibrous-looking. Occasionally,blood vessels or muscle fibers maybe present in the frenum.

Assessment of newborn tonguefunction is challenging, particularlyduring nursing, when most struc-tures are not visible. Because mater-nal characteristics also contribute tothe structural mechanics of the in-fant’s task (eg, the length, firmness,and stretchability of the nipple and

Figure 2. During nursing, the infant’s tongue must: 1) protrude over the alveolar ridge toinhibit the bite reflex, 2) assist the flanged lips in maintaining an airtight seal on theareola, 3) with its prehensile function, manipulate the nipple into the proper position(note the depth of the nipple tip and its proximity to the hard-soft palate junction), and4) via distal-to-proximal muscular contractions that end with the lowering of the base ofthe tongue, produce an intraoral vacuum, resulting in milk flow.

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areolar tissue), it is difficult to predict from examination ofthe infant whether or not he or she will be able to nurseeffectively with his or her particular mother. Hazelbaker(20) developed a scoring system, the Assessment Tool forLingual Frenulum Function, that includes assessment ofstructural and functional aspects of the infant’s tongue. Useof this tool is not widespread, possibly because of its com-plexity and the large number of items to be scored. In this

author’s opinion, as well as that of others, including theUnited Kingdom’s National Institute for Health and Clin-ical Excellence, (21)(22) if a thin anterior frenum is foundin association with clinical signs and symptoms, frenotomyshould be considered because the procedure is simple andsafe and may solve the problem. Posterior frena are morelikely than thin anterior ones to be associated with breast-feeding difficulties (4) and have received more attention

recently. In addition, anecdotal re-ports suggest that thick posterior fre-num tissue may remain after anteriormembrane frenotomy (personalcommunication, E. Coryllos, C.O’Callahan, J. Murphy, 2010), sopersistent tongue tie should be con-sidered if signs and symptoms do notresolve. Submental ultrasonographyallows viewing of nipple-tongue rela-tionships and tongue movement. Al-though this tool so far has been usedonly for research, it may, in the fu-ture, be helpful in diagnosis, particu-larly when clinical findings are equiv-ocal.

TreatmentWhen tongue tie is associated withbreastfeeding difficulties, frenotomy

Figure 3. The two ends of the ankyloglossia spectrum. On the left is a classic thin anteriorfrenum. Note the notch in the tongue tip and the limited height of the tongue lift. On theright is a thick posterior frenum, visible as a white line in the posterior floor of the mouth.On palpation, this tissue is taut and firm. Pictures courtesy of Catherine Watson Genna,used with permission, all rights reserved.

Table. Signs and Symptoms of Tongue Tie in the Breastfeeding DyadInfant Signs/Symptoms Mechanism

Poor latch Inadequate seal, inability to manipulate nipple/areola into positionClicking sound while nursing Intermittent loss of sealGradual sliding off breast Inability to maintain hold on nipple/areola“Chewing” Failure to inhibit bite reflex; compensatory use of jaw muscles to maintain

nipple positionIneffective milk transfer Failure of breast emptyingPoor weight gain or weight loss Failure of milk transferHypernatremic dehydration (18) Unrecognized severe failure of milk transferFussiness and arching away from breast Infant response to frustrationFalling asleep at breast Infant exhaustion

Maternal Signs/Symptoms MechanismNipple trauma: pain, blister, crack, bleeding,

scabLocalized ischemia from sustained point compression; tissue destruction

from repetitive crush or roll, excessive vacuum (19)Painful breasts Engorgement from failure to empty during primary lactogenesis; infectionLow milk supply Failure of secondary lactogenesis from failure to emptyPlugged ducts Stasis from failure to emptyMastitis Failure to empty with bacterial ingress from nipple tissue barrier breakFrustration, disappointment, discouragement

about breastfeedingPain, infant frustration, sense of failure because of inability to nourish

infantUntimely weaning Lack of availability of tongue tie diagnosis and remediation

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is an effective treatment. Frenotomy for thin anteriortongue tie is a safe and simple nursery or office procedurethat uses readily available equipment (see Video 2 in thedata supplement). (23) Frenotomy for thick posteriortongue tie currently is performed either as an office proce-dure or in the operating room, depending on the experi-ence and training of the operator. Specialized training isrequired to perform frenotomy for posterior tongue tiesafely.

Because few physicians are knowledgeable abouttongue tie and even fewer perform frenotomies, only themost persistent and knowledgeable families can takeadvantage of this treatment and, thus, maintain breastfeed-ing. Historically, severe bleeding and infection werereported as complications of fre-notomy. (24)(25) There is also apotential for damage to the sublin-gual salivary ducts. However, allreported of series of newborn andinfant frenotomy in the modernmedical literature, including thosecited in this article’s reference list,(5)(6)(7)(8) state that no compli-cations occurred related to the pro-cedure.

After frenotomy, the infant shouldbreastfeed as soon as hemostasis hasbeen assured, usually after one blotwith a gauze pad, as seen in Video 2.Tongue movements during nursingprovide range of motion exercise andhelp to prevent re-adhesion. Skilledlactation support must continue untilthe infant establishes functional mo-tor patterns and injured nipples heal.Some infants have difficulty develop-ing normal tongue movements; feed-ing specialists can provide detailedassessment and targeted therapy.

Outcomes of Treated andUntreated Tongue TieThe effectiveness of frenotomy fortongue tie-associated breastfeedingdifficulties has been documentedin observational (5) and random-ized (6)(8) studies, including onethat was well-blinded. (6) Geddesand associates (7) used ultrasonog-raphy to document improvementin tongue mechanics following fre-

notomy, along with improved milk transfer, decreasednipple pain, and better latch (Fig. 4). Studies of neonataland infant frenotomy have examined only its short-termeffects on breastfeeding parameters. It is unknownwhether frenotomy in infancy alters the natural history ofuntreated tongue tie. Dollberg and colleagues (26) ex-amined speech at age 8 years in infants treated withneonatal frenotomy. Their speech was not different fromchildren who had not had tongue tie. A comparisongroup with untreated tongue tie had significant misar-ticulations.

Untreated tongue tie is associated with nursing diffi-culties that may result in early weaning, depriving fami-lies and infants of the well-documented short- and long-

Figure 4. Submental ultrasonographic images obtained pre- and postfrenotomy. Theorientation is the same as in Video 1. Both images were obtained in the “tongue up”portion of the suck cycle. In this patient, the primary findings were an increased distancefrom the tip of the nipple to the hard-soft palate junction (HSPJ) and compression of thetip of the nipple by the back of the tongue. The second image was obtained 1 week afterthe procedure. Notable are the shortened (and normal) distance between the nipple andthe HSPJ and the smoother contour of the back of the tongue, which no longer isdeforming the nipple. For more information about ultrasonographic assessment in tonguetie, see Geddes and associates. (7)(17) Images provided by Donna T. Geddes, PhD, all rightsreserved.

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term benefits of breastfeeding. There are anecdotalreports of spontaneous rupture of the lingual frenum.(27) Clinical problems associated with tongue tie in olderchildren and adults have been documented in case reportsand series. (28) Problems include difficulties with speech,tooth alignment requiring orthodontia, oral hygiene (lick-ing lips and removing debris, especially from posteriorteeth), and kissing. Some, although not all, of these prob-lems improved following frenectomy. No controlled stud-ies are available.

Summary and ConclusionsWhen the lingual frenum does not apoptose properly dur-ing embryologic development, the residual tissue can, insome cases, interfere with tongue function and cause avariety of breastfeeding problems that may result in earlyweaning and its attendant risks. Persistence of this tissuebeyond infancy can interfere with full tongue function inthe older child and adult. Every mother-infant dyad withbreastfeeding problems, particularly the maternal symptomof nipple pain and the infant sign of failure to transfer milkdespite vigorous attempts to latch and suckle, should beevaluated for tongue tie and treated if it is present. Treat-ment ideally should occur within 24 hours of diagnosisbecause of the fragility of lactation physiology in the neo-natal period.

Frenotomy is an effective treatment and, for thin ante-rior frena, is a simple and safe procedure. The proceduremust be followed by skilled lactation and oral skill develop-ment support until breastfeeding is re-established. Thickposterior tongue ties are more difficult to diagnose andtreat.

Frenotomy is not as widely available as is needed. Be-cause facilitating the full breastfeeding potential of allmother-baby dyads is critical to individual and publichealth, more practitioners need to be trained to assesstongue tie and perform frenotomy. Neonatologists, withspecific procedural skills and commitment to breast-feeding, can lead the way as advocates and teachers. Moreresearch is needed, particularly on posterior tongue tie,to facilitate and standardize diagnosis and treatment.

Follow-up studies are needed to examine the long-termoutcome of frenotomy in infancy.

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