Tongue Tie in Babies

This page answers the following questions about tongue tie in babies (also known as ankyloglossia in babies)

What does tongue tie mean?

What are the symptoms of tongue tie?

What does tongue tie in babies look like?

How is tongue tie assessed?

What is the definition of tongue tie?

What is posterior tongue tie?

What is the treatment of tongue tie in infants?

What are the risks of tongue tie release (frenulectomy or frenectomy)?

Does a tongue tie interfere with speech?

What is a lip tie?

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What does tongue tie mean?

Tongue tie refers to a tighter than normal membrane (frenulum) under the tongue. If you look in the mirror and lift your tongue you will see a membrance attaching the tongue to the floor of your mouth - this membrane is called the lingual frenulum (or tongue frenulum). In tongue tie in babies, the lingual frenulum attaches close to or at the tip of the tongue which may impede tongue mobility. Tongue tie is also known as ankyloglossia. 

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What are the symptoms of tongue tie?

In some babies with tongue tie, the tongue is not able to move freely enough to allow a good latch on the breast and an adequate suck, so the most frequent symptom of tongue tie in babies is difficulty feeding because they can't latch. The other common symptom is painful nipples for the mother because the tongue is not able to protect the nipple from the baby's gum - in normal breast feeding action, the baby's tongue covers the lower gum., whereas in tongue tie, because of the forward position of the frenulum the tongue can't protrude out far enough to cover the gum, so the baby's gum continually hits the nipple during feeding causing it to become sore.


It is important to realise that not all babies with a tongue tie will have difficulty feeding, just some. So if your baby is feeding normally, there is no need to be concerned even if the frenulum seems attached to near the tip of the tongue.


Tongue tie is more common in boy babies than in girl babies.

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What does tongue tie in babies look like?

As mentioned, you might notice that the lingual frenulum attaches very close to the tip of the tongue - you will see this best when you baby is crying. 

You may also notice that your baby has a small cleft in the center of the tongue or that the tongue is heart shaped, so there is an indent in the center of the tongue.

Depending on where the frenulum attaches, the tongue may have limited protrusion, so the baby may not be able to poke his tongue out, or it may limit elevation, so the baby may not be able to lift his tongue up to the hard palate. 

The photos of tongue tie below were taken in a toddler (you can see the teeth) but show the tongue tie on the left - you can see the frenulum (membrane) attaching close to the tip of the tongue. This leads to a heart-shaped tongue when he protrudes his tongue (photo on the right). This is a Type 1 tongue tie and in this child this did not impede feeding as a baby.


tongue-tie-photoTongue tie - frenulum attaching at the tip of the tongue
Heart-shaped tongue seen in tongue tieHeart-shaped tongue seen in Type 1 tongue tie

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How is tongue tie in babies assessed?

Your midwive, lactation consultant or pediatrician will usually assess what the tongue and lingual frenulum looks like and also how the tongue moves, particularly during sucking. They will be looking at protrusion, elevation and how the tongue curls around the finger (as a proxy for the nipple)

There is an assessment tool that is commonly called called the Hazelbaker Assessment Tool for Lingual Frenulum Function.

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What is the definition of tongue tie?

There are a few classifications of tongue tie, but a simple one used by some paediatric ENT surgeons in New Zealand is:

Type 1 - frenulum attaches close to the tip of the tongue and limits mainly protrusion

Type 2 - frenulum attaches a few millimeters back from the tip of the tongue

Type 3 - frenulum attaches mid-tongue and limits mainly elevation of the tongue

Type 4 - frenulum attaches normally at back of the tongue but is tight and fibrous and limits elevation of the tongue

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What is a posterior tongue tie?

A posterior tongue tie is what people often call the Type 3 or 4 tongue tie mentioned above. The tongue can usually protrude but there are issues with elevation.

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What is the treatment of tongue tie in babies?

In babies who are having difficulty feeding or whose mothers have very sore nipples, a simple treatment for tongue tie in babies is a frenulectomy, also known as a frenectomy or tongue tie release, which is simply a division of the frenulum either by cutting with surgical scissors or by laser or diathermy in a sterile environment. This can usually be done without an anesthetic or with only minimal anesthesia. 


Often babies are given sucrose (sugar solution) by mouth as pain relief and then the frenulum is divided with surgical scissors. 

In my experience, this is a very safe and easy procedure for tongue ties that are Type 1 or 2.  Most babies I have seen undergo this procedure don't even cry and there is usually minimal bleeding, if any. Babies usually breast feed quite happily after the procedure.


Posterior tongue ties will likely need an anesthetic and a more formal surgical procedure.

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What are the risks of tongue tie release (frenulectomy or frenectomy)?

Most babies will have no adverse reaction to tongue tie release. The risks are very small but include:

  • bleeding 
  • infection
  • scarring leading to tightness of the frenulum - this is less common with cutting than with laser
  • no improvement with feeding - as mentioned, not all babies with tongue ties have difficulty feeding and similarly, releasing the tongue tie will not always result in improved feeding

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Does a tongue tie interfere with speech?

In most cases, tongue ties do not interfere with normal speech development, therefore it would be unusual to require a tongue tie release for speech delay.

However, in some cases, there may be issues with formation of particular sounds and assessment by a speech and language therapist would be helpful in those cases. They will likely be able to advise whether tongue tie release may be helpful, in which case referral to a ENT surgeon will necessary.

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What is lip tie?

You will be aware that there is also a frenulum (thin membrane) between the inside of the lip and the front of the upper gums which is called the labial frenulum (or lip frenulum). This can be quite prominent and can extend between the upper teeth. Most babies do not have issues with a prominent labial frenulum.

Division of the labial frenulum (called labial frenectomy or labial frenulectomy) is usually indicated for dental issues, so not needed in babies who don’t yet have any teeth.

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References

  • Isaacson G.Ankyloglossia (tongue tie) in infants and children. UpToDate, 2010
  • Hogan et al. Randomised controlled trial of division of tongue-tie in infants with feeding problems. J Paed Child Health (2005) 41, 246-250
  • Amir et al. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. Int Breastfeed J. 2006; 1: 3. Published online 2006 Mar 9. doi:  10.1186/1746-4358-1-3
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Last reviewed 27 August 2016

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