Does your baby have a classic tongue-tie (or true ankyloglossia)?

What is a true or classic tongue-tie?

It's not possible for me to give you information here which determines whether or not your baby has a true tongue-tie which is causing or contributing to the breastfeeding problems that you and your baby are experiencing. It is important to make this decision in consultation with your own local GP, midwife, or other health professional, who is able to properly examine you and your baby, offer you an assessment, and work collaboratively with you to decide what needs to be done.

There are important things to know so that you feel empowered as a breastfeeding mother or parent of a breastfed baby to make the best possible decisions when you face this question.

Sometimes a newborn has a prominent anterior frenulum, either transparent or opaque, which runs right to the tip of the tongue so that the tip of the tongue pulls into a severe heart-shape when baby is pushing the tongue out. Sometimes this frenulum might insert into or close to the top of the lower gum ridge. If this is your newborn, your doctor might suggest a snip straight away, with the aim of protecting breastfeeding. Since a simple scissors frenotomy is low risk, that seems sensible to me.

However, most commonly, your baby's lingual (or under-the-tongue) frenulum is somewhere on a spectrum of variations. Because multiple factors contribute to good fit and hold, the most important next step after an oral examination is to use strategies which help your baby draw up as much breast tissue as possible into her little mouth, regardless of your anatomic variations and her own anatomic variations.

• You can find out what a frenulum is here.

• You can find out how anatomic variations affect breastfeeding here.

• You can find out about frenotomy here.

• You can find out about the gestalt method of fit and hold starting here.

The gestalt method of fit and hold has been shown in a small case series using ultrasound measures inside the baby's mouth to increase the amount of nipple and breast tissue that the baby is able to draw up, equivalent to the amount of nipple and breast tissue that was drawn up in another study before and after a frenotomy.

Breastfeeding problems aren't usually caused by problems with your baby's tongue movements (though tongue shape and movement change in response to fit and hold changes)

You deserve science-based, heart-connected, and effective help if you have breastfeeding problems, whether your experiencing

• Nipple pain and damage (here)

• Baby fussing at the breast or having difficulty coming or staying on (here)

• Poor baby weight gain (here).

However, these problems are almost never caused by the way your baby's tongue moves. This might seem hard to believe, when you hear from so many breastfeeding support professionals and on so many social media sites that your baby's oral connective tissues must be restricted if you're having these problems!

• You can find what the latest science tells us about how your baby's tongue moves here and here.

• Torticollis and plagiocephaly are interrelated, and are important to discuss with your health professional - but they do not impact upon how your baby's tongue moves, despite what you might here. You can find out about torticollis here and plagiocephaly here.

• Your baby will not develop snoring, sleep problems, or behavioural problems if you fail to go ahead with a frenotomy or bodywork therapy. There is also no evidence to prove that tongue-tie causes speech difficulties in later childhood (although this could be because the diagnosis of 'posterior tongue-tie' has been confused with classic tongue-tie, so that we can't really tell what the effects of untreated classic tongue-tie are long-term). You can find out about this here.

Here are common signs which shouldn't be used to make the diagnosis of tongue-tie

Your baby might have frenula variations that people around you worry are signs of tongue-tie - but your baby doesn't actually have a tongue-tie. These signs include

• A divet or heart-shape at the tip of the tongue

• A prominent anterior membrane which runs along the undersurface of baby's tongue

• The tongue bunching up when you're trying to look

• Tightening of baby's lips when you're trying to look

• A firm string or band that you can feel when you run your finger along the floor of mouth under your baby's tongue

• The little tongue not lifting up much when baby cries

• The little tongue only extending to touch baby's lower gum

• Sucking blisters (- possibly a sign of fit and hold problems, but not of tongue-tie).

Overdiagnosis and overtreatment of restricted oral connective tissues is widespread amongst breastfeeding support professionals

You can find out about overdiagnosis and overtreatment of tongue-tie or restricted oral connective tissues here.

• Overdiagnosis and overtreatment of tongue-tie happens because we have a health system blind spot concerning the importance of stable fit and hold, including the importance of eliminating nipple and breast tissue drag during breastfeeding. You can find out about fit and hold starting here.

• When all the existing evidence concerning the effects of frenotomy or bodywork therapy on breastfeeding to date is carefully analysed, the research is unable prove there are positive benefits of frenotomy or bodywork on breastfeeding. You can hear more about analysis of research on this topic here. I predicted this back in 2013, when I first began to publish papers on this topic, arguing that we were focussing on the wrong questions, that breastfeeding was not that simplistic.

• The whole range of clinical tools which are variously used to help screen babies for tongue-tie or to help health professionals make the decision about whether or not to diagnose tongue-tie or recommend frenotomy are not valid tools, and don't actually effectively help with this decision-making, despite what the researchers or clinicians who use them believe.

• In my view, the decision about whether or not a simple scissors frenotomy is required is a clinical decision based upon my assessment of many different factors. These factors are complex, and are not able to be reduced to a numeric tool. I am a GP, and many of the important decisions I made collaboratively with my patients over the years arise out of complex contexts which can't be reduced to numbers (though we may use a range of investigations). As a GP, I use our clinical judgement, which draws together multiple complex contextual factors, with the patient at the very centre of the decision-making process.

There is no reason to use laser frenotomy when you and your baby have breastfeeding problems (unless your baby has a complex congenital medical syndrome)

If you and your health professional decide to proceed with frenotomy, there is no reason to use laser. There is an increased risk of side-effects if laser frenotomy is used. A simple scissors frenotomy, which is low risk, is all that will be required.

(In the rare case of your precious little one being born with a complex congenital medical syndrome which includes fusion of the tongue with the floor of the mouth, your baby will be cared for by an ENT surgeon who is likely to use laser surgery.)

• You can find out about possible side-effects of frenotomy here.

• You can find out getting the right fit and hold for you and your baby starting here.

• You can locate an NDC Accredited Practitioner in your locality here.

Although it does seem likely that the baby in the photograph at the top of the page has an ankyloglossia or tongue-tie and may benefit from a simple scissors frenotomy, it would be irresponsible of me (and any other clinician) to make a diagnosis from this single photograph. Ankyloglossia is a poorly defined category at the functionally more constrained end of the spectrum of oral connective tissue variations. A clinician can only make the diagnosis of ankyloglossia by performing a thorough oromotor assessment and watching baby breastfeed or feed. The diagnosis is a clinical judgement which arises out of complex contexts, requiring the collation and synthesis of many dozens of pieces of information, working in collaboration with the parents.

Selected references

Borowitz SM. What is tongue-tie and does it interfere with breast-feeding? - a brief review. Frontiers in Pediatrics. 2023;11:1086942.

Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.

Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(1):94. DOI: 10.1186/s12884-12021-04363-12887.

Fedlens CA, Da Silva Heck AB, Rodrigues PH. Ankyloglossia and breastfeeding duration: a multicentre birth cohort study. Breastfeeding Medicine. 2024;19(1):17-25.

Knight M, Ramakrishnan R, Ratushnyak S. Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT. Health Technology Assessment. 2023;27(11):https://doi.org/10.3310/WBBW2302.

Kummer AW. Ankyloglossia: misinformation vs. evidence regarding its effects on feeding, speech, and other functions. Journal of Otolaryngology - ENT research. 2024:DOI: 10.15406/joentr.12024.15416.00552.

LeForte Y, Evans A, Livingstone V, Douglas PS, Dahlquist N, Donnelly B, et al. Academy of Breastfeeding Medicine Position Statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine. 2021;16(4):278-281.

Thomas J, Bunik M, Holmes A. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605.