Does your baby have a posterior tongue-tie?

Treatment for a frenulum which has been labelled as a posterior tongue-tie won't help you and your baby breastfeed (and might even make breastfeeding worse)

You don't need to worry when someone tells you that your baby has a posterior tongue-tie! It's not a thing, I'm afraid, either anatomically or functionally. But I do worry alot about the kind of problems which brought you in to seek help. Possums Breastfeeding and Lactation aims to give you information which will help you find your way through.

If your baby has a frenulum which isn't very visible, or which you can feel but not really see, this is nevertheless a normal anatomic variation. The science tells us clearly that the connective tissue under the moist mucosa of your baby's tongue undersurface which connects that little tongue to the floor of your baby's mouth

• Doesn't connect with the posterior part of the tongue in any way

• Doesn't change the shape of the tongue, and

• Doesn't change how the tongue moves.

In 2020 Dr Nikki Mills published her pioneering research which proved, in painstakingly detailed anatomic dissections of the floor of the mouth of babies who had died, that there was no anatomic feature in the oral fascia or connective tissue which could in any way correlate with a proposed diagnosis of a posterior tongue-tie. In response to Dr Mill's research, and communicating directly with Dr Mills, Gray's Anatomy has changed it's description of and illustration of infant lingual frenula and floor of mouth fascia. You can find out more about Dr Mill's work here. There is a series of three podcasts on this topic between me and Dr Mills starting here.

The breastfeeding problems which make families or health professionals wonder if there is a tongue-tie need to be addressed

We need to address the other real reasons why you and your baby are having breastfeeding problems.

• You can find out how your baby's tongue works during breastfeeding here.

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

• You can find the possible side-effects of an unnecessary frenotomy here.

• You can find a short history of the diagnosis of posterior tongue-tie here.

• You can find out about classic or true tongue-tie, which may require a frenotomy, here.

These days, because of this research, breastfeeding support professionals are less likely to apply the diagnosis of posterior tongue-tie - but still label many normal anatomic variants of the lingual frenulum as a tongue-tie, or sometimes a 'deep' tongue-tie. These are variants which might earlier have been labelled a posterior tongue-tie.

Unless your baby has a prominent anterior membrane, which you too can see, your baby won't have a tongue-tie. Even prominent anterior membranes most commonly do not interfere with tongue movement and shape in any way that is relevant to you and your breastfeeding baby. Some babies have shorter tongues with squarer tongue-tips, a normal variation which in itself doesn't interfere with breastfeeding, although these variation of tongue shape is more common in babies with delicate chins. The gestalt method uses strategies to address delicate chins, starting here.

You can see under the tongue of a baby who was diagnosed with posterior tongue-tie in the photo at the top of this page. In fact, this baby has a normal (not very prominent or visible) frenulum. This is not a posterior tongue-tie. The baby's breastfeeding problems related to fit and hold, which resolved when we worked together.

Selected references

Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.

Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.

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. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):180-181.

Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation. 2017;33(3):519–523.

Ghaheri BA, Cole M, Fausel S, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: a prospective cohort study. Laryngoscope. 2017;127:1217–1223.

Ghaheri BA, Cole M. Response to Douglas re: 'Conclusions of Ghaheri's study that laser surgery for posterior tongue and lip ties improves breastfeeding are not substantiated'. Breastfeeding Medicine. 2017;12(3):DOI:10.1089/bfm.2017.0016.

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.

Mercer NSG. Posterior tongue tie and lip tie - division of tongue tie: an assault on a baby. BMJ. 2021;372(n11).

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.