Does my baby have a tongue-tie?

Some babies are born with a tongue-tie, a condition that restricts the movement of the tongue and may interfere with breastfeeding. The movement is restricted by the tongue frenulum, a fold of tissue that connects the bottom of the tongue to the floor of the mouth. There are a number of tools for diagnosing tongue-tie but none is universally accepted. The reported rate in babies ranges from 0.1% to 33%. With a tongue-tie, the frenulum may prevent the baby from raising the tip of the tongue and from sticking it out of the mouth. Babies may have a heart-shaped tongue when crying or have an indent in the tongue tip. They may or may not have trouble breastfeeding. Tongue-tie diagnoses and surgery have dramatically increased in the past few years. A tongue-tie caused by deeper tissues in the frenulum (posterior) has recently been described. There are no validated tests for diagnosing a posterior tongue-tie and there is no conclusive research on treatment benefits or risks.

A) What is a tongue-tie?

A tongue-tie.

Virtually all babies (99.5%) have a frenulum, a dynamic structure found under the middle of the tongue (Haham 2014). It is composed of mucosa, the wet, pink skin that lines the mouth but sometimes contains fibous or muscle tissue (Mills et al. 2019).

The frenulum:

  • May be thick or thin.
  • May be shorter or longer.
  • Has its bottom attached to the bottom of the mouth and may extend to the back of the lower gum.
  • Has a top part that may extend to the middle, front, or even the tip of the tongue.

Veins, salivary gland ducts and their openings are found at the bottom of the frenulum in a little triangle of tissue.

Some babies are born with a condition called tongue-tie, in which movement of the tongue is restricted by the tongue frenulum. This is also known as ankyloglossia. 

Tongue-ties may affect the function of the tongue and the muscles of the floor of the mouth (França 2020).

B) The appearance of a tongue-tie

A tongue-tie that goes from the back of the jaw to the tip of the tongue.

Tongue-ties have been recognized for many years. They can be recognized by looking at the distance between the top part of the frenulum and the tip of the tongue, the placement of the bottom part of the frenulum, and the length of the frenulum.

Tongue-ties can run in families (Han 2012). It is slightly more common in boys (Walsh 2019). Tongue-ties can be related to genetic syndromes.

Babies who are diagnosed with tongue-ties generally:

  • Have a frenulum that ties the tip of the tongue or most of the tongue to the bottom of the mouth or the back or top of the lower gum.
  • Have an indent in the tongue tip.
  • Have a heart-shaped tongue when crying.
  • Can’t stick their tongue out over the lower gum.
  • Can’t raise their tongue to the top of the mouth.
  • Can’t move their tongue from side to side in the mouth.

These babies may or may not have breastfeeding problems (Emmerson 2018; Power and Murphy 2015; Rowan-Legg 2015). There is some evidence that cutting the frenulum can help babies who have trouble breastfeeding and decrease nipple pain.

C) Assessment tools

Assessing tongue-tie is challenging (Francis 2015; Walsh 2017b). There are a number of ways of diagnosing them (classification tools). Here are some:

  • Coryllos (Coryllos 2004)
  • Bristol Tongue Assessment Tool (BTAT) (Ingram 2015)
    • Tongue-tie and Breastfed Babies (TABBY) (Ingram 2019)
  • Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) (Hazelbaker 1993)
  • Kotlow (Kotlow1999)
  • Kotlow revised (Kotlow 2011)
  • Neonatal Tongue Screening Test (NTST) (Martinelli 2012)
  • Tip-frenulum length (Walker 2018)
  • Tongue range of motion ratio (Yoon 2017)

Some of these tools focus on the anatomy of the frenulum and where it attaches to the tongue and mouth floor. Others also consider the function of the tongue. The Coryllos, ATLFF, and BTAT are most commonly used.

None of these assessment tools can reveal what the tongue and the rest of the mouth do as the baby latches and sucks or how the nipple responds to breastfeeding. This can be seen using an ultrasound machine but there is no reliable ultrasound test for a tongue-tie (Douglas 2018; Geddes 2008).

As there is no universally accepted tool for diagnosing tongue-tie and identifying which babies benefit from cutting the frenulum, there has been much debate and controversy around this topic (Hill 2020b).

It is not surprising that the reported rate of tongue-tie has a large range: 0.1% of babies to 33% (Hill 2019; Maya-Enero et al. 2020; Walsh and Tunkel 2017). One summary of the best studies estimated 8% of babies under one year are tongue-tied (Hill 2020a).

Nor is it surprising that health-care providers’ opinions about the importance of tongue-tie in breastfeeding differ between professions and vary around the world (Jin 2018) and advice to families is similarly varied.

D) Posterior tongue-tie

Recently, some clinicians have separated tongue-ties into anterior (toward the front of the mouth) and posterior (toward the back). However, the exact definition remains vague, with some authors using the term to mean the part of the frenulum that inserts into the posterior part of the tongue and other refer to a cord within the frenulum.

Ultrasound studies have not shown the present of a discrete cord and the consensus is now that the division into anterior and posterior is arbitrary and should not be used (LeFort 2021; Messner 2020; Mills 2019).

There are no validated tests for diagnosing posterior tongue-tie and there is no conclusive research on treatment benefits or risks.

E) Lip and other ties

1) Lip ties

There is a second normal frenulum in the mouth that lies under the top lip and connects the middle of the upper gum and the inside of the upper lip. Some health-care providers believe this frenulum can cause difficulty breastfeeding and refer to this situation as a lip-tie.

2) Other ties

The cheek has a frenulum that connects to the jaw and face bone (buccal frenulum). It helps to keep the cheeks firm and the food between the teeth.

A small number of practitioners have identified the buccal frenulum as also being tied and causing breastfeeding problems. There is virtually no published research on this frenulum, on how to diagnose it, on the problems it may cause, or on the risks or benefits of any treatment. It should not be cut (LeFort 2021; Messner et al. 2020).

F) The popularity of the tongue-tie diagnosis

Concern about tongue-tie and other ties has grown rapidly in recent years. As a result, surgery rates have increased by (Kapoor 2018; Lisonek 2017; Walsh 2017a):

  • 800% in the USA from 1997 to 2012.
  • 390% in Canada from 2004 to 2014.
  • 520% in Australia from 2006 to 2016.

Factors that have increased the popularity of tongue-tie diagnosis and surgery include (Messner 2020):

  • Increased awareness that tongue-tie can cause breastfeeding problems.
  • Increased numbers of health-care providers that identify tongue-ties.
  • Increased social media posts and websites related to tongue-tie (Aaronson 2018; Grond 2021).
  • Increased numbers of health-care providers, in particular dentists, who treat tongue-tie.

The increased financial reward from laser surgery over clipping with scissors may also have played a role.

As a result of this popularity, breastfeeding problems may be misdiagnosed and babies may undergo unnecessary surgery. One American study looked at 115 babies who were referred for tongue-tie surgery. After a thorough examination, only 38% were found to need it (Calaway 2019).  

It can also result in multiple surgeries. One study (Lyudin 2018) of babies in the Dunedin area of New Zealand reported 23% of babies had a second cutting and a small number had three or more cuttings. In online posts, mothers have reported up to four cuttings in one baby for a posterior tongue-tie diagnosis. 

Given the popularity of the diagnosis, there are concerns that it is reaching fad status (Douglas 2013; Joseph 2016; Kapoor 2018; Walsh 2017a).

Programs are now being instituted to minimize unnecessary tongue cutting (Dixon 2018).


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