Diagnosis and Treatment of Ankyloglossia (Tongue – Tie) in infants
Dr. Deena Zimmerman M.D, IBCLC, MACCABI Healthcare, CLALIT, LEUMIT and MEUHEDET, and Jerusalem Breastfeeding Center, Israel
Prof. Francis Mimouni M.D, "DANA-DWEK" Children's Hospital Director, Tel Aviv Medical Center, Israel
Prof. Shaul Dollberg M.D, Department of Neonatology, Tel Aviv Medical Center, Israel
Purpose of this document:
Summation of the available information about the indications and symptoms that may be caused by Ankyloglossia (Tongue–Tie) in infants, and to define the cases in which it is recommended to treat it.
Infants' tongue movement disorders have been described for thousands of years. Still, there is no consensus on the clinical significance of Tongue–Tie indications for surgical release of the tongue.
There is supporting information in medical literature, whereby pain disorders due to poor latch of the breast or other breastfeeding associated pain can be caused by clinically significant Tongue–Tie. Recently there is an expert opinion that some breastfeeding difficulties caused by a functional disorder arising from posterior tongue-tie, that interferes with breastfeeding. Posterior tongue-tie is hard to visualize but can be diagnosed by palpation. It is yet unclear if Tongue-Tie causes pronunciation disorders, comprehension of speech is not interrupted by Tongue-Tie in most cases.
In newborns, surgical release of tongue-tie (frenotomy) is done by lifting the tongue and sterile cutting of the lingual frenulum using specific scissors. Procedural complications are usually minor and mainly include minor bleeding who usually stops with no further treatment.
There are two position papers published on the treatment of Tongue-Tie. One was published in the US by the AAP in 20041 and the other was published in Canada at 20112 . The Canadian paper has a deficient and partial literature review and the conclusions are not well backed by the literature, and therefore it is required to have a position paper of the Israeli Association of Pediatricians.
- Tongue-tie – the common name for a phenomenon that relates to connecting the undersurface of the tongue and the floor of the mouth. In the simplest case, this is a thin, almost transparent string like tissue, and in other cases, a thicker string that contains connective tissue or sometimes parts of the genioglossus muscle.
- Ankyloglossia – a term that describes a tongue that seated in the floor of the mouth. In some articles, the authors use this term as a synonym to Tongue-Tie as defined aboveand in others, short lingual frenulum is used.
- Posterior Tongue-Tie – describes a tongue that is tied by a string which is close to the tongue muscles very close to the oral mucosa or below it. It is hard to visualize and the diagnosed by palpation with a finger under the tongue. Some use the term submucosal tongue tie.
D.Symptomatic Tongue-Tie – In this case the appearance of the string is not enough to define Tongue-Tie associated with functional disorders. Whenever there is tongue functioning disorder that interferes with breastfeeding (such as nipple pain or latch difficulty) perhaps there is a restraint of tongue movement.
- Classification of tongue-tie:
- The American Association of Pediatrics (AAP)1 divided Tongue-ties into four types, according to how close to the tip of the tongue the leading edge of the frenulum is attached: Type 1 is the attachment of the frenulum to the tip of the tongue, usually in front of the alveolar ridge in the lower lip sulcus. Type 2 is two to four mm behind the tongue tip and attaches on or just behind the alveolar ridge. Type 3 Tongue-Tie is the attachment to the mid-tongue and the middle of the floor of the mouth and is usually tighter and less elastic. Type 4 is essentially against the base of the tongue, and is thick, shiny and very inelastic. These types refer to tongue structure only and are not related to the severity of symptoms or therapeutic indication.
- Hazelbaker assessment tool for lingual frenulum function3. This paper documents the tongue function as well.
III. Frenotomy decision Rule for Breastfeeding Infants4. A combination of tongue functions with symptoms.
"Tongue-Tie" is existed in 2.4% to 10.1% of all newborns5-8.
Indications for treatment of tongue-tie:
General: Several random and controlled studies have shown that cutting the frenulum in certain cases reduces the pain caused during breastfeeding for most mothers9,10. Also an improvement in milk transfer was reported11 and prolongation of breastfeeding10. Some professionals state that tongue-tie is associated with other disorders such harm to pronunciation in older age, but that statement does not have a solid scientific basis.
- The Committee believes that there is no scientific basis for frenotomy in infants who do not have signs and / or Symptoms that can be attributed to this phenomenon.
- It is recommended to treat a tongue that causes signs and symptoms, which are mostly prominent pain during breastfeeding, with or without sores and cracks on the mother's nipples. Relative indications for treatment are repeated disconnecting of baby's mouth from the breast during feeding and the baby that does not gain weight.
- "Classical" Tongue-Tie has an absolute indication to perform cutting if it causes interference with breastfeeding for the baby or the breastfeeding mother9,10 .
- In cases where breastfeeding difficulties have not improved after professional counseling, we recommend cutting the posterior tie of the tongue (Expert Opinion).
C.It is highly recommended that breastfeeding consulting should take place prior to tongue-tie treatment, because in many cases, guidance of the mother and improvement of breastfeeding position may make the treatment unnecessary (Expert Opinion).
- Treatment is preferably as soon as possible in order to not harm breastfeeding. However, in cases where signs and symptoms are ambiguous, it is better to wait a few days post-partum to try to establish breastfeeding (Expert Opinion).
Cases where there is no clear medical indication for tongue-tie treatment:
- As to prevention of pronunciation problems in the future14: It should be emphasized that there is lack of information whether tongue-tie treatment will prevent pronunciation problems in the future. In rare cases, witch problems in pronunciation was related to tongue-tie, it is known from medical literature that if diagnosed, it is possible to treat the difficulties with excellent results13.
- In cases there is an esthetical disorder (Expert Opinion): Although, one may consider operating in these cases because frenotomy at infancy is much easier than at older ages (Expert Opinion).
- In other cases not referred here or to prevent various illnesses that attributed to tongue-tie on the web (for example: ear infections, diarrhea, obesity, Etc.) (Expert Opinion).
- Infants that have difficulties feeding from a bottle or a pacifier sucking (Expert Opinion).
- There is no scientific evidence that treatment of the membrane that ties the upper lip to the gums (upper Labial frenulum) will ease breastfeeding difficulties (Expert Opinion).
Contraindications for treatment:
(Could be carried out if necessary after consulting an expert in the relevant field)
Abnormal face anatomy.
Cleft lip or palate.
Personal or family history of hemorrhagic disease.
The information professionals should give to parents of the patient after informed consent for performing frenotomy:
- In classical tongue-tie, studies have shown that there is an improvement in breastfeeding in most patients.
- In posterior tongue-tie, there is no published information about the treatment success rates but only therapists' opinion.
- There are a few cases when there will not be an improvement after the procedure, or in very rare instances, there will be deterioration.
- Frenotomy has a rare potential complication of bleeding, sometimes significant bleeding.
The treatment of Tongue-tie:
A., The action can be performed at the baby's crib or the doctor's office, except in cases of exceptional anatomy. The procedure is performed using special sterile scissors. The use of laser has not been proven to improve the outcome of the action and is even raises the price significantly and is therefore not recommended.
- Pain of the treatment of Tongue-Tie in infancy causes tears of seconds to few minutes and does not require general anesthesia. One can use a local anesthetic, a specific gel for oral mucosa, based on Lidocaine or similar, at the discretion of the doctor performing the procedure. In neonates it is recommended to give a few drops of Sucrose water at concentration of 45-30% on the baby's tongue before the procedure.
- Immediate complications are rare. Usually minor bleeding that stops immediately and slightly significant bleeding must be stopped by applying local pressure. Noteworthy long term complication is scarring of the incision area, which can manifest in breastfeeding problems that occurred a few days after the procedure, even when there is initial improvement observed immediately after the first treatment. Some advocate opening the wound with a finger to prevent scarring of the incision but this recommendation has no validity in the literature and thus depends on the performing doctor's experience.
- Operation will be carried out only by a physician experienced in it. Usually, but not necessarily, it is your pediatrician, family doctor, a pediatric surgeon, pediatric otolaryngology or pediatric Dentist.
- Repeated breastfeeding consulting should be considered, in case of lack of sufficient improvement in breastfeeding after the tongue release. If there is no improvement after consulting you may consider referral to a Speech pathologist specializing in eating and / or eating disorder clinic. There is no evidence that second cutting due to unsolved breastfeeding difficulties contributed more than a single cutting.
Symptomatic tongue-tie can interfere with the success and experience of the breastfeeding mother and baby. The anatomic description of the tongue is not the major parameter while deciding whether to continue treatment. It is recommended to treat when there are signs and symptoms that are related to Tongue-Tie, such as mother's nipple pain, that is not improved after breastfeeding consultation.
There is no indication to treat asymptomatic cases, in bottle fed infants or in order to avoid future difficulties in pronunciation. Treatment in infancy is a clinic act and should be performed without sedation or with local anesthetic by an experienced doctor.
Translated from Hebrew to English by Leeron Piechota
Breastfeeding Management Course 2015
- Coryllos E, Genna CW, Salloum AC. Congenital tongue-tie and its impact on breastfeeding AAP section on Breastfeeding Summer 2004. Available from URL:
- A Rowan-Legg. Ankyloglossia and Breastfeeding. Canadian Pediatric Society Position Statement. Available from URL: http://www.cps.ca/english/statements/CP/cp11-01.htm.
- Hazelbaker AK. The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation Consultant Private Practice [master's thesis]. Pasadena, CA: Pacific Oaks College;1993 (available in part: Forlenza GP et al. Pediatrics 2010; 125: e1500-e1504)
- Forlenza GP, Paradise Black NM, McNamara EG, Sullivan SE. Ankyloglossia, exclusive breastfeeding, and failure to thrive. Pediatrics 2010; 125: e1500-e1504.
- Ballard JL, Auer CE, Khoury JC, Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics, 2002; 110: e63.
- Messner AH, Lalakea ML, Aby J, Macmahon J, & al, Ankyloglossia: incidence and associated Difficulties feeding. Arch Otolaryngol Head Neck Surg, 2000; 126: 36-39.
- Lalakea ML, Messner AH, Ankyloglossia: does it matter? Pediatr Clin North Am, 2003; 50: 381-97.
- Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA, Newborn tongue-tie: prevalence and effect on breast-feeding. Am Board Fam J Pract 2005; 18: 1-7.
- Dollberg S, Botzer E, Grunis E, Mimouni FB, Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg, 2006; 41: 1598-1600.
- Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics 2011; 128: 280-288.
- Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul; 122 (1): e188-94.
- Dollberg S, Manor Y, Makai E, Botzer E. Evaluation of speech intelligibility in children with tongue-tie. Acta Paediatr 2011; 100 (9): e125-7.
- Lalakea ML & Messner AH. Ankyloglossia: the adolescent and adult perspective. Otolaryngol Head Neck Surg 2003; 128: 746-752.
Dollberg S, Botzer E. Neonatal Tongue-tie: Myths and Science. Harefuah 2011. 1: 150.
Knox I. Tongue Tie and Frenotomy in the Breastfeeding Newborn. NeoReviews 2010; 11: E513 -E519.