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NICU guideline identifier

Ankyloglossia (Tongue-Tie)

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  • The bottom of the tongue is tethered to the floor of the mouth by a membrane (frenulum).
  • This restricts the range of movements of the tongue.
  • If the frenulum is too restrictive (tongue-tie, ankyloglossia), it may impact feeding, speech, swallowing, and associated oral development problems.


  • Most reports give an incidence of 3-5%, although an incidence of up to 10% has also been cited.
  • Males are more commonly reported to be affected than females (1.5:1 to 2.6:1 ratio)
  • Fewer than half of those infants identified as having a tongue-tie will require intervention for symptoms.

Diagnosis of clinically significant tongue-tie

Based on a combination of anatomical appearance and functional disturbance.

Anatomical    Type 1: Frenulum attaches to tip of tongue in front of alveolar ridge in low lip sulcus Ankyloglossia
Type 2: Attaches 2-4mm behind tongue tip and attaches on alveolar ridge
Type 3: Attaches to mid-tongue and middle of floor of the mouth, usually tighter and less elastic.
The tip of the tongue may appear "heart-shaped"
Type 4: Attaches against base of tongue, is shiny, and is very inelastic
Functional disturbance    Feeding difficulties
Cannot initiate tongue grooving, cupping or depression
• Interferes with front-to-back peristalsis as well as tongue palate synchronisation in breast feeding
• May also adversely affect bottle feeding (rare)
Older children may have difficulties with feeding (for example, licking ice creams) or speech


There is no single reliable tool for assessment that adequately predicts the degree of problems an individual infant will have. Staff familiar with the Hazelbaker Assessment Tool For Lingual Frenulum Function (ATLFF) may wish to use this.

Physical examination • Rule out thrush, clefts, and other defects including neuromuscular conditions
• Range of motion of tongue and degree of extension beyond lower dental ridge and lip
• Elevation to palate with mouth wide open
• Transverse movement of tongue without twisting of the tongue
Maternal assessment • Document degree of maternal nipple pain and nipple skin erosion
• Painful breasts
• Low milk supply
• Plugged ducts
• Mastitis
• Untimely weaning
• Candida
Infant assessment • Adequacy of latch and milk transfer
• Efficiency of bolus handling
• "Clicking" during feed due to loss of latch
• Sliding off breast
• Fatigue
• Irritability during/after feeding
• Poor weight gain (serial test weighs, supervised by a senior team member, may be helpful)


  • Not all infants with tongue-tie will need any intervention other than good lactation support.
  • Assessment should be performed by a lactation consultant and/or speech language therapist. If it is determined that the baby is likely to benefit from a frenulotomy, this should be discussed with the specialist looking after the baby.
  • Frenulotomy has been shown in prospective studies to improve feeding outcomes and maternal symptoms in infants with significant ankyloglossia. Whilst some institutions undertake frenulotomy using sucrose analgesia, local practice is to refer to a paediatric surgeon. Other institutions may instead refer to ORL or plastic surgical services.
    Contact the paediatric surgical registrar on call and indicate that the infant has a significant tongue-tie that is interfering with feeding.
    Frenulotomy should be performed within a few days of the referral being made. The procedure will usually be performed under a light general anaesthetic, using diathermy.
  • All babies should have had Vitamin K administered at birth or at least 1 day prior to the procedure.
  • Post-operatively, babies will require a period of observation for at least 4 hours. Ex-premature infants should have a longer observation period in view of the increased risk of apnoea.
  • Paracetamol may be given as needed.
  • If mothers are Hepatitis C positive, breast feeding should be postponed until the wound has healed.
  • Complications (such as excessive bleeding) are rare and should be documented carefully.


  1. Hall DMB, Renfrew MJ. Tongue tie. Arch Dis Child 2005;90;1211-5.
  2. Messner AH. Lalakea ML. Aby J. Macmahon J. Bair E. Ankyloglossia: incidence and associated feeding difficulties. Archives of Otolaryngology -- Head & Neck Surgery 2000;126:36-9.
  3. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002;110:e63.
  4. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board of Family Practice 2005;18:1-7.
  5. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): use in a lactation consultant private practice [thesis]. Pasadena (CA): Pacific Oaks College; 1993
  6. Amir LH, James JP, Beatty J. Review of tongue-tie release at a tertiary maternity hospital. J Paediatr Child Health 2005;41:243-5.
  7. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005;41:246-50.
  8. Maternity and Neonatal Services, Women's Health Division, Canterbury DHB. Recognition, assessment and ankyloglossia release and its impact on breastfeeding outcome: a quality-team initiative.

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Document Control

  • Date last published: 01 December 2005
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years