Overview 

Tongue-tie (or ankyloglossia) is a condition present at birth that restricts tongue movements, which may affect a baby’s ability to breastfeed effectively. This can have a major impact on a baby’s health and development. Tongue-tie can also cause severe nipple pain in breastfeeding mothers and is a common reason for early abandonment of breastfeeding. Recognising and treating tongue-tie early is essential to enhancing breastfeeding success and promoting the well-being of both mother and baby.

Understanding tongue-tie

To understand what tongue-tie is, it’s vital to look at the anatomy of the tongue. The tongue is normally secured to the floor of the mouth by a fold of fascia known as the lingual frenulum.¹ When the tongue is relaxed, the frenulum rests loosely on the floor of the mouth. When the tongue is lifted, the frenulum lifts with it and is pulled tight. In some infants, the frenulum is too thick, short or tight, thereby preventing the tongue from moving normally. This condition is known as tongue-tie or ankyloglossia. 

How common is tongue-tie?

There is still a lot of controversy about how many babies are truly affected by tongue-tie. The estimates of newborns with the condition range between 2 to 10% .^2,3 There has been a sharp rise in newborn babies diagnosed and treated for tongue-tie in recent decades due to increased awareness and a lack of agreement on how to diagnose the condition.^2,4

Tongue-tie is a hereditary condition and is more common in male babies.^3,5 It has been linked to rare syndromes, such as Beckwith-Wiedemann syndrome, Moebius syndrome, orofaciodigital syndrome, and X-linked cleft palate.⁴

How tongue-tie affects breastfeeding

Successfully feeding at the breast requires a baby to extend the tongue and keep it over the lower gum while suckling. The baby should have a deep latch (attachment), which means they take in a large portion of the nipple-areola complex and not just the nipple. A deep latch creates a strong seal, allowing the baby to suck in a steady rhythm while the tongue creates a wave-like motion to extract the milk. A frenulum which is too short, thick or tight, could restrict the movement of the tongue, leading to an ineffective latch and ability to suck effectively.³ As a result, the baby could have difficulty drawing out the milk properly from the breast. This leads to increased effort for the baby, leading to frustration and ultimately longer and more frequent feeding.  

Common signs of tongue-tie in babies:

• The tongue may look heart-shaped
• Difficulty sticking the tongue out
• Difficulty latching or staying attached to the breast
• Clicking sounds while breastfeeding
• Poor weight gain and growth
• Fussiness resulting in longer and more frequent feeds
• Gastrointestinal symptoms
• Excessive drooling⁴

The link between tongue-tie and nipple pain

An abnormal frenulum often results in a shallow latch and a poor seal. The baby tries to compensate by holding onto the nipple with the gums, which causes friction and compression of the nipple.⁵ This is painful for the mother and often leads to sore or cracked nipples, which can increase the risk of infection. Furthermore, ineffective milk removal from the breast leads to painful breast engorgement, decreased milk production and increased risk of mastitis. Nipple pain can negatively affect a mother’s activity levels and sleep quality. It often leads to low mood, depression and decreased confidence and is one of the main reasons mothers choose to stop breastfeeding.⁵ 

Treatment options for tongue-tie

There is no universal agreement as to the best way to treat tongue-tie in babies. Many sources recommend conservative management as first-line treatment, while others recommend surgery as primary therapy.^2,4,5 Since approximately half of all babies with tongue-tie have no breastfeeding problems, it would seem reasonable to begin with conservative management. Surgery could be considered if the problem does not resolve thereafter.⁴  

Conservative treatment

Conservative treatment of tongue-tie involves non-surgical approaches to help mothers and babies adapt to breastfeeding challenges. Support typically involves working with a lactation consultant or healthcare worker to provide advice on issues such as poor latch, feeding positions, low milk intake, nipple trauma and pain. Many experts also advise orofacial myofunctional therapy, which focuses on strengthening muscles of the face, tongue and mouth to improve suckling reflexes in newborns.⁴

Professional support is essential in helping mothers continue breastfeeding while managing tongue-tie. With proper guidance and adjustment, many babies can improve their feeding skills without needing surgical intervention.

Surgical treatment

When conservative treatment is not successful, surgery is often recommended. Frenotomy (also sometimes called frenulotomy) is a minor surgical procedure in which the lingual frenulum is cut with a scalpel, scissors or laser. The procedure offers several benefits for both mother and babies. Improved tongue movements leads to a better latch, more effective sucking and increased milk intake. Furthermore, a better latch reduces nipple trauma and pain for the mother. While the procedure is generally regarded as safe, there are reports of serious complications.

Researchers previously believed that the frenulum was simply a cord of fibrous connective tissue which remained behind when a fetus was developing in the womb. However, more recent anatomical studies have found that the frenulum is a fold of fascia which contains small branches of the lingual nerve^1,6 The lingual nerve plays a role in tongue sensation and affects the movement of the tongue’s muscles. Cutting the lingual frenulum is therefore painful and may cause loss of feeling at the tip of the tongue.^1,6,7 

Complications involved in frenotomy:^2,6,7

• Infection
• Abscesses
• Severe bleeding and damage to the blood vessels in the tongue
• Airway obstruction
• Damage to salivary glands and ducts
• Oral aversion or feeding refusal
• Compromised tongue sensation and movement
• Pain
• Scars

Importance of early diagnosis and treatment

Breastfeeding has substantial benefits for both mother and baby. The World Health Organisation recommends exclusive breastfeeding for the first six months of life.⁸ However, despite the known benefits, less than half of babies under six months of age are exclusively breastfed.^5,8 Nipple pain caused by tongue-tie is a common reason for early abandonment of breastfeeding.^3,4,7 Early diagnosis and treatment of the causes of nipple pain, therefore, increases the chance of continued breastfeeding.

The main advantages of breastfeeding for babies and young children includes:⁹

• Reduced risk of diarrhoea
• Protection against respiratory infections
• Decreased risk of Sudden Infant Death Syndrome 
• Decreased risk of middle ear infection
• Protection against type 1 and type 2 diabetes
• Reduced risk of obesity later in life

Breastfeeding also offers benefits for mothers, such as a lowered risk of ovarian and breast cancer.⁹ The psychological advantages of breastfeeding for both mother and baby are just as important. Breastfeeding fosters a strong maternal bond and decreases the likelihood of postpartum depression.¹⁰ Simultaneously, breastfeeding facilitates cognitive and emotional development in children.^9,10 

Managing nipple pain during breastfeeding

Nipple pain is common during breastfeeding, particularly in the first week after birth. More than half of women experiencing nipple pain develop visible signs of damage, which may appear as redness, swelling, bruising, cracks, fissures, bleeding and ulcers.⁷ Early treatment of damaged nipples is important to prevent getting an infection in the nipple.

Tips to manage nipple pain and damage:⁷

• Avoid using breast pads unless absolutely necessary
• Ensure breast pads remain dry and change them regularly
• Avoid using nipple shields unnecessarily
• Keep nipples warm in between feeds
• Avoid wearing a bra at night to allow air to circulate around the breasts
• Avoid using lanolin or hydrogel dressings for damaged nipples
• Seek help early from a lactation specialist

Summary

Tongue-tie in babies can significantly affect breastfeeding and have negative consequences for both mother and baby. A frenulum which is too short, thick or wide can restrict the tongue’s movement. This can make it difficult for the baby to latch properly, causing ineffective sucking and poor milk intake. The long-term effects can be detrimental to a baby’s health, growth, and emotional and cognitive development. Tongue-tie can also have a negative impact on mothers. It can cause intense nipple pain and damage during breastfeeding and is a common cause of early weaning. 

Early identification and treatment of tongue-tie is essential for preventing breastfeeding challenges and promoting both the mother's and the baby's well-being. Prompt treatment of the condition can help mothers experience less discomfort, avoid potential long-term complications and enhance the breastfeeding experience. Professional support and timely intervention can make all the difference in improving the breastfeeding journey.