Ankyloglossia (Tongue-Tie)


Reviewed by Simon Rowley, Carl Kuschel, Lynley Nichols (Lactation Consultant NICU), and Stuart Ferguson (Paediatric Surgery)
Clinical Guidelines Back Newborn Services Home Page
Definition Incidence Diagnosis of Clinically Significant Tongue-Tie
Assessment Management References



Diagnosis of Clinically Significant Tongue-Tie

  • Type 1: Frenulum attaches to tip of tongue in front of alveolar ridge in low lip sulcus
  • 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


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)



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.