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Tomara, E.; Dagla, M.; Antoniou, E.; Iatrakis, G. Ankyloglossia as a Barrier to Breastfeeding. Encyclopedia. Available online: (accessed on 18 June 2024).
Tomara E, Dagla M, Antoniou E, Iatrakis G. Ankyloglossia as a Barrier to Breastfeeding. Encyclopedia. Available at: Accessed June 18, 2024.
Tomara, Eirini, Maria Dagla, Evangelia Antoniou, Georgios Iatrakis. "Ankyloglossia as a Barrier to Breastfeeding" Encyclopedia, (accessed June 18, 2024).
Tomara, E., Dagla, M., Antoniou, E., & Iatrakis, G. (2024, January 15). Ankyloglossia as a Barrier to Breastfeeding. In Encyclopedia.
Tomara, Eirini, et al. "Ankyloglossia as a Barrier to Breastfeeding." Encyclopedia. Web. 15 January, 2024.
Ankyloglossia as a Barrier to Breastfeeding

Ankyloglossia, commonly referred to as tongue-tie, brings about functional difficulties and, in some cases, may lead to early weaning. It is crucial to use breastfeeding as the exclusive food source for the first six months of an infant’s life, and the interference of the tongue contributes substantially to success in this regard. Even though there are many publications about ankyloglossia, there are still many controversies about its definition, diagnosis, classification, and treatment decision determined via frenotomy.

ankyloglossia breastfeeding breastfeeding difficulties frenotomy infant lingual frenulum tongue-tied

1. Introduction

Nowadays, more and more mothers are becoming aware of the advantages of breastfeeding, and they are choosing breast milk as the fοοd source for their newborns. The global guidance of the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend exclusive breastfeeding for the first 6 months of life and then continuing breastfeeding on demand along with the supplementation of solid foods up to the age of 2 and beyond [1][2][3]. If this recommendation is adopted, it is estimated that approximately 823,000 deaths under the age of 5 will be prevented per year [4]. Based on the global breastfeeding scorecard of 2022, the percentage of babies who breastfed exclusively under the 6 months of age was 48%, while the global target for 2030 is 70% [5].
Alongside the advantages of breast milk, the breastfeeding process itself plays an important role in the stability and stimulation of the perioral muscles of the stomatognathic system, such as the temporal muscle, the masseters, and the orbicularis [6][7]. The growth of the oral cavity muscles, which contributes to lactation, is also a part of the natural training for subsequent mastication [8]. The maturation of the masticatory muscles establishes an effective cycle of breathing and swallowing during lactation.
It is considered that around 90–95% of mothers will be able to breastfeed their babies successfully. As a consequence, mothers set high expectations for breastfeeding and believe that it will be an easy and natural experience [9]. Unfortunately, this discrepancy between expectations and the reality that mothers experience is crucial for the duration of breastfeeding, especially for the 14-day postpartum period [10][11][12]. When lactation problems occur without proper lactational assistance, they may provoke breastfeeding mothers to adopt early weaning and/or formula supplementation [13][14][15][16].
A neonatal situation that is linked to the aforementioned lactation problems is ankyloglossia. It is also known as tongue-tie or short lingual frenulum. The purpose of this review is to present broadly accepted criteria for the definition, diagnosis, assessment tools, classification, related problems, and treatment of ankyloglossia, covering the topic in its entirety. For many years, health care providers supporting breastfeeding mothers have been searching for a potential negative impact of a tight or short lingual frenulum on children’s lives, as these issues may reduce their lingual mobility, affect their ability to breastfeed effectively and/or speak clearly in later life, or have an impact on some mechanical and social activities, like licking the lips and maintaining oral hygiene (Figure 1) [17].
Figure 1. The lingual frenulum of a tongue-tied infant.
The prevalence of tongue-tie among infants varies from 0.1% up to 12%, with the majority of these cases being males [18][19][20][21]. Since ankyloglossia affects many aspects of a child’s life, many professionals from different specialties are involved in consultation and management in clinical practice. These professionals can be, among others, pediatricians, lactation consultants, otolaryngologists, pediatric surgeons, speech therapists, dentists, and orthodontists, and each one approaches tongue-tied infants, near-toddlers, and children from their own professional perspective [22]. This is probably the reason why there are more controversies on this matter and fewer agreements.

2. Lactation Problems

The relationship between ankyloglossia and breastfeeding difficulties hinges on the inadequate mobility of the tongue in forward, upward, and side-to-side motions [23]. Hence, symptomatic tongue-tie will interfere with proper latching onto the breast and, thus, effective sucking with subsequent adequate milk flow into the infant’s mouth, resulting in poor stimulation of the mother’s milk ejection reflex and low weight gain of the infant [24][25][26]. Long feedings, along with poor latching on the infant’s part and a low milk supply and sore or cracked nipples on the mother’s part, are outcomes of this problem. Their main cause is ankyloglossia.
Focusing on mothers, ankyloglossia may affect their breastfeeding experience, milk supply, or breast and nipple anatomy [18]. Therefore, nipple pain and inflicted trauma as well as low milk supply as a result of the ineffective sucking of tongue-tied infants and their difficulty in adequately emptying the breasts may be the reasons that lead mothers to early weaning [18][27]. In fact, intense maternal nipple pain has been reported to be due to persistent difficulty in latching and the subsequent compression of the nipple in the front part of the infants’ mouth between the upper and lower alveolar ridges [23][26]. Walker et al. pointed out that the closer the frenulum is attached to the tip of the tongue, the higher the maternal nipple pain [28]. All these complications result in maternal feelings of stress and failure. Early weaning negatively affects both the infant and the mother because of its psychological implications [12].
When it comes to the infants, some symptoms can be presented, such as long-duration feedings, signs of a lack of satisfaction through feedings, poor or no gain weight, and constant loss of the latch. Meanwhile, supplementary bottle feeding may be used as an alternative approach [18][27]. In a recent cross-sectional study, Campanha et al. confirmed that newborns with ankyloglossia have a 36.07 times higher probability of presenting with lactational problems, especially in their sucking skills [29]. Riskin et al. also emphasized with their findings that tongue-tied infants, regardless of their previously referred to anterior or posterior types of ankyloglossia, will face more breastfeeding difficulties during the first 30 days of life [30].
On the other hand, other studies in the scientific literature, as well as health care providers, contend that ankyloglossia is rarely or never the reason for interfering with feeding, concluding that there is a non-existing correlation between them. As noticed by Messner et al., the professionals involved are mainly pediatricians and otolaryngologists [31]. There is a constant need for further publications, which will emphasize the breastfeeding problems and the types of ankyloglossia [32]. When conservative lactation management is failing and lactational problems still exist, the division of the lingual frenulum can be suggested [27]. Bruney et al. pointed out in a meta-analysis study that frenotomy helps mothers in their lactation experiences by improving their scores on the pain scale and ameliorating lactation problems [33].

3. Difficulties with Speech and Solid Foods

A further controversial topic that has been gaining ground is the association between ankyloglossia and speech difficulties. If the tongue has restricted mobility during breastfeeding, could this not lead to future complications in articulation and fluent speech? Only a small percentage of pediatricians admit this correlation exists, while the majority state that it remains unclear [31][34][35]. A recently published systematic review with 1857 participants concluded that there is no correlation between ankyloglossia and speech difficulties. However, the authors claimed that the data were derived from small-sample and low-quality studies [34]. Another relevant study conducted in 2019, which has been marked as the first one to base its cases on tongue-tied children without division, pointed out that the analyzed children had the same speech quality as those treated via frenulectomy [36]. In fact, the data were selected via phone interview according to caregivers’ perceptions, and no objective evaluations of speech and articulation were factored in. Moreover, the diagnosis of ankyloglossia was made according to the ability to protrude the tongue, and none of the available assessment tools or classifications were used. Therefore, it seems that the limitations of the evidence, with a small sample size and heterogeneity in diagnosis, classification, and outcomes, creates a gray zone, limiting the applicability of the published data. High-quality evidence diminishes once popularity invades the field of research.
Following the same theory again, another connection between ankyloglossia and solid foods is considered in [37]. Masticatory function is investigated as one more aspect for attaining a better quality of life. Baxter’s prospective cohort study confirmed this correlation positively. In 37 treated tongue-tied children, progress in their feeding abilities was observed in 83% [38]. Feeding difficulties can occur during an infant’s transition to solid foods and swallowing [39]. In a case study involving a 5-year-old tongue-tied boy, in addition to being a “picky eater”, he demonstrated gagging and vomiting reflexes when eating foods with a variety of textures, but primarily with soft foods [40]. By releasing the tongue, the ability of the tongue to move freely in the oral cavity returns. This also allows food to move freely, and better mastication is accomplished [41].

4. Frenotomy

During the last 20 years, in the United States, Canada, and Australia, a rise in ankyloglossia cases has been noticed [42]. However, in European countries like Italy, the Netherlands, and Scandinavian nations, this increase has not been mentioned [43]. Nonetheless, this increase in the cases and divisions of frenulum did not contribute to the universal management of ankyloglossia. The procedure of lingual frenulum division or cutting during infancy is referred to as frenotomy [23]. The available means of division are scissors, a scalpel, and lasers [44]. Frenotomy via laser seems superior since it requires less time and less local anesthetic [45][46]. Furthermore, it facilitates local hemostasis, tissue cauterization, and sterilization [45][46][47]. Nevertheless, using non-thermal techniques of division, less histological tissue injury and inflammation have been reported [48]. In general, complications of the division of the lingual frenulum are quite uncommon [49]. Among the most reported are poor feeding, hemorrhage, inflammation, and trauma inflicted on the local tissues in the oral cavity [44].
In addition, for the first aforementioned case with the symptomatic tongue-tied infant, the clinical consensus statement of Messner et al. is also in favor of an early frenotomy during the first month of life [17]. An interesting issue about frenotomy is parental perception. In 2019, Caloway and her colleagues offered a multidisciplinary evaluation with lactation consulting of feeding for 115 patients before performing a frenotomy. After helping the mothers based on their breastfeeding difficulties, more than half of these cases (62.6%) did not proceed in undergoing a division of the frenulum [50]. Both health care providers and parents should be informed in advance about the advantages, disadvantages, and possible complications of frenotomy.
A Cochrane review verified that frenotomy eliminates mothers’ nipple pain in the short term [51]. Three more studies confirmed this statement using statistically significant results [52][53][54]. Ghaheri et al. confirmed, in a prospective cohort study, that the division of the frenulum is associated with improved lactation outcomes, starting from one week after the division to up to one month [53]. In another study, mothers reported a reduction in nipple pain ranging up to 92% after 3 months of frenotomy [55]. There are also studies that assess mothers’ feelings and willingness to continue to breastfeed their infants as a positive outcome of the division [53][56][57]. On the other hand, when it comes to the infant, it has been noticed that feedings do not take as much time and that there are fewer feedings during the day, with better latching and improved milk transfer [58][59]. Similarly, Miranda and Milroy indicated that there was an improvement in neonatal growth 14 days after the division, as determined via weight gain centiles [60].
Once a frenotomy is performed, there is some recommended advice and there are some interventions that can aid in the healing process and eliminate the rates of the regeneration of the tissue [61]. Firstly, it is helpful for an infant to breastfeed immediately after frenotomy, due to hemorrhage prevention [62]. Secondly, there are post-procedure exercises, which are performed by the parents, in which thoroughly clean hands or gloves are used. After the division of the frenulum, those who assist in lactational counseling should educate parents on how to massage the division’s spot by adding some pressure [63]. Also, it is recommended to stimulate the infant’s tongue using lifting movements directed toward the palate and from side to side. Therefore, the aforementioned myofunctional exercises will enhance the functional mobility of an infant’s tongue by revealing its new range of motion. The frequency of the exercises is four to six times during the day [53][64]. Last but not least, it would be useful to arrange a post-frenotomy meeting with the mother in order to reassess the lactation difficulties and the progress of the breastfeeding dyad.


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