Understanding tongue-tie: symptoms, diagnosis and treatment

Around one in 10 babies born in the UK will have tongue-tie, also known as ankyloglossia. Tongue-tie occurs when the strip of tissue that connects the base of the tongue to the floor of the mouth (the lingual frenulum) is shorter than usual. It is not painful but can limit the movement of the tongue. 

Types of tongue-tie 

There are four types of tongue-tie, which are categorised according to their severity. 

Type 1 is the most severe, where the lingual frenulum is thin and elastic, and is located closest to the front of the tongue. Consequently, the frenulum anchors the tip of the tongue to the lower gum ridge just behind where the teeth will be. 

In type 2 tongue-tie, the frenulum is also thin and elastic, but it is located about 2–4 millimetres from the tip of the tongue, where it anchors the tongue close to the lower gum ridge. 

In type 3 tongue-tie, the frenulum is thick and stiffened and is located in the centre of the tongue, where it anchors the tongue to the floor of the mouth. 

In type 4 tongue-tie — the mildest type — the frenulum isn’t visible but can be felt on the undersurface of the tongue.

Diagnosing tongue-tie

In the UK, tongue-tie is usually picked up by a health visitor during a newborn screening. This screening occurs in the first 72 hours of birth and can take place in hospital or at home, a community clinic or GP surgery.

Type 1 and 2 tongue-tie can be seen when observing your baby’s mouth when they are awake or about to feed; as they try to stick their tongue out a heart-shaped tip may be seen. 

If you are referred to a specialist, you may be asked to hold your baby facing towards you, with their head on your lap, while the ENT (ear, nose and throat) surgeon lifts their tongue up with a gloved finger. 

What causes tongue tie?

During development in the womb, every foetus has a type 1 tongue-tie. However, before birth, the tongue-tie is released from the floor of the mouth. In some cases, this release doesn’t happen effectively, resulting in tongue-tie at birth. 

Genetics has a role to play, with tongue-tie sometimes running in families. There is also some evidence to suggest it is an X-linked condition, which means boys are more likely to have it. 

In most cases, tongue-tie isn’t associated with any other congenital (present-from-birth) health conditions.

Symptoms of tongue tie

The earliest symptom is an inability or difficulty creating and maintaining a latch when your baby tries to breastfeed. Consequently, when they try to extend their tongue beyond their lower lip to help maintain the latch, the tip of their tongue will appear heart-shaped. 

These attempts at latching can become painful for the mother, causing sore nipples and mastitis. 

If your baby is bottle-fed, they may gag when feeding and ingest more air, leading to bloating and more regurgitation than normal. 

Tongue-tie treatment and recovery

A tongue-tie won’t resolve on its own and if left untreated can lead to ongoing feeding problems, slow growth and potentially unclear speech in older children. 

For mothers, changing breastfeeding technique can help ease discomfort eg holding your baby upright (koala hold) or with your nipple in a tilted-up position on latch so that your nipple falls to the back of their mouth. 

The only cure for tongue-tie is a procedure called tongue-tie division. An ENT surgeon, with your assistance, will hold your baby facing towards you on their lap and will use surgical scissors to carefully snip the frenulum. If you would prefer, a paediatric nurse can hold your baby during the procedure.

Your surgeon will assess how much of the frenulum needs to be snipped — too little and you will not see any improvement in your baby’s feeding and too much can cause bleeding and tissue damage. 

The procedure is quick and almost painless — it is less painful than having a plaster removed and consequently, no anaesthesia is needed. 

Once completed, a soft, sterile gauze is placed under your baby’s tongue with a little pressure. Your baby may cry at this point as they find this unpleasant; however, it is not painful. 

Recovery 

Immediately after a tongue-tie division, mother and baby are taken to a breastfeeding room to attempt a latch. Afterwards, both can return home and a follow-up appointment will be scheduled for a few days later.

A white diamond-shaped patch will be present under your baby’s tongue after the procedure. This is not a sign of infection. As breast milk has a protective effect, infection after a tongue-tie division is rare. If, however, you notice a foul smell coming from your baby’s mouth or an increase in drooling, contact your care team immediately. 

Your baby will naturally start to move their tongue around more freely than prior to their tongue-tie division. There is, therefore, no need for physiotherapy, tongue exercises or physical manipulation of their tongue.  

Tongue-tie in older children

If tongue-tie was missed when your child was a newborn, it may later be picked up in preschool or nursery when it becomes obvious that their speech is unclear. 

Tongue-tie doesn’t cause speech delay as there is no problem with understanding. Instead, tongue-tie causes difficulty in clearly pronouncing certain sounds, particularly n, d, t and s.  

Treatment is the same as in newborns ie tongue-tie division; however, after six months of age this procedure can’t be performed and you will need to wait until your child is 12 months old or reaches a weight of 10 kilograms. At this age, the tongue-tie procedure can be performed under a general anaesthetic. 

Lip tie

Another similar condition, which may be picked up in older children, is lip tie. This occurs when the tissue connecting the upper lip to the underlying gums (maxillary labial frenulum) is too short, which restricts lip movement. 

Lip tie can also cause the two middle front teeth of the upper jaw (central incisors) to become separated and can cause pain when biting. Lip tie is treated in the same way as tongue-tie, that is, with a division procedure. This is performed under general anaesthesia in a hospital or under local anaesthesia in a dental clinic.