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Infant Feeding Guidelines for Health Workers submission

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4.16 Ankyloglossia p.92.


The excerpt from the NHMRC guidelines is shown below, with our comments shown in bold, and excerpts from our literature review shown in indented sections.


4.16 Ankyloglossia

Ankyloglossia or ‘tongue tie’ is a developmental variant in which the tongue

has limited mobility within the mouth due to a thickened or shortened lingual

frenulum. There is limited evidence that ‘tongue-tie’ occurs in approximately

4-10% of healthy newborns (Evidence Grade D) (Messner, Lalakea et al.

2000; Suter and Bornstein 2009).


In regard to statistics of occurrence, our published literature review revealed:

Tongue-tie occurs in between 2.8% to 10.7% of all infants

(Ballard, Auer & Khoury 2002; Hogan, Westcott & Griffiths

2005; Messner & Lalakea 2000; Ricke et al 2005; Ridgers,

McCombe & McCombe 2009; Messner & Lalakea 2000).

This range is similar to the prevalence of 4.2–10.7% found in

a 2007 review by Segal et al.


There is difference of opinion regarding the effects of ankyloglossia upon

breastfeeding, compounded by inconsistency in definition of the anomaly

(Suter and Bornstein 2009).

In regard to definition, our published literature review revealed:

Tongue-tie or ankyloglossia is described as a congenital

condition with an unusually thickened, tightened or

shortened frenulum (membrane or string under the tongue)

(Hillan 2008; Wallace & Clarke 2006). The frenulum may

vary in length, elasticity and placement along the underside

of the tongue to the floor of the mouth, which then can affect

infants’ breastfeeding skills in different ways (Watson Genna

2008) and can affect other activities such as feeding, dental

hygiene, and speech (Amir 2006; Kummer 2005; Messner &

Lalakea 2002; Wallace & Clarke 2006).


There is limited evidence (Evidence Grade D) to

suggest that breastfeeding difficulties are experienced more commonly by

babies with ‘tongue-tie’ (Messner, Lalakea et al. 2000; Ballard, Auer et al.



In regard to effects of ankyloglossia on breastfeeding, our published literature review revealed:

A number of high-quality studies demonstrate that tongue tie

affects breastfeeding. One large study from theUSA

demonstrated that tongue-tie causes breastfeeding difficulties

and pain for mothers (Messner et al 2000). [Already cited in the guidelines]

This study demonstrated that mothers of infants

with tongue-tie experienced more breastfeeding difficulties

than mothers whose infants did not have tongue-tie, and that

tongue-tie can affect breastfeeding duration. This finding is

supported by a case-control study, which examined the effect

of tongue-tie on breastfeeding (Ricke et al 2005). During the

study, 3490 infants were assessed, with 148 infants identified

as being tongue-tied; a prevalence of 4.2%. Researchers found

that tongue-tied infants were three times more likely to be

bottle-fed at 1 week than control infants, but by 1 month

control infants and tongue-tied infants were equally likely to be

bottle-fed. Twice as many mothers of tongue-tied infants had

sore nipples and breast pain at 1 month compared to control

infants. This finding provides further evidence to indicate that

tongue-tie reduces breastfeeding duration and is associated with

breastfeeding difficulties.

Reasons for breastfeeding difficulties were determined

in a significant Australian study, where Geddes, Langton et

al (2008) used ultrasound imaging to assess infants while

breastfeeding, before and after frenotomy (tongue-tie

separation). Researchers conducted ultrasound imaging on

24 infants during breastfeeding, both before a frenotomy

and at least 7 days afterwards. The researchers identified two

groups: one group of infants compressed the tip of the nipple

during breastfeeding pre-frenotomy, and a second group

compressed the base of the nipple. The authors postulated that

the former group might represent the clinical group of infants

who are unable to maintain a seal to the breast, whereas the

latter group represents infants who either bite or latch strongly

to the breast. Both groups may cause nipple trauma. Nipple

compression was reduced or resolved following frenotomy.

The distance from the tip of the nipple to the hard soft palate

junction was greater before frenotomy than after frenotomy.

This demonstrates that tongue movement is restricted by

tongue-tie and infant latch to the breast is therefore also

affected. The ultrasound demonstrated that the infants had

a disorganised, piston-like motion with their tongue when

suckling prior to the procedure, which was reduced following

the frenotomy. Six of the mothers in this study measured their

milk production in the 24 hours before frenotomy and after the

procedure, which revealed that the infants were able to remove

more milk from the breast post-frenotomy, and that there was

a significant increase in total milk production in the 24 hours

after frenotomy. All the women reported that breastfeeding

comfort was improved. This study was the first to measure

the effect of tongue-tie and frenotomy on milk production,

providing evidence that tongue-tie can reduce milk intake and

affect breastfeeding due to its effect on suckling.

In a recent study using a small case series, Geddes et al

(2010) examined the sucking characteristics of five infants

with tongue-tie who were successfully breastfeeding.

Ultrasound was used to image tongue action, with intraoral

vacuum measured using a supply line filled with

sterile water and connected to a pressure transducer. The

researchers found that, despite some nipple compression and

intra-oral vacuum pressures outside the normal range, milk

production, milk intake and maternal pain were not affected

by tongue-tie. The researchers suggested that other factors,

such as particular breast/nipple shape and milk ejection

reflex contribute to some mothers being able to successfully

breastfeed an infant with tongue-tie and is in contrast to the

previous study. Further research is required in this area.


The presence of an abnormal lingual frenulum does not however preclude

successful breastfeeding, although additional support and counselling of the

mother may be required (Messner, Lalakea et al. 2000; Ballard, Auer et al.

2002;Geddes,Kentet al.2010).

In regard to effects of ankyloglossia on breastfeeding, our published literature review revealed:


Several studies have explored the effectiveness and safety of

tongue-tie procedures while studying their effects on feeding

problems. In the only randomised controlled trial published

to date examining tongue-tie and breastfeeding, 28 infants

in an experimental group had immediate division of tongue-tie;

27 of these infants improved and fed normally, while

one continued to feed on a nipple shield (Hogan, Westcott

and Griffiths 2005). The parents of 29 control group infants

received 48 hours of intensive lactation support; only one

of these infants had improved breastfeeding at 48 hours.

[This does not support the statement made in the guidelines]

Parents were offered tongue-tie separation, and all accepted.

Subsequently, 27 infants improved and fed normally. Thus,

separation of the tongue-tie resulted in improved feeding in

54 of 57 infants, with no complications identified. This high quality

study provides evidence that separation of tonguetie

for infants with feeding problems is more effective in

improving infant feeding than intensive lactation support.

Researchers inIsraelalso examined the effect of frenotomy

on breastfeeding problems (Dollberg et al 2006). Employing

a randomised, prospective, blinded trial, the purpose of their

study was to identify if breastfeeding improved following

tongue-tie separation. Twenty-five full term infants with

tongue-tie were recruited, with the main breastfeeding

problems identified as nipple pain and trauma, and poor

latch. The trial was blinded and randomised in order to

reduce favourable bias towards separation of tongue-tie

by the mothers. The infants were randomised into two

groups: i) a sham procedure followed by breastfeeding then

frenotomy followed by breastfeeding (11 infants) and ii)

frenotomy followed by breastfeeding then a sham procedure

followed by breastfeeding (14 infants). The mothers were

supervised during the procedure to verify that they did not

try to examine the mouth of their baby to determine whether

frenotomy or a sham procedure had been performed. In

both groups, nipple pain score when breastfeeding reduced

significantly after frenotomy (p<0.001) and the latch score

improved, although this was not statistically significant

(p=0.06). Following frenotomy, any bleeding was minor and

controlled within a few seconds and no other complications

were identified. Although the sample size was relatively

small, this study provides additional evidence that separation

of tongue-tie for breastfeeding difficulties improves pain and

infant latch to the breast.

Further evidence supporting frenotomy is provided by

Australian researchers who conducted a telephone survey to

assess the effect of tongue-tie release on breastfeeding difficulties

and maternal satisfaction (Amir, James & Beatty 2005). Initial

breastfeeding problems included difficulty latching, nipple pain

and damage, frequent and prolonged feeding, and poor weight

gain. A structured telephone interview was conducted by a

lactation consultant with each mother 3 months after a tongue-tie

assessment. Sixty-six infants were assessed initially with follow-up

data collected on 46 infants; frenotomy was performed in 75%

of the infants assessed. No problems were reported following

the procedure; most mothers felt they had been given enough

information (89%) and reported being ‘very satisfied’ with the

procedure (74%) (Amir, James & Beatty 2005).

A recent United Kingdom audit of a new service examined

the effect of frenotomy on breastfeeding problems for 220

infants with tongue-tie (Ridgers, McCombe & McCombe

2009). Feeding problems resolved following division of

tongue-tie in 168 of the infants, improved in 47 infants and

were unchanged in only five cases. Minor bleeding following the

procedure occurred in only four cases, which ceased

completely within a maximum of 2 minutes. Infant crying

was usually caused by the surgeon inserting his finger into

the mouth to perform the procedure. This demonstrates the

effectiveness and safety of the frenotomy procedure; however,

no controls were used to compare breastfeeding outcomes of

infants who did not have tongue-tie separation.

A UK prospective cohort study of breastfeeding mothers

demonstrated that frenotomy increased breastfeeding

duration (Khoo et al 2009). Of the 62 mother-infant pairs

who underwent frenotomy, 78% were still breastfeeding at

3 months despite having initial breastfeeding difficulties,

including nipple pain and trauma; however, the study was

limited because only mothers self-referring to a clinic with

their infants for separation of tongue-tie due to breastfeeding

difficulties were included in the sample. The study was also

dependent on voluntary completion of questionnaires by

mothers. Similar results were found in an uncontrolled case

series examining the effect of frenuloplasty on maternal pain

levels while breastfeeding, and on infants’ latch to the breast

(Ballard, Auer & Khoury 2002). The researchers examined

2763 in-patient breastfeeding infants and 273 out-patient

infants with breastfeeding problems, looking for possible

tongue-tie. Each breastfeeding dyad was observed while

breastfeeding, and when latch problems were identified,

the mother was asked to describe the sensation and quality

of the baby’s suck at the breast. Tongue-tie was diagnosed

in 3.2% (n=88) of the in-patients and 12.8% (n=35) of the

out-patients. One hundred and twenty-three mothers elected

to have surgery. In all cases, only a simple separation of the

tongue-tie was required, and all procedures were performed

without complications. Both in-patients and out-patients

were followed up after the procedure and all mothers reported

improved latch and decreased pain while breastfeeding. The

results of this study provide further evidence that separation of

tongue-tie improves the ability of the infant to breastfeed and

reduces maternal nipple pain when breastfeeding; however,

the study lacked a control group and there was no long-term

follow up to monitor breastfeeding duration.

The indications, safety and outcome of tongue-tie

separation were studied in a large non-randomised, single

centre prospective study of 215 infants (Griffiths 2004).

Mothers in the sample had major breastfeeding problems

including painful, bleeding nipples, continuous feeding

cycles and difficulties latching to the breast, despite

receiving support from health professionals. Twenty-four

hours following frenotomy most infants (80%, n=173)

were assessed by their mothers to be feeding better. For 40

infants (19%) there was no change to their feeding while two

infants (1%) had increased problems feeding, with no reasons

provided. Minor bleeding was identified as a complication,

with 113 (53%) producing only ‘a few drops of blood’ and

18 (8%) producing ‘a small amount’ following the procedure

(Griffiths 2004). Minor ulcers were found under the tongue

in four (2%) infants. These results indicate that tongue-tie and

these difficulties can be resolved in most mother/infant

dyads with frenotomy, without complications.

Finigan (2009) published the results of evaluation of a

new frenotomy service in northern England. Over a threeyear

period from 2005 to 2008, 501 women and infants were

referred for treatment with 416 infants receiving frenotomy.

Of the mothers who were able to latch and breastfeed their

infants straight after the procedure, most (n=383) reported

that breastfeeding was less painful; that is, the infants

latched better and remain latched for a full breastfeed. Of

the 33 mothers who did not notice a difference, their infants

either would not breastfeed after the procedure or there

were other problems before the procedure, such as fungal

infection or extremely sore nipples. The 228 women who

were contacted 24 hours after the procedure reported that

breastfeeding was more comfortable and the infants were

latching better. At a three-month phone follow up, contact

was made with 139 mothers: 60 mothers reported that they

were still exclusively breastfeeding, 13 mothers stated they

had exclusively breastfed for their intended period of time,

10 mothers reported mixed breastfeeding and formula-feeding

and 2 mothers were expressing and giving breastmilk in a

bottle. No problems were identified with the frenotomy.


There is difference of opinion regarding the effects of ankyloglossia upon

breastfeeding, compounded by inconsistency in definition of the anomaly

(Suter and Bornstein 2009).

In regard to difference of opinion, our published literature review revealed:

 Lack of consensus regarding tongue-tie management

....a review of

medical guidelines reveals a lack of consensus regarding the

need to treat tongue-tie in this manner. In 2007, the Canadian

Paediatric Society reaffirmed its position statement from

2002, which states that management of tongue-tie should

be conservative, ‘requiring no intervention beyond parental

education and reassurance’ (Canadian Paediatric Society 2002

p. 270). Neither the American College of Pediatricians nor

The Royal Australasian College of Physicians: Paediatrics and

Child Health has a published position statement on tonguetie

and its management, which is significant by omission. This

would suggest that the need for treatment of tongue-tie is not

well recognised or that there is lack of consensus in regard

to tongue-tie management. A lack of consensus is further

supported by two large research studies of opinion of tonguetie


A large survey in Canada and the USA of otolaryngologists

(n=423), paediatricians (n=425), speech pathologists (n=400)

and lactation consultants (n=350) revealed differences of

opinions in relation to tongue-tie (Messner & Lalakea 2000).

Sixty-nine percent of lactation consultants, but only 10% of

paediatricians and 30% of otolaryngologists, believed that

tongue-tie was associated with feeding problems. Sixty percent

of otolaryngologists and 50% of speech pathologists, but only

23% of paediatricians, believed that tongue-tie was sometimes

associated with speech difficulties and 67% of otolaryngologists

as opposed to 21% of paediatricians believed that tongue-tie

was associated with social/mechanical issues. Surgery was

recommended for tongue-tie by otolaryngologists for feeding

(53%), speech (74%) and social/mechanical reasons (69%).

In contrast, paediatricians recommended surgery for feeding

issues (21%), speech (29%) and social/mechanical reasons

(19%). This survey highlighted the difference of opinion

amongst specialty medical groups, especially paediatricians,

in relation to management of tongue-tie. This suggests

that mothers may receive conflicting advice from health

professionals concerning tongue-tie and its management.

The beliefs and practices of paediatric surgeons in regard

to management of tongue-tie were explored in an Australian

survey (Brinkmann, Reilly & Meara 2004). Four hundred

surgeons in three different specialties were surveyed using a

questionnaire that explored their beliefs and practices and

their management and follow up of infants with tongue-tie.

The response rate was 80.8% (n=323) with 73% reporting that

they practised surgery to release tongue-tie. The majority of

participants in this survey (80.5%) stated that reduced tongue

mobility was the main indication for releasing the tongue-tie,

followed by poor speech/articulation. Over half the surgeons

(57.6%) stated that they received less than five referrals per year.

Paediatric surgeons stated they received most referrals from

dentists (38.1%), followed by speech pathologists (16.9%)

with very few received from lactation consultants. In Australia,

lactation consultants cannot refer directly to specialist medical

officers. If a mother of an infant with tongue-tie is referred to

a general practitioner by a lactation consultant for referral to

a surgeon for release of tongue-tie, that general practitioner

may choose not to provide a referral to a surgeon. As suggested

by available research evidence, this is likely due to the fact

that many medical officers do not consider tongue-tie to cause

problems with breastfeeding (Messner & Lalakea 2000), and

medical societies do not have a position statement on tonguetie

management, resulting in a lack of consensus in regard

to management of tongue-tie. Finigan (2009) experienced

strong resistance to the development of a frenotomy service,

and concluded that there is still controversy in the United

Kingdom over division of tongue-tie.


While surgical management of the tongue-tie

has been tried (frenulotomy, frenectomy or frenuloplasty) further

controlled trials are required.


In regard to frenotomy, our published literature review revealed:

Safety of frenotomy

The weight of research evidence reviewed above suggests that

frenotomy is an effective treatment for tongue-tie and that it is

conducive to successful breastfeeding; however, it is important

also to establish the safety of frenotomy. Several of the studies

cited above provide evidence concerning safety of frenotomy:

no problems, other than minor bleeding, have been identified

(Amir, James & Beatty 2005; Ballard, Auer & Khoury 2002;

Dollberg et al 2006; Finigan 2009; Griffiths 2004; Hogan,

Westcott & Griffiths 2005; Ridgers, McCombe & McCombe

2009). Safety has been examined further by some researchers

with the purpose of evaluating complications or negative

outcomes following the procedure. These studies are reviewed

in this section.

A telephone audit was conducted in Edinburgh, United

Kingdom to determine the safety of tongue-tie separation

(Hansen, MacKinlay & Manson 2006). This study was not

controlled and did not include specific measures of outcome.

Breastfeeding problems identified prior to the procedure included

poor latch, sore nipples and mastitis. Forty-four mothers were

telephoned after a minimum 14-day period following the

procedure, with 80% reporting an improvement in feeding and

64% reporting that feeding took less time after the procedure.

The study also demonstrated minimal complications following

separation of tongue-tie. One infant had a small amount of

bleeding after the procedure, which was self limiting. Another

infant was given paracetamol for possible pain with good effect.

There were no reports of infection or other medical problems

identified post-procedure. Although this study provides some

evidence supporting the safety of frenotomy, it should be noted

that it was described in brief in response to another article on

tongue-tie (Hall & Renfrew 2005). As such the validity of the

results cannot be established fully.

The safety of frenotomy is supported by Blenkinsop (2003),

who undertook a retrospective audit of 21 infants referred

for frenotomy to a feeding clinic in the United Kingdom,

to evaluate the success of the treatment and to determine

parental satisfaction with the procedure. Information was

gathered by reviewing case notes and by contacting mothers

by phone to discuss if frenotomy had reduced or eliminated

the breastfeeding difficulties they had been experiencing. All

mothers reported satisfaction with the procedure, and no

complications were identified. The researchers concluded that

division of tongue-tie improved feeding in 95% of cases and

that frenotomy is a safe intervention for feeding problems

caused by tongue-tie.

Wallace and Clarke (2006) had similar findings after they

undertook a small case series in Yorkshire, United Kingdom

to determine indications for tongue-tie division and the

outcomes of the procedure. Eleven infants with breastfeeding

difficulties associated with tongue-tie underwent frenotomy

in an out-patient setting. Breastfeeding problems identified

prior to the procedure included difficulties with latching,

sore nipples and continuous feeding. Following frenotomy,

the mothers were contacted by phone, with most reporting

an improvement with breastfeeding following separation of

the tongue-tie. No complications were reported. Neither this

study nor Blenkinsop’s (2003) study used a control group with

non-surgical intervention to compare outcomes and neither

assessed breastfeeding technique following the procedure;

however, in both studies frenotomy was shown to be a safe,

effective procedure for mothers experiencing problems

breastfeeding an infant with tongue-tie.

Another small telephone survey follow up was undertaken

in Canada (Srinivasan et al 2006) to measure the effectiveness

of frenotomy in infants with tongue-tie. This study confirmed

that frenotomy reduced pain experienced by mothers when

breastfeeding an infant with tongue-tie. The researchers

measured the change in latch and nipple pain in the mothers

of 27 infants under the age of 12 weeks. No complications

were identified during or after the procedure. Mothers were

phoned 3 months after the frenotomy to determine if they

were still breastfeeding, whether they continued to have

nipple pain and whether they found the frenotomy improved

breastfeeding. All women who were contacted had decreased

nipple pain after the frenotomy. Even though this was a small

evaluation study, it demonstrates that tongue-tie does affect

breastfeeding and may be a reason why women stop feeding

their infants. It also demonstrated that frenotomy was a safe

and effective procedure for reducing pain experienced by

mothers when breastfeeding infants with tongue-tie.

Yeh (2008) published an anecdotal evaluation of his

tongue-tie division service in Taiwan. Between 1980 to 2006,

2620 cases of tongue-tie in infants, and 158 cases in children,

were treated with frenotomy. Post-procedure bleeding was minimal

 with most self limiting spontaneously in a very short

period of time, concluding that tongue-tie separation was a

very safe and effective procedure. In this study, three patients

required further tongue-tie division under general anaesthetic

due to recurrent tongue-tie, which the author stated was most

likely due to ‘inadequate release by the quick cut’.


While surgical management of the tonguetie

has been tried (frenulotomy, frenectomy or frenuloplasty) further

controlled trials are required.


In regard to our overall conclusion and in regard to further trials, our published literature review revealed:


Further research using blinded randomised controlled trials

to compare frenotomy with no treatment for tongue-tie would,

theoretically, provide the strongest evidence for frenotomy.

However, our review of the evidence demonstrates significant

benefits of frenotomy for both mother and infant. Thus, our

conclusion, in common with others (Segal et al 2007), is that

not offering a treatment that has shown to be beneficial would

be unethical.

Based on this review of research, it is concluded that all

health professionals should consider referral for frenotomy as

the primary strategy for resolution of breastfeeding difficulties

experienced by a mother of a child with tongue-tie, in order to

prevent cessation of breastfeeding. It is suggested that further

education of health professionals regarding the problems

caused by tongue-tie and the effectiveness of frenotomy is

required, so that they become aware of the research in this area.

This will enhance their ability to confidently inform and refer

mothers on the basis of current evidence, while supporting

them with breastfeeding for their infant with tongue-tie.


It would seem that publishing guidelines for infant feeding that do not acknowledge the difficulties experienced by mothers breastfeeding infants with tongue-tie is also unethical.

The main author of this literature review recently completed a study understanding the experiences of mothers who are breastfeeding an infant with tongue tie. This study revealed that mothers experience great difficulty and despair when trying to breastfeed an infant with tongue-tie, and that mothers experienced great relief when frenotomy was performed, with their infant finally able to breastfeed appropriately.

Prepared by Janet Edmunds, author of literature review into tongue-tie and breastfeeding in collaboration with Sandra Miles, co author. See reference below.


Edmunds,J.E., Miles,S., & Fullbrook, P. (2011).Tongue-tie and breastfeeding:a review of the literature. Breastfeeding Review",19(1):19-26.

Page reviewed: 31 August, 2016