Breastfeeding is exclusively recommended for the first 6 months of life given the established synergistic benefits between mother and child, supported by the American Academy of Pediatrics (AAO) and World Health Organization. ^, Mothers gain increased protection from breast cancer, ovarian cancer, cardiovascular disease, and postpartum depression, while infant benefits include decreased respiratory infections, acute otitis media, obesity, diabetes, and sudden infant death syndrome as well as increased cognitive performance. There are many potential barriers to breastfeeding including maternal factors such as available leave, lactation education, and discomfort but also infant limitations such as a nasal obstruction, airway obstruction, laryngopharyngeal reflux, and craniofacial abnormalities. ^{, ,} The LATCH (latch, audible swallow, nipple type, comfort, help) score can be used to quantify breastfeeding quality. The BTAT (Bristol Tongue Assessment Tool) is an easy tool to use in the clinic setting to help determine if a frenotomy is indicated. The TABBY (Tongue-tie and Breastfed Baby) tongue assessment tool is the pictorial version of the BTAT ( Fig. 9.3 ). Diagnosing ankyloglossia is functional and requires clinical evaluation, ideally with breastfeeding observation. Examination may demonstrate frenulum insertion to the floor of the mouth or lower alveolar ridge, along with limited tongue protrusion and elevation.

TABBY tongue assessment tool. Like the BTAT, each item is scored 0-2 with low scores indicating significant ankyloglossia.

With permission from University of Bristol.

Studies have demonstrated that 15% to 44% of babies with tongue-tie will have breastfeeding issues ^, and that 13% to 67% of cases of breastfeeding issues or nipple pain are partially influenced by ankyloglossia. ^{, ,} Ankyloglossia may cause a poor latch and contribute to maternal nipple pain, which is a common postpartum cause of breastfeeding discontinuation. Nipple pain, however, is an issue with multiple potential etiologies, and though tongue-tie is easily pinpointed on examination as the primary culprit, it may not be the sole cause of the breastfeeding problem. ^{, , ,}

Positive outcomes after frenotomy for impaired infant latch have been repeatedly demonstrated in the medical literature (see section 4). However, the association between breastfeeding and ankyloglossia, the unlikelihood of restarting breastfeeding after stopping, false information on social media, as well as increased identification by lactation consultants and dentists, all contribute to the overdiagnosis and treatment of tongue-tie. ^, The American Academy of Breastfeeding emphasizes that frenotomy may be offered after shared decision making between provider and family, but that the normal anatomic structure of a sublingual frenulum is not an indication for surgery. The AAO–Head and Neck Surgery (HNS) clinical consensus statement outlined that while caregivers should be counseled on nonsurgical options and that frenotomy is not always effective, potential benefits may include relief of maternal pain and feeding improvement.

Older children with ankyloglossia are usually seen in the clinic due to concerns regarding speech production ( Figs. 9.4 and 9.5 ). As the tongue is the most vital articulator, the relationship between ankyloglossia and speech has been debated. ^, More research is needed to confidently demonstrate this association. Speech production requires more than articulation, including respiratory control, phonation, muscle manipulation, and velopharyngeal function. Sounds thought to be limited due to ankyloglossia include lingual dental sounds (/t/ and/d/), sibilants (/z/,/s/, and/th/), and tongue elevation sounds (/l/ and/r/). However, many children normally express age-appropriate speech errors ^, and typically cannot master these complex sounds until 3 to 5 years old. The consensus is that ankyloglossia does not cause speech production delay, and it is still possible to achieve normal speech without frenotomy.

Ankyloglossia in an older child. Note how the lingual frenulum inserts onto the alveolar ridge instead of the floor of the mouth.

Ankyloglossia in an older child demonstrating a heart-shaped tongue due to a tight lingual frenulum.

Other ankyloglossia indications for frenotomy are not well established, such as mechanical and social issues that include licking lips, French kissing, and playing wind instruments. Additionally, ankyloglossia has been attributed to diastasis between the central lower incisors and maintaining dental hygiene given the difficulty cleaning the teeth with a tethered tongue. ^, These potential consequences may lead to social embarrassment.

Sleep-disordered breathing and obstructive sleep apnea have also been linked to tongue-tie, but data are currently insufficient. The proposed mechanism is unclear. Studies have attributed ankyloglossia to orofacial dysmorphism that decreases the upper airway lumen and increases risk of upper airway collapsibility. These studies also claim that frenotomy would improve mouth breathing and apneic episodes. On the other hand, ankyloglossia may actually be a protective factor in patients with retrognathia and glossoptosis, preventing tongue collapse.

There is poor-quality evidence that associates ankyloglossia with gastroesophageal reflux. The pathophysiology is explained by a poor latch leading to swallowing of air and subsequent colic. Literature in this realm, however, did not use the gold standard pH probes for gastroesophageal reflux diagnosis but rather subjective scales and poor control measures.

The only consistent result in ankyloglossia systematic reviews concludes that frenotomy can be beneficial for breastfeeding, ^, with many studies demonstrating a reduction in maternal nipple pain. ^{, , ,} One randomized controlled trial resulted in improved feeding after frenotomy in 95% of infants, while a different single-blinded trial comparing frenotomy to a sham procedure demonstrated significantly decreased pain score and improved breastfeeding. Another study reported all infants had an equal or improved latch score after frenotomy and that 92% of mothers were pain free after 3 months. The improved breastfeeding mechanics and latch from frenotomy can subsequently increase maternal milk production and transfer. ^{, , ,} Studies have suggested a greater chance of success if performed before the infant is 30 days old, so frenotomy should be performed soon after diagnosis if indicated when infants fail to respond to conservative measures. ^,

While most of these studies reflect data from “anterior” ankyloglossia, the definition of “posterior” ankyloglossia is less consistent and evidence is of variable quality, with weaknesses in treatment bias, recall bias, and lack of control groups. The American Academy of Breastfeeding highlighted the lack of published evidence to support surgically treating other intraoral or perioral tissue rather than the sublingual frenulum. The AAO-HNS clinical consensus statement outlined that “maternal reported breastfeeding efficacy and nipple pain in the presence of ankyloglossia are more likely to improve with lingual frenotomy compared to no surgical treatment” but that “it is not necessary to perform lingual frenotomy in an infant with little to no restriction in tongue mobility to prevent a future feeding disorder.” These outcomes and statements support a multidisciplinary approach, including the pediatrician, lactation consultant, speech language pathologist, and pediatric otolaryngologist, delineated by the American Academy of Pediatrics and American Academy of Pediatric Dentistry. ^,

Although some literature has indicated articulation speech improvement after frenotomy, ^, current data are insufficient and more research is needed. ^, One study in 2020 looked at 59 children with either treated tongue-tie, untreated tongue-tie, or no tongue-tie, finding that there was no difference between tongue mobility, speech production, and intelligibility. A prospective study in 2021 sought to determine the effects of frenotomy on speech articulation and eligibility. Articulation was assessed preoperatively and 1 month postoperatively by the Goldman-Fristoe Test of Articulation 2 (GFTA-2) and intelligibility by independent review of audio recordings. Authors concluded that 88% of speech sound errors were age appropriate, and there was no significant difference in GFTA-2 or mean intelligibility scores.