Feeding Difficulties in Infants with Tongue Tie and Lip Tie
Ankyloglossia, also known as tongue tie, is a congenital condition that can affect infants and children due to having a short lingual frenulum that restricts tongue movement and impacts the function of the tongue. The incidence of tongue tie affects at least 4% of infants and is most commonly diagnosed in males by a 2-3:1 predominance.1 Around 50% of infants with ankyloglossia experience feeding difficulties because of the condition.2
There are two different types of tongue tie that can make feeding problematic for infants and young children. An infant can have a tongue tie that’s attached anteriorly toward the tip of the tongue, posteriorly at the base of the tongue, or both. Unlike an anterior tongue tie that is easiest to view because the frenulum attaches closer to the tip of the tongue, the posterior tongue tie is a form of akyloglossia that is less visible when the tongue is lifted. The frenulum may appear short and thick, or may not be visible because it’s often hidden by the mucosal covering of the tongue.3 This type of tongue tie may not look atypical upon first glance, but the tongue lacks the ability to lift from the floor of the mouth for proper feeding.4 Anterior tongue ties can be viewed more easily. The infant may appear to have a flat tongue that is heart-shaped at the tip, and it may only extend past the alveolar ridge slightly.3
Similar to tongue ties, lip ties can also be the cause of feeding difficulties for infants. Upper lip tie forms from a tight maxillary or labial frenum and can cause infants to have difficulty latching, because it limits the upper lip’s movement. The lip should be able to flange upward to latch along the upper portion of the areola and the nipple, or form a proper seal around a bottle. Lip ties of the maxillary or labial frenum can look like a small string attachment or fanned piece of tissue and sometimes, infants with the condition develop a callus on the upper lip.5,6
Caregivers may notice their child with tongue tie or lip tie is not meeting age appropriate feeding milestones or is exhibiting atypical feeding behaviors. Possible warning signs of these conditions include:
- Difficulty latching and feeding-when infants breastfeed or bottle feed, their lower jaw is raised during suckling, and they use their top gum and the tip of the tongue (which rests on the lower gum) to hold the nipple/bottle in place. Tongue tie and lip tie may prevent the infant from taking enough breast tissue into the mouth to properly latch for feeding as the latch is often very shallow. Some infants may be able latch but are unable to achieve the proper suckling motions. Tongue tie may also inhibit peristaltic tongue movements—the tongue’s wave-like motion needed to move food from the front to the back of the mouth before swallowing. This can result a poor suck, swallow, breath pattern.4,5,7
- Mother experiences pain while nursing-as a result of the restricted and atypical tongue movements or improper latch, the mother may experience additional friction while the infant nurses. This can result in pain and nipple soreness, and bleeding.4,6
- Frequent pattern of feedings-occurs because the infant consumes less milk during each feeding than typically developing infants. The infant may also show signs of hunger shortly after a feeding. Another common warning sign is poor weight gain even though the infant feeds for extended periods of time.4,6
- Fatigue during or immediately after feeding-the strained feeding experience requires the infant to expend more energy for milk removal. She may become frustrated during feedings or fall asleep within one to two minutes of beginning a feed. 4,6
- Dimpling of cheeks or clicking sound while feeding-this is specific to tongue tie, and occurs as a result of the atypical latching and sucking motions. Jaw tremor may also be present. Infants with tongue tie are sometimes fussy and/or pull away from the breast or bottle frequently.4
If you suspect a child may have tongue tie or lip tie, referring to a specialist can help determine the proper treatment and support for the family. Specialists who evaluate these conditions and feeding issues include:
- Lactation consultants
- Speech language pathologists with specialized knowledge in tongue tie or lip tie
- Pediatric dentists
- Oral surgeons or Otolaryngologists (ENTs) 3,4
After a diagnosis has been made, there are multiple treatment options for families to consider. A frenotomy is one form of treatment for tongue tie that involves snipping the short or tightened frenulum. Other surgical procedures involve using lasers to revise the frenulum. If surgery is not an appropriate form of treatment, a specialist can work with the mother and infant to adjust feeding techniques for either breast feeding or bottle feeding. Caregivers must learn how to listen to their infant’s swallows and monitor the infant’s weight closely.4 Similar treatment options also exist for infants with lip tie, and for either condition, caregivers should always follow post treatment advice from their physician. If families are interested in learning more about tongue tie, they can read the Pathways.org blog on tongue tie. They can also view our feeding brochure to learn about feeding milestones and age appropriate foods.
 Brookes A, Bowley D. Tongue tie: The evidence for frentonomy. Early Human Development. Nov 2014; 90(12): 765-768
 Buryk, at el. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics. Aug 2011; 128(2): 280-288.
 Potock Melanie. Tip Back that Tongue! The Posterior Tongue Tie and Feeding Challenges. The ASHA Leader Blog. 26 May 2015. www.asha.org.
 Henry Lydia, Hayman Rebecca. Ankyloglossia and Its Impact on Breastfeeding. Nursing for Women’s Health. Apr/May 2014; 18(2): 122-129.
 Kotlow, Lawrence. Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. Journal of Human Lactation. 2013; 29(4): 458-464.
 Potock Melanie. Just Flip the Lip! The Upper Lip-tie and Feeding Challenges. The ASHA Leader Blog. 10 March 2015. www.asha.org.
 Edmunds at el. Tongue-tie and breastfeeding: a review of the literature. Breastfeeding Review. Mar 2011; 19.1: 19.