RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Tongue Tie

July 2022 v1.0 
Condition and Intervention

Ankyloglossia, also known as tongue-tie, is a congenital anomaly characterised by an abnormally short lingual frenulum which may restrict mobility of the tongue. It varies from mild to severe, but can result in breastfeeding difficulties, maternal nipple pain and failure to thrive. There is also some concern that it may be associated with speech difficulties in older children and adults. 

Input from a specialist in breastfeeding (e.g., midwife or health visitor) may be able to support the mother to successfully breast feed her infant with tongue-tie. Some practitioners, however, believe that if a baby with tongue-tie has difficulty breastfeeding, surgical division of the lingual frenulum should be carried out as early as possible. 
In early infancy, division of the tongue-tie, known as frenotomy, is usually performed without anaesthesia. The frenulum is cut using sharp, blunt-ended scissors. After the early months of life, general anaesthesia is usually required. Current evidence suggests that there are no major safety concerns.

For infants with feeding problems: 
Division of the frenulum should only be conducted:
  1. When under 3 months of age, AND
  2. Where there are perceived breastfeeding difficulties, AND
  3. Where the parent and child have received a face-to-face feeding assessment by a trained health visitor or midwife with specialist expertise in breastfeeding AND
  4. Where the feeding assessment demonstrates that a notable degree of tongue tie exists and is impacting on the ability to effectively feed AND
  5. As an outpatient procedure.
For older children or adults with speech problems:
Surgery should only be considered for management of speech problems in adults or children with speech problems when:

1. The child is at least 5 years of age.
2. Speech is significantly and noticeably affected.
3. The speech sounds affected are consistent with tongue tie. 
4. A Speech and Language Therapist has assessed the patient, and states that: 
a.the speech problem is highly likely to be due to the tongue tie
b.the child is unlikely to grow out of the speech problem
c.conservative management e.g., speech therapy is unlikely to be successful.
5. Other causes of speech abnormalities have been ruled out, for example audiological assessment and an assessment for a sub-mucous cleft. 

Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the ICB policy.

Surgery for infants with feeding problems:

The National Institute for Health and Clinical Excellence (NICE) Interventional Procedure Guidance reports current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure. 
More recent studies published since this guidance also show improved outcomes in infants with tongue tie who have had the procedure. 

Surgery for older children and adults where there are concerns regarding the speech

There has long been a common belief that if the tongue tip cannot move well due to ankyloglossia, it must affect speech. However, there are few articles in the literature that address the effects of tongue-tie on speech. Despite these reports and the lack of evidence, many professionals still believe that ankyloglossia is a common cause of speech problems.
In evaluating the effect of ankyloglossia on speech, it is important to focus on lingual-alveolar sounds (particularly /l/) and interdental sounds (voiced and voiceless /th/). Tongue-tie could be considered a contributing factor if the child cannot produce these sounds. Tongue tie may also be a bigger problem if there is also oral-motor dysfunction.
It should be recognised that both ankyloglossia and speech problems commonly occur in children. Therefore, it is not surprising that these conditions often occur together. However, there is some evidence that surgical intervention can improve speech in patients with ankyloglossia. 

  1. Ann W Kummer. (2005) Ankyloglossia: To Clip or Not to Clip? That’s the Question. The ASHA Leader, Vol. 10, 6-30
  2. National Institute for Health and Clinical Excellence. (2005) Interventional Procedure Guidance 149:  Division of ankyloglossia (tongue-tie) for breastfeeding
  3. O’Shea JE et al. (2017) Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews 
  4. S Chinnadurai et al. (2015). Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review, Pediatrics, Volume 135. 
  5. Visconti A et al. (2021) A systematic review: The effects of frenotomy on breastfeeding and speech in children with ankyloglossia. Int J Speech Lang Pathol. 

Lingual frenulum      A small fold of tissue that reaches from the floor of the mouth to the underside of the tongue.
Tongue tie                 When the frenulum linguae is shorter (and may be thicker) than normal preventing normal movement of the tongue.
Ankyloglossia           Tongue tie
Congenitalanomaly   An abnormality in anatomy present at birth.
Frenotomy                 A simple splitting (cutting) of the frenulum.
Frenuloplasty            A more complex procedure to release the tongue from the floor of the mouth, usually closed with stitches and performed under general anaesthetic.
Frenulotomy             A surgical procedure for excising the frenulum.

Clinical coding:  OPCS codes: F262-268