Tongue tie

Pre-referral guidelines for primary care providers

Tongue tie (ankyloglossia) is a term that refers to an anterior extension of the lingual frenulum (membrane connecting the base of the tongue with the floor of the mouth) which limits tongue movement and/or interferes with effective feeding. The management of tongue tie remains controversial, with only limited studies to influence decisions regarding tongue tie release (frenulomtomy). There is even less evidence to correlate tongue tie with the future development of speech difficulties.

Upper lip tie (frenulum between the middle upper teeth and the gum line) generally does not cause difficulties, either with feeding or with tooth development. Surgical ligation of these is an extremely controversial topic with very limited evidence to support any intervention.


The most common accepted standardized assessment tool for tongue tie evaluation is the Hazelbaker Assessment form.

There is very little literature to support a standardized approach to the evaluation of ‘posterior tongue ties’ or ‘lip ties’.

Practice Points

  • The role of tongue tie in feeding difficulties and speech difficulties remains a controversial issue
  • Frenulotomy is a minimally invasive procedure for release of a tongue tie, however there is only limited evidence points for this procedure being effective.
  • There is little to no evidence to support ligation of an upper lip tie.


Assessment using the Hazelbaker Assessment form will ascertain whether there is a role for frenulotomy.

If it is to be performed, frenulotomy can be undertaken safely as a simple office procedure, or even whilst the infant remains an inpatient after birth. It is not advisable for the procedure to be undertaken after a few months of age, given the risk of bleeding as the frenulum thickens – this would then be performed by a plastic surgeon under anaesthetic.

Frenuolotomy should only be undertaken by an experienced operator. The use of sucrose solution (20-33%) for infant calming prior to the procedure is widely accepted. Infants who have not received vitamin K at birth, or with a family history of a bleeding diathesis, should be treated with caution given the risk of bleeding.

Referral pathways

  • Paediatrician
    • Referral to paediatric outpatients services is recommended if ligation of a tongue tie is being considered, although not for a lip tie.
    • Most paediatricians in Ballarat are generally happy to perform frenulotomy after clinical evaluation. Early referral (less than 2-3 months old) is advised to minimize chances of the frenulum thickening.
  • Surgeon
    • A plastic surgery referral is required for ligation if the child is aged more than 3 months old, although can generally wait until the child is over 2 years of age.