A short history of the diagnosis of posterior tongue-tie

The diagnosis of posterior tongue-tie started a movement which has benefited breastfeeding mothers and babies (just not in the way the pioneers of this diagnosis imagined!)

For the past 20 years, starting in 2004, I watched as the diagnosis of posterior tongue-tie spread around the world. It started with two New York City International Board Certified Lactation Consultants (or IBCLCs, one of whom was also an ENT surgeon). These IBCLCs proposed the existence of hidden 'submucosal ties' in babies in an American Academy of Pediatrics newsletter. The diagnosis of 'submucosal tongue-tie' soon morphed into the diagnosis of 'posterior tongue-tie'.

At that time, there was very little documented about the interior connective tissue anatomy of a baby's mouth. Even classic tongue-tie was commonly missed as a cause of breastfeeding problems. Those two pioneering IBCLCs, like others at the time, were using a method of fit and hold which required baby's forearms to be crossed over each other and secured between the mother and baby's body. Unfortunately, this approach to fit and hold was a recipe for positional instability and breastfeeding problems (even though it was intended to help with breastfeeding problems).

Over the following years, one of these IBCLCs was invited to speak at many international conferences and workshops, about posterior tongue-tie and tongue-tie more broadly, including here in Australia. I flew down to Sydney to hear her speak. That was when I saw the video this IBCLC believed showed a baby trying to breastfeed with a posterior tongue-tie. What I saw, however, was a baby struggling desperately with positional instability, trying to breastfeed with those little arms and hands secured between the mother's and the baby's body. It was heartbreaking. The baby breathed in fast and irregular ways because of the effort required to stay on when breastfeeding under such motoric stress, and kept fussing and pulling off the breast.

These New York City IBCLCs have left an important and positive legacy. They helped raised awareness worldwide of the importance of performing oromotor assessments and also of the urgent need for research clarifying normal infant oral anatomy in newborns and babies, including when they experience breastfeeding problems. These pioneering IBCLCs successfully helped raised awareness of the diagnosis of classic tongue-tie. As a direct result, classic tongue-ties in babies are no longer overlooked.

I knew however from my clinical experience that the breastfeeding problems that these IBCLCs attributed to posterior tongue-tie were actually signs of motoric positional instability, having watched the pioneering work emerge concerning mammalian reflexes and breastfeeding. I also knew that these IBCLCs were using outdated models of the biomechanics of infant suck, because I was also closely watching the ultrasound studies of infant suck during breastfeeding coming out of the Geddes Hartmann Human Lactation Research Centre here in Australia.

It seemed to me a response was called for if we were to prevent overtreatments and potential harm to families, even though my own capacity to work with breastfeeding and lactating patients was on the line.

It was risky to one's own livelihood to speak out! Lists were circulating online of 'ankyloglossia-informed' health professionals - parents were strongly advised to not to see anyone else for help with breastfeeding problems, as those who disagreed with the diagnoses of posterior tongue-tie, upper-lip, and buccal ties were labelled ignorant and non-evidence-based.

My own efforts to address misinformation about the diagnosis of posterior tongue-tie haven't made me popular!

Here is a time-line of my response.

• In 2013 I published a paper in the journal Breastfeeding Medicine called Rethinking posterior tongue-tie.

• In 2016 with my colleague Renee Keogh, I published the approach to positional stability which I'd been developing up in the clinic, and which we were both finding achieved great results with breastfeeding women and their babies who had difficulties - which had often been diagnosed as due to posterior tongue-tie.

• In 2017 in the journal Breastfeeding Medicine, I published a critique of a study by the United States ENT surgeon Dr Bobak Ghaheri and colleagues, demonstrating its methodological weaknesses.

• In 2017 I also published an article that analysed the methodological weaknesses more broadly which were apparent in the studies that were being touted on conference circuits, by breastfeeding organisations, and in social media as proof that frenotomy for diagnoses of posterior tongue-tie improved breastfeeding outcomes.

• In 2018 I published a paper which proposed a new clinical translation of the ultrasound research work with Professor Donna Geddes as my co-author, proposing the gestalt biomechanical model of infant suck.

• In 2022 I published a paper which showed that a brief application of the gestalt method in four patients with comprehensive previous intervention by IBCLCs achieved the same change in intra-oral measures that had been documented elsewhere as equivalent to changes post-frenotomy.

Publication of these two latter papers has resulted in a serious ideological backlash from the world's dominant organisation for lactation consultants, which aims to 'cancel' my education work.

In 2020 Dr Nikki Mills published her pioneering research which proved, in painstakingly detailed anatomic dissections of the floor of the mouth of babies who had died, that there was no anatomic feature in the oral fascia or connective tissue which could in any way correlate with a proposed diagnosis of a posterior tongue-tie. In response to Dr Mill's research, and communicating directly with Dr Mills, Gray's Anatomy has changed it's description of and illustration of infant lingual frenula and floor of mouth fascia. You can find out more about Dr Mill's work here. There is a series of three podcasts on this topic between me and Dr Mills starting here.

These days, because of this research, breastfeeding support professionals are applying the diagnosis of posterior tongue-tie less often - but still label normal anatomic variants of the lingual frenulum a tongue-tie, or sometimes a deep tongue-tie, which they might earlier have called a posterior tongue-tie.

If your baby doesn't have a prominent anterior membrane, which you can see, your baby doesn't have a tongue-tie. Some babies have small chins and shorter tongues, with squarer tongue-tips, which is a normal variation (though this variation can pose challenges to fit and hold). And even prominent anterior membranes most commonly do not interfere with tongue movement and shape in any way that is relevant to you and your breastfeeding baby.

• You can find an animation of how babies suck during breastfeeding here.

• You can find out about your baby's tongue and breastfeeding here.

You can see under the tongue of a baby who was diagnosed with posterior tongue-tie in the photo at the top of this page. In fact, this baby has a normal (not very prominent or visible) frenulum. This is not a posterior tongue-tie. The baby's breastfeeding problems related to fit and hold, which resolved when we worked together.

The woman and her baby breastfeeding in the photo below are likely to experience breastfeeding problems due to the baby's motoric positional instability. The baby's right arm and hand are held between the mother and baby's body, and the little chest and tummy are rolled out away from the mother's body. The IBCLCs who created the diagnosis of posterior tongue-tie ensured that baby's hands and arms were held between the mother and baby's body as a breastfeeding support strategy - which caused the problems which they then attributed to posterior tongue-tie. Importantly, a range of positive advances in breastfeeding science resulted from this mistaken understanding.

Selected references

Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.

Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.

Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.

Douglas PS. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):180-181.

Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation. 2017;33(3):519–523.

Ghaheri BA, Cole M, Fausel S, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: a prospective cohort study. Laryngoscope. 2017;127:1217–1223.

Ghaheri BA, Cole M. Response to Douglas re: 'Conclusions of Ghaheri's study that laser surgery for posterior tongue and lip ties improves breastfeeding are not substantiated'. Breastfeeding Medicine. 2017;12(3):DOI:10.1089/bfm.2017.0016.

Kummer AW. Ankyloglossia: misinformation vs. evidence regarding its effects on feeding, speech, and other functions. Journal of Otolaryngology - ENT research. 2024:DOI: 10.15406/joentr.12024.15416.00552.

LeForte Y, Evans A, Livingstone V, Douglas PS, Dahlquist N, Donnelly B, et al. Academy of Breastfeeding Medicine Position Statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine. 2021;16(4):278-281.

Mercer NSG. Posterior tongue tie and lip tie - division of tongue tie: an assault on a baby. BMJ. 2021;372(n11).

Thomas J, Bunik M, Holmes A. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605.