Identifying tongue tie: Does that tell us who will have breastfeeding problems?

If you’ve spent much time discussing tongue ties with other medical professionals, then you probably already know it’s a controversial topic. And if you’ve spent much time around breastfeeding parents (either as a professional or a parent yourself), you probably know that it is sometimes difficult, painful, and emotionally-loaded for the breastfeeder.


So what’s an SLP to do when working on feeding with breastfeeding infants who might have tethered oral tissues??! (Freeze! Step one is to make friends with a lactation consultant.) This study from Schlatter et al., which follows more than 700 breastfeeding dyads might give you a little guidance. Using structured assessment tools, they evaluated every infant’s tongue appearance and function and interviewed each mother to determine if there were any breastfeeding problems. Dyads who demonstrated both impaired infant tongue function and breastfeeding problems were referred for a frenotomy (or, “…if their parents actively opted for the procedure”). Then the interview was repeated two weeks later to see if breastfeeding had improved.

The authors used three assessments that are open access (!!!). Hazelbaker’s Assessment Tool for Lingual Frenulum Function (HATLFF), the LATCH Assessment Tool, and the Bristol Breastfeeding Assessment Tool. The full article has great details on how these assessments were used to determine frenotomy referrals and how maternal interviews were carried out (along with a very readable summary of similar research that has come before this study).

So what did they learn?

  1. Infants with a tongue tie were more likely to have breastfeeding problems, but it’s not quite so cut and dry as that might sound. 55% of the babies with tongue tie had breastfeeding problems, whereas 42% of babies without a tongue tie had breastfeeding problems (significantly less than those with tongue tie).

  2. In infants with tongue tie, the overall tongue function subscore on the ATLFF and the item measuring tongue peristalsis were the best way to predict which dyads would have more frequent breastfeeding problems.

  3. Looking across all dyads, tongue tielow birthweight (under 2500g), birth before 37 weeks gestation, and lack of prior breastfeeding experience increased the odds of breastfeeding problems.

  4. The majority of moms do report an improvement in breastfeeding post-frenotomy.

Here’s what this means for your practice: identifying a tongue tie may increase the odds of breastfeeding problems in some infants, but there's more to investigate. Looking at medical history, discussing breastfeeding history, and comprehensive feeding assessment are essential to decision-making. And when you are checking for tongue tie, tongue function is much more relevant than the appearance of the frenulum. 

Schlatter, S.-M., Schupp, W., Jörg‐Elard, O., Sabine, H., Kunze, M., Stavropoulou, D., Hentschel, R. (2019). The role of tongue‐tie in breastfeeding problems—A prospective observational study. Acta Paediatrica. doi: 10.1111/apa.14924.

Oral feeding success: What does that mean for future development?

Let’s say you’re working in a NICU: how well are you able predict which preemies will have difficulty with oral feeding? Or which ones will have impaired global development long after discharge? Or maybe you’re an early intervention SLP. How do you decide who needs services after discharge from the NICU and who might benefit from a wait-and-see approach? This study of extremely low gestational age (ELGA, meaning born before 28 weeks gestation) can help build our sense of who might need extra or earlier support.

Researchers collected data from the charts of ELGA infants, tracking which factors were related to feeding difficulties while still in the NICU, as well as cognitive, language, and motor skills during follow-up visits at 8 months and 20 months corrected age. For this study, infants with feeding difficulties meant no oral feeding by 35 weeks gestational age or inability to consume at least 100ml/kg/day by 38 weeks (aka, not meeting standard nutritional needs by mouth). Let’s break down what they found out by time period:

In the NICU: 59% of the ELGA infants in this study had feeding difficulties. These infants were more likely to have comorbidities that we associate with the sickest preemies (bronchopulmonary dysplasia, hypotension, retinopathy of prematurity, etc.) Other factors associated with feeding difficulties* included longer use of mechanical ventilation, steroid treatment, significant GI issues, and a late start to oral feeding trials. If you’re spending your days feeding NICU babies (and fielding the tricky question of “How soon do you think they will learn to eat so we can take them home?”), keeping these risk factors in mind might help you determine needed treatment frequency or to help parents understand how difficult it really can be for ELGA infants to master oral feeding.
At eight months corrected age:  The babies who had feeding difficulties in the NICU were more likely to have lower cognitive and motor skills than the preemies who had a smoother oral feeding course. Additionally, the later an infant started oral feeding attempts, the more likely they were to have poor cognitive or motor outcomes.

But then at twenty months corrected age? Feeding difficulties in NICU no longer helped researchers predict who would demonstrate deficits in development, though authors say that this may have been impacted by a drop in follow-up rates at the 20 month visits.

So if you’re either serving infants post-NICU discharge or deciding which infants to refer to the full gamut of therapy services when they leave your facility, this study can help shape your practice. ELGA infants with feeding difficulties are likely to require early intervention, particularly in their first year. But that doesn’t mean that the ELGA infants without feeding difficulties are home free since prematurity plays a significant role in development. If “which of these babies is most at risk” is a question that keeps popping up for you, check out our growing collection of reviews on prematurity.

*If you’re a NICU SLP, be sure to check out the full text of the article for specifics on which factors (especially those related to GI function) the researchers included in their analysis. Not only can it help inform your treatment, but could be handy to pass on to your neonatologists if you’re advocating for more appropriate referrals on your unit!


Patra, K. & Greene, M.M. (2019). Impact of feeding difficulties in the NICU on neurodevelopmental outcomes at 8 and 20 months corrected age in extremely low gestational age infants. Journal of Perinatology. doi: 10.1038/s41372-019-0428-4.