The parents of a 3.5-month-old infant present to a primary care clinician with complaints of difficulty breastfeeding that began approximately 2 weeks ago. The infant’s medical history includes normal labor, delivery at 39 gestational weeks, and gastroesophageal reflux disease (GERD) for which he is currently treated with ranitidine. He is exclusively breastfed and receives vitamin D drops daily. The mother has no other difficulties with breastfeeding besides initial pain when she first started to breastfeed and frequent clogged ducts, which have been managed at home.

She reports her son will initially latch and then pull away and scream as if in pain. He refuses a bottle of pumped breastmilk and his parents have been feeding him with a dropper, giving approximately 60 to 90 mL of breastmilk after each breastfeeding attempt. The infant is currently breastfeeding on demand, which is approximately every 3 hours during the day and night. The mother is concerned about the possibility of tongue-tie.

Physical examination reveals a normal-appearing infant who has been gaining weight since birth. At his 2-month well-child checkup he weighed 13 lb 1 oz, which is in the 66th percentile for weight. Today, his weight is 15 lb 12 oz, which is in the 67th percentile for weight. He has met all developmental milestones on time. Oral evaluation does not reveal an obvious tongue-tie. The mother is motivated to breastfeed for 6 months exclusively and to continue breastfeeding for the first year of life. The PCP recommends that the family consult with a local International Board Certified Lactation Consultant (IBCLC).


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The infant is seen by an IBCLC who also is an advanced registered nurse practitioner (ARNP). It is noted that the mother had an adequate milk supply and possibly an oversupply; however, the infant is only able to transfer about 30 mL in a 4- to 5-minute nursing session based on a weighed feeding. The recommended amount per feeding is approximately 90 mL. During the nursing session, the infant becomes distressed, pulling away from the breast and crying. The infant refuses to nurse from the alternate breast.

Signs and symptoms noted by the IBCLC for oral restrictions include cupping of the tongue with tongue lift, tight and thickened frenulum posteriorly, clicking while nursing, and the infant gagging and pulling off the breast with milk letdown. He is diagnosed with a class 3 posterior ankyloglossia. A recommendation is made for frenotomy by an otolaryngologist who has experience with the procedure.

The next day, the infant is seen by an otolaryngologist who agrees with the IBCLC/ARNP’s assessment and recommendation for frenotomy. The physician also notes that the infant’s GERD is likely a symptom of ankyloglossia and could resolve after frenotomy. Frenotomy is performed by laser without complication and the infant is able to breastfeed immediately after the procedure. The follow-up recommendation by the otolaryngologist is to schedule an appointment with the IBCLC/ARNP in 2 days.

The infant is seen 2 days later by the IBCLC/ARNP. The mother notes an immediate improvement in breastfeeding after frenotomy. A weighed feeding is done and the infant is able to effectively transfer 90 mL in 5 minutes from the right breast and 30 mL in 2 minutes from the left breast. The infant is no longer fearful and no longer pulls away from the breast during breastfeeding.

Review of the Literature

Ankyloglossia is defined as a congenital condition characterized by a short or thickened frenulum that limits tongue movement.1-7 Posterior ankyloglossia is less obvious and more challenging to diagnose than other forms of this condition because the frenulum is thicker and further back from the tip of the tongue.3,6 

The incidence of ankyloglossia varies in the literature between 0.1% to 16% 1,2,5-8 largely due to the lack of standard criteria for diagnosis.2,5-7 Boys are affected at a higher rate than girls at approximately a 3:1 ratio.1,2,6

The clinical presentation of symptomatic ankyloglossia varies. Breastfeeding difficulties may include poor infant latch, prolonged feedings, irritability with feeding, inability to breastfeed, and tongue clicking.2,3 The infant may experience poor weight gain, colic symptoms, or reflux symptoms.8 The mother may have pain with breastfeeding, nipple bleeding, frequently clogged ducts, or mastitis.2,8

On physical examination, cupping of the tongue or restriction of tongue mobility, heart-shaped tongue on protrusion, or restriction of tongue protrusion may be observed.2 For posterior ankyloglossia, palpation under the tongue typically reveals a thickened, more fibrous frenulum that anchors the tongue to the floor of the mouth without involvement of the tip of the tongue.6 Although these are common findings seen with ankyloglossia, there is no current standard for diagnosis and the classification methods only take into account anatomical structures and not function.

Limited studies show improvement in breastfeeding after frenotomy. A retrospective study by Pranksy et al4 that included 618 infants seen in a specialized ankyloglossia clinic demonstrated that 78% of infants with anterior ankyloglossia experienced some degree of improvement immediately following frenotomy, according to maternal report. In infants diagnosed with posterior ankyloglossia, 91% of mothers reported some degree of improvement immediately after the procedure.4 Limitations of this study included selection bias as infants were seen at a specialized clinic, lack of specific data on breastfeeding problems since this was a retrospective study, and the subjective measurement of improvement after frenotomy.4 Lastly, it is unclear if there was long-term improvement after frenotomy.