Posterior Tongue Tie – This Could Save Your Baby’s Mouth

Anterior Tongue Tie

Let’s talk about what tongue ties are. You may have heard the term ankyloglossia, which is the medical word for tongue tie. 

Your tongue has a piece of tissue that connects to the bottom of your mouth. This piece of tissue is called a frenulum. Sometimes when the frenulum extends too far forward or restricts movement of the tongue, it’s called a tongue tie. 

What is an anterior tongue tie? 

An anterior tongue tie is what most people think of when hearing the term tongue tie. It is easy to see; the frenulum extends all the way to the tip of the baby’s tongue. The term anterior means “front” in medical terminology. So it is a tie at the front of the tongue. 

An anterior tongue tie will secure the baby’s tongue to the bottom of their mouth. They cannot extend their tongue forward over their gums or upward. The sides of the tongue can lift off, but the center of the tongue stays attached –  making a baby’s tongue look heart-shaped. 

Anterior tongue ties are actually a congenital anomaly. 

What that means is there’s an error in one of the baby’s genes. 

In other words, the baby either has it or they don’t. It’s black and white. Those with the error in their genetic markers will have a tongue tie. 

Only about 5% of babies have this congenital anomaly. 

Posterior Tongue Tie

Let’s talk about posterior tongue ties in babies. The term posterior tongue tie didn’t exist until 2004 when a newsletter was published theorizing its existence. 

The newsletter wasn’t evidence-based and had no study backing it. But after it’s publication, the term started to become accepted. 

Now it’s a common term used in many studies but there’s speculation if it truly exists and to what extent. 

What is a posterior tongue tie? 

A posterior tongue tie is a tightened frenulum (connective tissue) at the back of the tongue. The word “posterior” means back in medical terminology. So a posterior tongue tie is a tongue that’s tied at the back of the mouth instead of at the front. 

But doesn’t everyone’s tongue connect at the back of their mouth? 

Yes. This is why posterior tongue ties are controversial. 

While there are some ways for a diagnosing provider to look for a posterior tongue tie, it’s very subjective. One provider might diagnose a baby with posterior tongue tie while another deems it normal attachment. 

This study is a great example of what different providers think. An expert panel of pediatric otolaryngologists was assembled to try and get a clear definition of tongue tie. While they all agreed that an anterior tongue tie was the tongue tethered to the floor of the mouth at the tip, here’s what they found about posterior tongue ties:

When the definition of posterior ankyloglossia was considered, the panel was unable to achieve consensus. Some in the group use the term to mean a frenulum that inserts into the posterior portion of the tongue, whereas others think of it as a submucosal tethering of the tongue. Still others feel that it does not exist as an anatomic entity and that the term “posterior ankyloglossia” should be abandoned.

https://journals.sagepub.com/doi/full/10.1177/0194599820915457

It’s unclear what exactly a posterior tongue tie is (compared to normal) and how many babies really have it. And medical professionals simply cannot agree on what a posterior tongue tie is or how to diagnose it.

The Research About Posterior Tongue Ties

I’ve compiled the research about posterior tongue ties and will explain what I’ve found here. There are many studies out there, so here I only include the most informative. 

Of the studies I didn’t include, I will explain why. 

Most of them were performed by researchers that primarily make their money from tongue-tie revision surgery. Further, they often don’t include controls in their research and many of the participants fail to respond for follow-up. Because of these things, I decided to omit the studies. 

But here are the studies that I think help explain this dilemma: 

Study #1

This study was done in 2018. It measured the distance from the tip of the tongue to the frenulum (tissue that connects it to the mouth). The closer the frenulum was to the tongue’s tip, mom was more likely to have issues breastfeeding. 

In 59% of babies, the practitioners could feel a “tight cord” but only 21% of babies had a tie that could be seen. The 21% with the visible cord were the ones with breastfeeding problems. 

The conclusion of this study says, “the diagnosis of posterior ankyglossia by palpation of a thick, fibrous posterior cord as described in the literature may suffer from high interobserver variability, and should be interpreted with caution, particularly when considering surgical intervention.”

In other words: when it comes to cutting a baby’s tongue, when there are questions we should err on the side of caution instead of clipping. 

Study #2

In this study, from 2010, 94% of the participants had anterior tongue ties while 6% of them were diagnosed with posterior tongue ties. Of the babies that got theirs clipped, 21% of the babies with posterior tongue ties had to get them clipped again. This is compared to only 3.7% of the anterior tongue tie participants. The study even says about posterior tongue ties that “the diagnosis is difficult due to the subtle clinical findings”. 

What I wonder about this study is of those babies that got their posterior tongue ties clipped, was that really the problem? If they decided to get it clipped again, then things didn’t significantly improve the first time. The study doesn’t explain how many went on to get their clipped a third time. 

If the tongue tie wasn’t the problem, multiple clippings could cause a problem where there wasn’t one. Scar tissue can be damaging to the tongue’s function. 

Study #3

This study was interesting. In it, of the babies with an anterior tongue tie, 100% of them had no breastfeeding difficulties after they got it clipped. They were all latching and breastfeeding successfully. 

But of the babies that had a posterior tongue tie clipped, 50% of them still had issues. Additionally, they had more pain a week after. And 29% of them had a second clipping done!

The study had 47% of the initial participants not respond in the follow-up, which also draws questions. And it doesn’t mention how many people had 3 or 4 additional revisions.

Study #4

This study was done in 2017, and in two of the groups that had their tongue ties clipped, the babies slowed their weight gain.

The study itself states, “Based on the available evidence, frenotomy cannot be recommended for all infacts with ankyloglossia, since there is no absolute relationship between ankyloglossia and breastfeeding difficulties.” 

Study #5

This is an example of the many studies out there that are questionable. The study was performed by people who make money as a result of tongue tie diagnosis. 

In the study, there is no control group. Additionally, each of the participants has lactation support so it’s hard to say if breastfeeding improved because of the surgery or because of the support. 

It also states that reflux improved in babies after surgery – but by 3 months of life reflux generally gets much better. As babies grow and get used to eating, reflux tends to improve even without cutting the tongue. 

And the third claim is that babies ate more following surgery. Again, as babies get older they grow and thus eat more per feeding. Not to mention, the amount of milk a baby eats changes each feeding and throughout the day. 

It’s studies like these that most practitioners refer to when they diagnose tongue ties and recommend surgery. 

Study #6

This study was very interesting to me. They found that when more babies were assessed for a tongue tie, that more babies were diagnosed with a tongue tie. 

I think of the saying, to a hammer everything looks like a nail. 

They speculate that many tongue ties are undiagnosed, but it could be the flip side of that too. In this study they may have been diagnosing something that wasn’t there. In other words, calling a normal tongue attachment a “tongue tie”. 

Should I get my baby’s posterior tongue tie clipped?

Generally, no. An anterior tongue tie is really a true tongue tie so that is different. Here are the reasons not to get a posterior tongue tie clipped: 

• Everyone’s tongue attaches at the back of the mouth.
• The way a posterior tongue tie is described in literature is the same way a normal tongue attachment is described. 
• It opens up the possibility of clipping a normal tongue attachment. 
• Diagnosis could be different with different providers – there isn’t a universally accepted method to diagnose. 
• Serious damage can take place with clipping – infection, scarring, bleeding, nerve or ductal damage. 
• Often clipping doesn’t solve the problem and they’re referred for a second surgery (or third, fourth, etc…).
• The evidence isn’t strong to prove that clipping the back of the tongue results in significant improvements. Improvements that were made could be attributed to lactation support or the baby getting older. 
• Until there is universal agreement on diagnosis and definition of a posterior tongue tie, and until it’s proved to help breastfeeding – we shouldn’t be cutting babies. Instead breastfeeding support should be given. 

In my personal opinion you shouldn’t get your baby’s posterior tongue tie clipped. If your baby has a visible and obvious anterior tongue tie, that’s a different subject. Those are easily diagnosed without question. 

If your baby has a true tongue tie, it’s an anterior tongue tie, and clipping it will result in immediate improvement in breastfeeding. Five minutes later, your baby will be breastfeeding normally and you should have a significant reduction in pain. 

Posterior tongue tie clippings do not consistently provide positive outcomes immediately following. It can take months, and when a mother does report improvement it’s unclear whether the improvement is due to the clipping or the baby getting older (as older babies become less colicky, breastfeed better, and have less reflux in general).

Babies get better with sucking skills, their nervous system improves, reflux decreases, they stay awake longer, learn how to suck-swallow-breathe and develop motor skills as they age. 

Breastfeeding with a Posterior Tongue Tie

If you are having breastfeeding difficulties and someone diagnoses your baby with an anterior tongue tie, that’s something you and your pediatrician need to talk about. If you both determine that the benefit outweighs the risk then consider clipping it. 

I never advise laser surgery because it causes more scar tissue to form and risks reattachment. It’s also much more painful for your baby because of the 6 weeks of aftercare. 

But if you’re having a hard time breastfeeding, and someone diagnoses your baby with a posterior tongue tie, know this: it’s not always the answer. 

Here are some reasons breastfeeding can be difficult (that there isn’t necessarily a solution for):

• Your baby’s mouth is small. 
• Your breasts are large or engorged. 
• Your baby has torticollis or nerve damage from delivery. 
• Your baby was preterm or early term. 
• Your baby has low energy. 
• You have flat or inverted nipples.
• Your baby could have silent aspiration. 
• Or many other reasons!

Often a posterior tongue tie is diagnosed as the culprit when there isn’t always an immediate answer to why there are problems. 

Posterior vs. Anterior Tongue Tie

When people ask me whether or not I believe in posterior tongue ties… I just say that belief has nothing to do with it! 

I’m a registered nurse… and also a mommy. I only want what’s best for babies and their moms.

Medical professionals take the Hippocratic Oath, which requires first that we DO NO HARM. 

Everything we practice and promote should be evidence based. When it comes to painful cutting and procedures, we need to know without a doubt that the risk outweighs the benefit. 

When the evidence isn’t compelling, a conservative approach is best. 

There are other options for babies including breastfeeding support and techniques, chiropractic, or massage therapy. Many problems in babies resolve by 3 months, so sometimes time is all we need. 

Until there is more evidence supporting posterior tongue ties I will be a proponent of avoiding surgery. 

As far as posterior vs. anterior tongue ties…

Anterior tongue ties are different. They are 100% diagnosable. They are a congenital anomaly. They are evidence based. 

If your pediatrician diagnoses your baby with one, a clipping may be beneficial. 

But before you do anything, make sure you are getting diagnosed by the right person (lactation consultants CANNOT legally diagnose) and research treatment options and aftercare. 

I hope this information can help educate and make a difference in some lives! 

Please reach out to me if you have any questions, I’m always happy to help.

More Evidence Based Information About Posterior Tongue Ties

Tongue Tie Surgery: You’ll Be Glad You Read This

Tips to Breastfeed a Baby with a Tongue Tie

Is Your Baby REALLY Tongue-Tied? How to Tell

Tongue Tie in Your Baby: Help for a Worried Parent

Kealy Hawk, BSN, RN, CLC

Kealy is a Registered Nurse, Lactation Counselor, and most importantly a mommy! Her own baby feeding struggles gave her a passion to help moms throughout their feeding journey. She specializes in breastfeeding support and evidence-based formula recommendations. To talk with Kealy or take one of her breastfeeding or formula classes, visit https://littlebearcare.com.