Low Tongue Tone and Tongue-Tie Division

Tongue tone can be relevant to infant feeding because the tongue needs to maintain an appropriate level of muscular activity while also making coordinated movements for sucking, swallowing and breathing. Effective oral feeding depends on the interaction of these movements rather than on the action of a single muscle, with the tongue working alongside the lips, jaw, palate, pharynx and respiratory system as the infant develops increasingly coordinated feeding skills (Lau, 2015; Lau, 2016; Watson Genna and Sandora, 2017).

When reduced tongue tone is observed in an infant, the finding therefore needs to be considered in relation to what the tongue is able to do during feeding. Tongue tone, tongue strength, tongue movement and tongue coordination describe different aspects of function and should not be used interchangeably, particularly when trying to understand why an infant may be experiencing difficulty with feeding.

What is tongue tone?

Muscle tone is generally described as the tension present within a muscle at rest and the resistance encountered when a muscle is passively stretched. It is influenced by the nervous system and the interaction between neural input and the muscular system, rather than being a simple measure of muscle strength (Ganguly et al., 2021).

Muscle tone and muscle strength are consequently different physiological concepts. Strength concerns the force a muscle can voluntarily or reflexively generate, whereas tone relates to the muscle's state and resistance to passive movement. Reduced tone does not therefore necessarily mean that a muscle is weak, just as apparently normal tone does not establish that a muscle has normal functional strength (Ganguly et al., 2021).

The tongue is a particularly complex muscular organ. It contains intrinsic and extrinsic muscles arranged in a three-dimensional network, with extensive neuromuscular innervation that permits changes in both tongue shape and position (Mu and Sanders, 2010; Sakamoto, 2018). The intrinsic muscles are contained within the tongue and contribute substantially to changes in its shape, while the extrinsic muscles connect the tongue with surrounding structures and contribute to its movement and positioning (Mu and Sanders, 2010; Sakamoto, 2018).

For this reason, when reduced tongue tone is described clinically, it is useful to consider what has actually been observed. An infant may demonstrate reduced resistance to passive movement, reduced ability to maintain a particular tongue position, limited elevation or protrusion, reduced endurance, or difficulty coordinating the tongue with the other movements required for feeding. These findings may have different underlying explanations and should not automatically be interpreted as evidence of a neurological or neuromuscular disorder.

Reduced tongue tone (hypotonia)

Reduced muscle tone, or hypotonia, describes a reduction in the resistance normally encountered during passive movement and may arise from abnormalities affecting the central or peripheral nervous system, neuromuscular junction or muscle itself (Ganguly et al., 2021). In an infant presenting with feeding difficulty, however, an apparently low-tone tongue does not necessarily indicate generalised hypotonia, as oral feeding skills develop through maturation and experience and differences in oral motor coordination can affect feeding without representing a primary neurological or muscular disorder (Lau, 2016).

Where reduced tongue tone is observed, consideration can therefore be given to how the tongue behaves during both rest and active feeding, including its ability to maintain position, elevate, protrude, retract and coordinate with the jaw and other structures involved in sucking and swallowing. Reduced tone may affect the tongue's ability to sustain the movements required for effective feeding, although the clinical significance depends upon the infant's overall functional presentation rather than the appearance of the tongue alone (Watson Genna, 2017).

Increased tongue tone (hypertonia)

Increased muscle tone, or hypertonia, represents the opposite alteration in tone and describes an abnormal increase in resistance to movement. Hypertonia can arise through a number of neurological mechanisms and should not simply be equated with having a strong or highly active muscle (Ganguly et al., 2021).

In the tongue, increased tone may influence the infant's ability to make smooth, graded and appropriately coordinated movements during feeding. As with reduced tone, however, the observation of increased resistance or tension does not by itself establish a diagnosis of hypertonia, and its significance needs to be considered alongside the infant's neurological, oral and feeding presentation.

Considering hypotonia and hypertonia together is useful because both represent alterations in muscle tone, but they can affect movement in different ways. Neither finding should be interpreted in isolation from function, and neither should automatically be assumed to explain a feeding difficulty without considering the wider clinical picture.

Development and anatomy of the tongue

The tongue begins developing during the fourth to fifth weeks of gestation from structures associated with the pharyngeal arches, while the muscular component develops predominantly from occipital somites and subsequently receives its principal motor supply from the hypoglossal nerve (Mu and Sanders, 2010; Thomas et al., 2024).

Its anatomy is consequently complex, with intrinsic and extrinsic muscles arranged throughout the tongue rather than functioning as a simple set of isolated muscles. The tongue's neuromuscular organisation allows it to change shape and position rapidly and with considerable precision, which is important for functions including swallowing, respiration and feeding (Mu and Sanders, 2010; Sakamoto, 2018).

This developmental and anatomical complexity is relevant when considering tongue tone because an infant's ability to use the tongue effectively depends not simply upon the presence of muscle tissue, but upon the interaction between muscular contraction, neural control, sensory information and the surrounding oral structures.

Tongue function during infant feeding

Infant feeding involves coordinated patterns of sucking, swallowing and breathing. Sucking provides the initial mechanism for obtaining milk, while swallowing then moves the milk safely from the oral cavity towards the pharynx, with these processes becoming increasingly coordinated as the infant matures (Lau, 2015; Lau, 2016).

Watson Genna and Sandora describe sucking and swallowing as closely integrated processes involving coordinated tongue, jaw and oral movements, with the tongue contributing to milk expression and movement within the oral cavity before and during swallowing (Watson Genna and Sandora, 2017). Swallowing itself comprises oral, pharyngeal and oesophageal phases, with the oral phase involving the tongue's preparation and propulsion of the bolus before the pharyngeal swallow is initiated (Watson Genna and Sandora, 2017).

The tongue therefore has an important influence on an infant's ability to manage milk within the mouth and to initiate effective swallowing, rather than its role being limited to attachment or milk removal. Lau (2016) similarly describes infant oral feeding as a developing motor skill that depends upon the maturation and coordination of sucking, swallowing and breathing.

A difference in tongue tone or movement may consequently have implications for feeding, but the observation itself does not identify the cause. Feeding ability can be influenced by developmental maturity, gestational age, neurological status, oral anatomy, sensory-motor organisation and the mechanics of the feeding method, making a functional feeding assessment more informative than considering tongue tone in isolation (Lau, 2016; Watson Genna and Sandora, 2017).

Resting tongue posture

The tongue remains under neuromuscular control when an infant is not actively feeding, and its resting position is influenced by the surrounding oral and craniofacial structures as well as by muscular activity (Mu and Sanders, 2010; Sakamoto, 2018).

An infant may therefore demonstrate a resting tongue posture that appears low, forward, retracted or otherwise different from that expected for effective oral function. Resting position alone, however, does not establish whether tongue tone is reduced because the position of the tongue results from the interaction between muscular activity, anatomy, sensory and motor control and the surrounding structures.

Considering resting posture alongside active movement and feeding function can therefore provide a more meaningful picture than treating a particular resting position as diagnostic in itself.

What can contribute to altered tongue tone or function?

Altered tongue tone does not have a single cause. Where genuine hypotonia or hypertonia is present, the underlying mechanisms may involve the central or peripheral nervous system, neuromuscular junction or muscle itself, with the clinical presentation depending upon the underlying condition (Ganguly et al., 2021).

In an infant presenting with feeding difficulty, however, an apparently low-tone or high-tone tongue does not necessarily indicate a primary neurological or muscular disorder. Infant oral feeding skills develop through maturation and experience, and differences in coordination or oral motor organisation can affect feeding without representing pathological alteration of muscle tone (Lau, 2016).

Other factors may therefore need consideration, including prematurity or developmental immaturity, neurological or neuromuscular conditions where clinically indicated, differences in oral anatomy, sensory-motor coordination, fatigue and mechanical restriction of tongue movement. These possibilities should be distinguished from one another rather than being grouped together simply because the tongue appears to have altered tone or movement.

A restrictive lingual frenulum is one anatomical factor that may be relevant when there is demonstrable limitation of tongue movement.

Tongue function exercises

Where reduced tongue tone or impaired tongue function has been identified as contributing to feeding difficulty, targeted tongue exercises may form part of a conservative management approach. The purpose is not simply to exercise the tongue for its own sake, but to encourage more effective muscular recruitment, movement, coordination and endurance in relation to the functional demands of feeding. Watson Genna's work on supporting infant sucking skills includes consideration of tongue exercises within the management of infants with anatomical or functional factors affecting sucking skills, including ankyloglossia (Watson Genna, 2017).

The aim of this approach is to improve the infant's ability to use the tongue functionally for feeding, including the movements involved in sucking and swallowing, rather than presenting exercises as a universal treatment for feeding difficulties. Their use is therefore best considered in relation to the findings of the individual feeding assessment and the particular functional difficulty being addressed.

Conservative management may be appropriate where the clinical findings indicate that supporting tongue function is a reasonable first approach, including situations in which there is reduced tongue tone or movement but no indication that a surgical procedure is required. Where a restrictive frenulum is also present, conservative management can provide an opportunity to assess whether functional improvement can be achieved without division, while recognising that some infants may continue to have a mechanically restricted tongue despite supportive measures.

Tongue-tie, tongue tone and feeding

Ankyloglossia refers to a congenital restriction of tongue movement associated with the lingual frenulum, although there remains variation in how ankyloglossia is defined and assessed (Thomas et al., 2024; LeFort et al., 2021). The presence of a lingual frenulum variation does not by itself establish that feeding will be affected, and the American Academy of Pediatrics emphasises the importance of identifying a functional feeding problem rather than diagnosing symptomatic ankyloglossia from anatomy alone (Thomas et al., 2024).

A restrictive frenulum can mechanically limit aspects of tongue movement, including elevation and extension, and this provides a plausible explanation for why some infants with ankyloglossia may experience difficulty using the tongue effectively during feeding (Thomas et al., 2024). If movement is restricted, the way in which the tongue is positioned and recruited during sucking and swallowing may also be altered, and this may be observed clinically as reduced functional tongue tone or reduced functional tongue movement.

The available evidence does not, however, establish a direct causal pathway in which ankyloglossia causes reduced tongue muscle tone, nor does it establish that division of the frenulum directly increases tongue muscle tone. The more established relationship concerns mechanical restriction of tongue movement and its potential effect on feeding function, while the question of how restriction may influence muscular recruitment and tone requires further research.

This distinction is important when considering frenulum division because the evidence for the procedure is primarily concerned with feeding outcomes rather than measurement of tongue muscle tone. The 2017 Cochrane review found that frenotomy reduced maternal nipple pain in the short term but did not consistently demonstrate improvement in objective measures of infant breastfeeding, with the certainty of the evidence limited by small studies and methodological weaknesses (O'Shea et al., 2017). More recent evidence has added to the available literature but has not removed this uncertainty: a 2026 umbrella review identified conflicting findings across systematic reviews, while a 2026 systematic review and meta-analysis of 47 studies found improvements in some feeding-related outcomes but concluded that the overall certainty of evidence supporting frenotomy was very low (da Silva et al., 2026; Dhar et al., 2026).

The current evidence therefore supports consideration of frenotomy where a restrictive frenulum is associated with documented functional impairment and conservative measures have not resolved the difficulty, but it does not support presenting division as a treatment for low tongue muscle tone itself. A functional feeding assessment remains important because feeding difficulties can have multiple contributing factors and because the presence of a restrictive frenulum does not necessarily mean that it is the cause of the observed difficulty (Thomas et al., 2024; Dhar et al., 2026).

Looking at the whole feeding mechanism

Reduced tongue tone is best regarded as one clinical finding within the wider assessment of oral feeding rather than as an explanation for feeding difficulty in itself. The tongue is a complex muscular and sensory structure, and effective feeding depends upon its interaction with the jaw, lips, palate, pharynx and respiratory system as well as upon developing neurological control (Lau, 2016; Mu and Sanders, 2010; Watson Genna and Sandora, 2017).

When altered tongue tone is observed, it is therefore useful to consider what movements are affected, whether the finding is consistent across different activities, how it relates to sucking and swallowing, and whether there is an identifiable developmental, neurological, muscular, anatomical or mechanical contributor. Where a restrictive lingual frenulum is present, its significance needs to be considered in relation to demonstrable tongue function rather than anatomy alone.

Tongue exercises may provide one conservative management option where reduced tone or function has been identified, with the aim of supporting more effective tongue movement and feeding. Where mechanical restriction remains significant despite appropriate conservative management, frenulum division may be considered when the clinical assessment indicates that the restriction is contributing to the feeding difficulty. Neither approach should be presented as a universal answer to low tongue tone, because the underlying cause and functional presentation will differ between infants.

The distinction between anatomy, tone, strength, movement and function is therefore important when considering an infant with feeding difficulty. An evidence-based assessment allows these findings to be considered individually and then brought together to establish the most appropriate explanation and management approach for the feeding dyad.

References

da Silva, B.V., Barollo, A.V., Sá, N.N.L., Oliveira, L.B. and Sanglard, L.F. (2026) ‘Lingual Frenotomy in Breastfeeding Infants: An Umbrella Review’, International Journal of Paediatric Dentistry, 36(1), pp. 90–104. doi: 10.1111/ipd.70031.

Dhar, V., Marghalani, A.A., Amini, H., Brickhouse, T., Caffrey, E., Jayaraman, J., Keels, M.A., Messner, A., Patterson, K.K., Raol, N., Shrestha, P., Stark, C.M., Susarla, H.K. and Thomas, J. (2026) ‘Frenotomy for Ankyloglossia Associated With Feeding Challenges in Infants: Effectiveness, Technique, and Safety—A Systematic Review and Meta-Analysis, Part 2’, Pediatric Dentistry, 48(2), pp. 33E–68E.

Ganguly, J., Kulshreshtha, D., Almotiri, M. and Jog, M. (2021) ‘Muscle Tone Physiology and Abnormalities’, Toxins, 13(4), 282. doi: 10.3390/toxins13040282.

Lau, C. (2015) ‘Development of suck and swallow mechanisms in infants’, Annals of Nutrition and Metabolism, 66(Suppl. 5), pp. 7–14. doi: 10.1159/000381361.

Lau, C. (2016) ‘Development of infant oral feeding skills: what do we know?’, The American Journal of Clinical Nutrition, 103(2), pp. 616S–621S. doi: 10.3945/ajcn.115.109603.

LeFort, Y., Evans, A., Arsenault, A., Mazzocchi, A., Dempsey, E., Cormier, C., Cuthbertson, L., Francis, D.O. et al. (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. doi: 10.1089/bfm.2021.29179.ylf.

Mu, L. and Sanders, I. (2010) ‘Human tongue neuroanatomy: nerve supply and motor endplates’, Clinical Anatomy, 23(7), pp. 777–791. doi: 10.1002/ca.21011.

O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 2017(3), CD011065. doi: 10.1002/14651858.CD011065.pub2.

Sakamoto, Y. (2018) ‘Structural arrangement of the intrinsic muscles of the tongue and their relationships with the extrinsic muscles’, Surgical and Radiologic Anatomy, 40(6), pp. 681–688. doi: 10.1007/s00276-018-1993-5.

Thomas, J., Bunik, M., Holmes, A., Keels, M.A., Poindexter, B., Meyer, A., Gilliland, A. et al. (2024) ‘Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report’, Pediatrics, 154(2), e2024067605. doi: 10.1542/peds.2024-067605.

Watson Genna, C. (ed.) (2017) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning.

Watson Genna, C. and Sandora, L. (2017) ‘Breastfeeding: normal sucking and swallowing’, in Watson Genna, C. (ed.) Supporting Sucking Skills in Breastfeeding Infants. 3rd edn. Burlington, MA: Jones & Bartlett Learning, pp. 1–42.