Baby

Tongue-tie (ankyloglossia) in babies can affect breastfeeding and bottle-feeding. Here we explain about tongue-tie symptoms and treatment.

What is a tongue-tie (ankyloglossia)?

When a baby has a tongue-tie, the movement of their tongue is restricted by a membrane (the frenulum) that connects the underside of the tongue to the floor of the mouth. Many babies have a visible frenulum without having any problems because it is loose enough to allow the tongue to move freely. It’s only when this membrane is tight enough to limit tongue function that it’s described as a tongue-tie (Walker, 2006).

Tongue-tie types

You’ll often hear people describe tongue-ties as anterior (at the front of the tongue) or posterior (towards the back of the mouth).

You might also hear tongue-ties described using a percentage. This percentage describes how far along the underside of the tongue the frenulum comes. So 100% means the tie comes all the way to the front of the tongue. A tight posterior tongue-tie could cause worse feeding problems than a loose anterior tongue-tie (Oakley, 2017).

Sometimes, tissue on the floor of a baby’s mouth (the mucosa) hides the tongue-tie. This kind of tongue-tie is called a sub-mucosal tongue-tie (Genna, 2013).

All of these descriptions are anatomical, so they don't relate to how severely a tongue-tie will affect your baby's feeding (Genna, 2013).

What problems does tongue-tie cause for babies?

Tongue-tie can affect both breastfeeding and bottle-feeding. For some babies, the effects will be quite mild. For others, tongue-tie can make feeding extremely challenging or even impossible.
 

If your baby has a tongue-tie and you're breastfeeding, you might notice one or more of the following in your baby:

  • a small gape so it feels like the baby is biting/grinding
  • breast refusal - your baby seems unable to latch onto the breast
  • difficulty in latching
  • unsettled behaviour during feeds
  • frequently coming off the breast or slipping back to the nipple
  • frequent or long feeds
  • poor weight gain or excessive early weight loss
  • clicking noises while feeding
  • colic/wind/hiccoughs
  • reflux (baby vomits and/or is miserable after feeds)
  • difficulties with taking solids or speech difficulties in older babies.

(NHS, 2017; ATP, 2019a)

If you're breastfeeding your baby and they have tongue-tie, you might experience one or more of the following:

  • sore or cracked nipples and pain during feeding
  • mastitis
  • breast engorgement
  • reduced milk supply.

(ATP, 2019a)

If you're bottle-feeding your baby, you might notice one or more of the following – your baby:

  • is very slow to take a bottle
  • needs to be fed very often in order to get enough milk
  • dribbles a lot during feeds
  • tends to push the bottle teat out
  • chokes on feeds even when you slow the feed down
  • can only manage a teat that has a very slow flow.

(Oakley, 2017)

Can I see if my baby has a tongue-tie?

It might be possible to tell that your baby has a tongue-tie if they:

  • are unable to extend their tongue fully
  • have a tongue with a heart-shaped appearance on the tip
  • have difficulty lifting their tongue or moving it from side to side.

(NHS, 2017).

Tongue-tie is not always obvious though. A tongue can look completely normal to an untrained eye yet still cause substantial problems with feeding (Young, 2011).

How is tongue-tie diagnosed?

If you and/or your baby are experiencing feeding difficulties, you might want to get your baby’s tongue function and their feeding assessed by a specially trained professional. They’ll be able to help you decide what to do next and will look at your baby, watch them feeding and hear from you about how feeding is affected (UNICEF, 2018).

Some health professionals might use a formal assessment of tongue-tie that’s based on how things look and function (e.g. the Hazelbaker Assessment Tool for Lingual Frenulum Function).

Tongue-tie treatment

What is tongue-tie division?

Your baby could have a tongue-tie division, which can release your baby’s tongue so it can move more freely. This involves cutting the frenulum (NICE, 2005).

Tongue-tie division is a safe procedure that can improve the breastfeeding problems that tongue-tie causes (NICE, 2005).

Does tongue-tie division hurt?

Tongue-tie division procedures are very quick and simple and are thought to be almost painless (NICE, 2005).

Does tongue-tie division resolve feeding problems?

Most parents say their baby’s feeding improves after a tongue-tie division and many find it resolves the problem completely (Buryk et al, 2011; Berry et al, 2012). But a few babies do continue to have feeding difficulties even after a tongue-tie division.

Some parents say manual therapy (e.g. osteopathy, craniosacral therapy or chiropractic) aids a tongue-tie division by helping with jaw or neck tightness and associated issues. But there is very limited scientific evidence to tell us whether these therapies are effective or not (ATP, 2019b).

Do I need to get my baby’s tongue-tie treated?

The decision on whether to have a tongue-tie divided is a personal one and different parents will make different decisions. Every tongue-tie is different too and the range of issues it causes can vary from very mild to severe. So how much the tongue-tie is affecting feeding and your life with your baby might influence your decision.

Some parents find the thought of cutting anything in their baby’s mouth scary. Others feel that the brief distress is worth the long-term improvements. If you are not sure how you feel, you might find it helpful to talk to other parents whose babies have had a tongue-tie division. You should be able to find these parents at a local breastfeeding drop-in or at an NCT Bumps and Babies group.

You might find it helpful to talk things through with an NCT breastfeeding counsellor too. They can help you explore your thoughts and feelings plus find ways of coping if you decide not to have the procedure done.

If you're considering a tongue-tie division, you can ask a health professional or breastfeeding counsellor to talk you through the procedure.

What else might help with feeding difficulties due to tongue-tie?

There are sometimes ways of improving feeding without having a tongue-tie division. Nipple shields used with good breastfeeding support often help.

Sometimes, finding a supportive breastfeeding position like the koala or the rugby hold, can help. A thorough breastfeeding assessment might also offer different ideas - see an NCT Breastfeeding counsellor or other skilled breastfeeding person in your area (Horsfall, 2013)

Babies who are bottle-fed might find feeds easier if paced bottle feeding techniques are used. Occasionally, finger feeding can be a more comfortable option than using a bottle (Genna, 2013).

How can I find tongue-tie division services near me?

Only registered healthcare professionals who have received proper training in tongue-tie division should perform this procedure. In many areas, the NHS provides a tongue-tie division service. But provision varies across the country and parents in some areas have to travel long distances to reach a tongue-tie division service.

It can be even harder to find a tongue-tie division service when a baby is having problems bottle-feeding. Unfortunately, some areas might have no service available (NCT, 2015).

The National Institute for Health and Care Excellence  - also known as NICE - recommends tongue-tie division. Yet there is no common agreement among tongue-tie dividers on how to carry out the procedure or how far the membrane should be divided (NICE, 2005). This means the service different health professionals offer varies.

Your midwife or health visitor should be able to signpost you to NHS tongue-tie assessment and division services in your area. Breastfeeding counsellors or lactation consultants can also give you information about tongue-tie division locally.

Online, you can see a directory of both NHS and private tongue-tie practitioners on the Association of Tongue-tie Practitioners (ATP) website.

What can I expect after my baby’s tongue-tie division?

Babies are often unsettled in the first day or two after a tongue-tie division and might need more cuddles and nurturing. After the procedure, you’ll probably see a white patch under your baby’s tongue; this takes 24 to 48 hours to heal but it won’t bother your baby (UNICEF, 2018).

Do I need to do anything after the tongue-tie division?

Some tongue-tie dividers will recommend that you massage underneath your baby’s tongue or do tongue exercises in the days after the procedure. Many parents find this kind of care is distressing for their baby and are reluctant to continue with it.

As yet, nobody really knows whether massage or exercise techniques are helpful or harmful. But it’s helpful to know that the research studies which showed tongue-tie release helps to improve feeding did not involve using exercises or massage afterwards (Oakley, 2017).

Will my baby’s feeding improve after their tongue-tie division?

Parents often expect that feeding will improve immediately after a tongue-tie division. But it usually takes a few days before things get better (ATP, 2019c).

Feeding is often more difficult for the first day or two after a tongue-tie division. This could be because it takes time for your baby to adjust to their new, free tongue, or they’re just recovering from the procedure (ATP, 2019c).

It helps everyone to be patient, ease your baby into feeding differently and to try to make feeds as easy and stress-free as possible rather than trying to force them to do it properly. Babies will gradually adapt without any special effort (ATP, 2019c).

Many other things can have an effect on feeding in addition to tongue-tie. So some babies might need further support even after a tongue-tie division. If things have not improved after a few days, you might find it helpful to get extra support to improve feeding - see below.

This page was last reviewed in July 2018.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby

Attending a Baby Cafe or other breastfeeding support drop-in can be a good way to access support with feeding your baby. You may also find other parents there whose babies have had a tongue-tie.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Pictures of babies with tongue-tie can be found on Catherine Genna’s website.

The Baby Friendly Initiative, part of UNICEF, has a list of locations where tongue-tie can be divided within the UK, as does the Association of Tongue-Tie Practitioners.

Tongue-tie UK raises awareness about tongue-tie and lip-tie in the UK to help parents get information and support.

ATP (Association of Tongue-tie Practitioners). (2019a) Tongue-tie and infant feeding. Available at: https://www.tongue-tie.org.uk/product/tongue-tie-infant-feeding-poster/ (accessed 18th October 2019)

ATP (Association of Tongue-tie Practitioners). (2019b) Manual therapy and infant feeding. Available at: https://www.tongue-tie.org.uk/manual-therapy-and-infant-feeding/ (accessed 18th October 2019)

ATP (Association of Tongue-tie Practitioners). (2019c) Care after tongue-tie division (frenulotomy) factsheet. Available at: https://www.tongue-tie.org.uk/product/care-after-tongue-tie-division/ (accessed 18th October 2019)

Berry J, Griffiths M, Westcott C. (2012) A double-blind, randomised controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeeding Medicine. 7(3):189-193. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21999476 (accessed 18th October 2019)

Buryk M, Bloom D, Shope T. (2011) Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 128(2):280-286. Available at:https://www.ncbi.nlm.nih.gov/pubmed/21768318 (accessed 18th October 2019)

Genna CW. (2013) The influence of anatomic and structural issues on sucking skills. In: Supporting Sucking Skills in Breastfeeding Infants, 2nd edn. Genna CW ed. Jones and Bartlett Publishers, Inc: Burlington, MA.

Horsfall C. (2013) Tongue-tie: breastfeeding and beyond. A parents’ guide to diagnosis, division and aftercare. Catherine Horsfall.  

NCT. (2015) Huge variation in NHS infant tongue-tie services. Available at: https://www.nct.org.uk/sites/default/files/related_documents/Wise%20Huge%20variation%20in%20NHS%20infant%20tongue-tie%20services.pdf (accessed 18th October 2019)

NHS. (2017) Tongue tie. Available at: https://www.nhs.uk/conditions/tongue-tie/ (accessed 18th October 2019)

NICE. (2005) Division of ankyloglossia (tongue-tie) for breastfeeding https://www.nice.org.uk/guidance/ipg149  (accessed 18th October 2019)

Oakley S. (2017) Tongue-tie in babies; a guide for parents. Available at: https://sarahoakleylactation.co.uk/wp-content/uploads/2018/08/tongue-tie-booklet-version-4.pdf) (accessed 18th October 2019)

Walker M. (2006) Breastfeeding management for the clinician, 4th edn. Jones & Bartlett Learning: Burlington, MA.

Young C. (2011) The hidden cause of feeding problems (however you feed your baby). Available at: http://milkmatters.org.uk/2011/04/15/hidden-cause-feeding-problems/ (accessed 18th October 2019)

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