Tongue-tie (ankyloglossia) in babies can affect both breastfeeding and bottle-feeding. Here we explain about tongue-tie symptoms and treatment.
What is a tongue-tie (ankyloglossia)?
Most people have a frenulum – a piece of tissue under their tongue that stretches from the underside of the tongue to the floor of the mouth. Tongue-tie occurs if the frenulum either extends forwards towards the tip of the tongue, is attached close to the lower gum, or is short and tight so it interferes with normal tongue movement (Oakley, 2021).
What problems does tongue-tie cause for babies?
If a baby has a tongue-tie, they may not be able to extend or lift their tongue or move it from side to side. Some will be able to lift the sides, but not the tip (v-shaped tongue). Some will be unable to lift the posterior of the tongue (bowl-shaped tongue). In babies where they frenulum extends all the way to the tip, the tongue may look heart-shaped.
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.
In order to breastfeed, a baby needs to be able to open their mouth wide, extend their tongue over their bottom lip and scoop the breast into their mouth. Then the tongue needs to massage the breast in a wave-like motion to remove milk from the breast (Oakley, 2021).
If your baby has a tongue-tie and you are breastfeeding, you might experience one or more of the following in your baby:
- difficulty in latching
- difficulty in maintaining a latch, with your baby frequently coming off the breast or slipping back to the nipple
- a shallow latch
- clamping down on the breast
- clicking noises while feeding
- unsettled behaviour during feeds
- frequent or long feeds
- poor weight gain or excessive early weight loss
If you are breastfeeding your baby and they have tongue-tie, you might find your nipples are sore and appear squashed after a feed, often appearing ridged, lipstick-shaped, flattened or blanched. If your baby isn’t draining your breasts adequately, this can lead to engorgement, blocked ducts and mastitis. It can also have a negative effect on your milk supply. Feeds which are long or frequent can be very tiring (NHS, 2020; Oakley, 2021).
If you are bottle-feeding your baby, you might notice one or more of the following – your baby:
- is very slow to take a bottle
- chomps on the teat
- needs to be fed very often in order to get enough milk
- dribbles a lot during feeds
- tends to push the bottle teat out
- gags on feeds even when you slow the feed down
- can only manage a teat that has a very slow flow.
How is tongue-tie diagnosed?
Can I tell if my baby has a tongue-tie?
If you look in your baby’s mouth, you might be able to see if they:
- are unable to extend their tongue fully
- have a tongue with a heart-shaped appearance at the tip
- have difficulty lifting their tongue or moving it from side to side.
Tongue-tie is not just about how your baby’s tongue looks. A tongue can look completely normal to an untrained eye yet still cause substantial problems with feeding (Young, 2011).
A tongue-tie is diagnosed by the baby’s tongue function too – what they can do with their tongue. It can only be diagnosed by a qualified tongue-tie practitioner (NHS, 2020).
Tongue-ties can be described as anterior (where the frenulum extends towards the front of the tongue) or posterior (towards the back of the mouth).
Tongue-ties might also be described using a percentage or a number (type I, II, III and IV). This percentage or number describes how far along the underside of the tongue the frenulum comes. So 100%, or type I, would indicate that the frenulum comes all the way to the front of the tongue.
A posterior tongue-tie, which may be described as a 10% tongue-tie, can restrict tongue function just as much as an anterior one. That means these anatomical descriptions of how the tongue looks don't always relate to how severely a tongue-tie will affect tongue function and your baby's feeding (Oakley, 2021).
Some babies have a visible frenulum that doesn’t cause problems with feeding (UNICEF, no date). Tongue-tie shares many of the symptoms of other breastfeeding problems, so it’s not always easy to determine whether these problems are caused by a tongue-tie or something else.
A full feeding assessment should be done before or as part of a tongue-tie assessment (Oakley, 2021). If you and/or your baby are experiencing feeding difficulties, a feeding assessment and some breastfeeding support from a breastfeeding counsellor or trained breastfeeding professional is recommended. Support to improve your baby’s attachment to the breast may resolve the problem (UNICEF, no date).
A baby’s inability to open their mouth widely and extend their tongue may also be caused by tension around the mouth and neck, resulting from birth tensions or interventions during labour. This might be resolved by manual therapy, such as osteopathy or chiropractic from a registered practitioner (ATP, no date; Oakley, 2021).
If the breastfeeding professional (breastfeeding counsellor, midwife or health visitor) suspects your baby has a tongue-tie, they will refer you to a local tongue-tie practitioner. Tongue-tie practitioners will do a formal assessment of tongue-tie based on how the tongue functions as well as how it looks (e.g. the Hazelbaker Assessment Tool for Lingual Frenulum Function). Most midwives and health visitors are not tongue-tie practitioners so are unable to make a diagnosis of tongue-tie themselves.
What is tongue-tie division?
Your baby could have a tongue-tie division, which can release their 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.
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.
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.
What else might help with feeding difficulties due to tongue-tie?
For some babies, it may be possible to improve feeding without having a tongue-tie division.
If babies are fed in a laid back position, they are more relaxed, can open their mouth wider and get a bigger mouthful of breast. But some babies are unable to extend their tongue enough to scoop the breast into their mouth, so this position doesn’t make feeding easier. A side-lying position or koala hold might also help.
Babies can also be helped by using an 'exaggerated latch'. This is where you hold your baby close to but below the breast, and use your forefinger to tilt your nipple upwards. That way, when your baby tips their head back and is brought into the breast, your nipple can be flipped towards the back of their mouth (Oakley, 2021).
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). A tongue-tie can make it difficult for babies to form a seal around the bottle teat. A high palate, often associated with a tongue-tie, can trigger the baby’s gag reflex. Shorter, wedge-shaped or flatter teats may be easier for babies with a tongue-tie to drink from (Oakley, 2021).
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 (Wise, 2015).
The National Institute for Health and Care Excellence – also known as NICE – supports considering 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.
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, no date).
Do I need to do anything after the tongue-tie division?
Some tongue-tie practitioners recommend some tongue exercises or wound massage after a tongue-tie division. The exercises involve encouraging the baby to move their tongue through finger sucking and tongue-poking games. Massaging the wound with a clean finger may help prevent the tongue division knitting together and re-forming but there is no evidence to suggest that this is safe or effective (Oakley, 2021).
Will my baby’s feeding improve after their tongue-tie division?
Parents often expect that feeding will improve immediately after a tongue-tie division.
Feeding can be more difficult for the first day or two after a tongue-tie division because it takes time for your baby to adjust to their new, freely-moving tongue (Oakley, 2021).
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 March 2022.
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 NCT New Baby courses 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.
Pictures of babies with tongue-tie can be found on Catherine Genna’s website.
The Association of Tongue Tie Practitioners has a list of locations where tongue tie can be divided.
ATP (Association of Tongue Tie Practitioners). (no date) Manual therapy and infant feeding. Available at: https://www.tongue-tie.org.uk/manual-therapy-and-infant-feeding/ [Accessed 1st March 2022]
Berry J, Griffiths M, Westcott C. (2012) A double-blind, randomised controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeeding Med. 7(3):189-193. Available at: https://doi.org/10.1089/bfm.2011.0030
Buryk M, Bloom D, Shope T. (2011) Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 128(2):280-286. Available at: https://doi.org/10.1542/peds.2011-0077
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 Learning, Burlington, MA.
NHS. (2020) Tongue-tie. Available at: https://www.nhs.uk/conditions/tongue-tie/ [Accessed 30th June 2022]
NICE. (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Available at: https://www.nice.org.uk/guidance/ipg149 [Accessed 30th June 2022]
Oakley S. (2021) Why Tongue-tie Matters. Pinter & Martin, London.
UNICEF. (no date) Overcoming breastfeeding problems; Tongue-tie. Available at: https://www.unicef.org.uk/babyfriendly/support-for-parents/tongue-tie/ [Accessed 1st March 2022]
Wise. (2015) Huge variation in NHS infant tongue-tie services. Available at: https://www.nct.org.uk/sites/default/files/related_documents/Wise%20Hug… [Accessed 30th June 2022]
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 30th June 2022]