Tongue-tie (ankyloglossia) in babies

What is a tongue-tie?

Most people have a frenulum (FREN-yuh-lum) – a piece of tissue under their tongue that stretches from the underside of the tongue to the floor of the mouth. Tongue-tie or ankyloglossia [ank-ilo-gloss-e-a) happens when the frenulum interferes with normal tongue movement. 

This can occur if it extends too far forwards towards the tip of the tongue, or is short and tight and attaches close to the floor of the mouth. Cases can range from mild to severe (Bruney et al, 2022; NICE, 2005; Oakley, 2024). In babies where the frenulum extends all the way to the tip, the tongue may look heart-shaped (NHS, 2024).

What problems does tongue-tie cause?

If a baby has a tongue-tie, they may not be able to fully extend or lift their tongue or move it from side to side (Bruney et al, 2022).

Tongue-tie may make both breastfeeding and bottle-feeding difficult (NHS, 2024).

If a baby has a tongue-tie and is being breastfed or bottle-fed, they may experience (Cordray et al, 2024; NHS, 2024):

• Difficulty attaching and staying attached onto the breast or teat
• Dribbling when feeding
• Clicking noises while feeding
• Coughing or spluttering while feeding
• Very frequent or long feeds
• Poor weight gain or excessive early weight loss
• Possible reflux

Breastfeeding a baby with tongue-tie can cause sore nipples, and painful and swollen breasts (Cordray et al, 2024; NHS, 2024).

For parents, it can be stressful if the baby is having problems feeding and affect the parents’ wellbeing. Partner support can be really helpful when dealing with breastfeeding difficulties caused by tongue-tie (Hill et al, 2021).

Tongue-tie diagnosis

Many babies who have tongue-tie don’t have problems with feeding (Bruney et al, 2022; NICE, 2005). If breastfeeding, tongue-tie has symptoms which are similar to other breastfeeding issues, so it’s not always easy to tell if tongue-tie, or something else is the cause.

If the mother or breastfeeding parent, and/or the baby are experiencing feeding difficulties, a feeding assessment is recommended. It is also helpful to get some support from one of our NCT Breastfeeding Counsellors (call 0300 330 0700 any day of the year) or another trained infant feeding professional. If breastfeeding, support to improve your baby’s attachment to the breast may resolve the problem.

If an infant feeding professional thinks the baby may have a tongue-tie, they can signpost to a local tongue-tie practitioner.

Tongue-tie practitioners will assess tongue-tie by looking at how the tongue works and what it looks like. Most midwives and health visitors are not tongue-tie practitioners so are unable to make a diagnosis of tongue-tie themselves, but they can refer onto a tongue-tie practitioner.

Tongue-tie types

Tongue-ties can be described as anterior or posterior. Anterior is when the frenulum goes towards the tip of the tongue. Posterior means it restricts movement towards the back of the tongue (Oakley, 2024).

A posterior tongue tie can restrict tongue function just as much as an anterior one, even though it is less obvious (Oakley, 2024).

Tongue-tie treatment

What is tongue-tie division?

The baby could have a tongue-tie division, or frenotomy, which can release their tongue so it can move more freely. This involves cutting the frenulum.

Is tongue-tie division safe?

Tongue-tie division is a generally safe procedure. It can improve the feeding problems that tongue-tie causes (Borrowitz, 2023; Bruney et al, 2022; Cordray et al, 2024; NICE, 2005).

It’s considered a small procedure so is likely to be done without any anaesthetic (NHS, 2024).

Is an anterior tie division easier than posterior tie?

The division technique is similar for both an anterior and posterior tie. While an anterior tie may seem more complex as there is more frenulum to cut, a posterior tie can be thicker. So in both cases, more than one cut may be required (Oakley, 2024).

Are there any risks to tongue-tie division?

Although rare, there are some risks to tongue-tie division (Bruney et al, 2022; NICE, 2005):

• Bleeding
• Infection
• Ulceration
• Pain
• Damage to the tongue and saliva ducts

In 2 cases in 100, a second procedure may be needed (Oakley, 2024).

It is important to keep bottle teats and all feeding equipment sterile after a tongue-tie division (Association of Tongue-Tie practitioners, 2024).

Contact the GP urgently if there are signs of infection in the area after the operation (Association of Tongue-Tie practitioners, 2024). This includes:

• Redness
• Swelling
• Inflammation
• Fever
• Reluctance to feed
• If the baby is sleepy or irritable

Is tongue-tie division effective?

Tongue-tie division is thought to be effective, and research has shown that it can (Cordray et al, 2024; Ghaheri et al, 2021):

• Improve the baby’s tongue function
• Show improvement in breastfeeding
• Relieve nipple pain
• Improve reflux symptoms in the baby

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 (Bruney et al, 2022), so how much the tongue-tie is affecting feeding and life with the baby might influence the decision.

It may be helpful to talk things through with an NCT Breastfeeding Counsellor, however the baby is fed. It can be helpful to explore options, plus find ways of coping if it is decided 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 breastfeeding, it can help to use:

• A different breastfeeding position – laid back, side-lying or koala hold positions.
• An 'exaggerated latch'. This is where the baby is held close to (but below) the breast, and the forefinger is used to tilt the nipple upwards. That way, when the baby tips their head back and is brought onto the breast, the nipple can be flipped towards the back of their mouth.

If bottle-feeding, it may help to use:

• Paced bottle feeding techniques

While some parents may find these helpful, others will not as every circumstance is different.

Can tongue-tie affect speech?

There is a lack of evidence to suggest whether or not tongue-tie affects speech. One study found that most children being referred for speech concerns due to tongue-tie actually had normal speech levels for their age (Melong et al, 2021).

However, another study showed that tongue-tie division could improve speech outcomes in children, especially if done before the age of five (Carnino et al, 2024).

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.

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

It can be helpful to have extra support after a tongue-tie division, as the baby adjusts. A good tongue-tie practitioner or service should provide aftercare and support, which can be accessed straight away.