Tongue-tie in babies: signs, feeding problems and frenotomy

Tongue-tie (ankyloglossia) is when the piece of skin connecting your baby's tongue to the floor of the mouth, the frenulum, is shorter or tighter than usual, so the tongue can't move as freely. Many babies with tongue-tie feed well and never need treatment. In some, it makes breastfeeding painful or less effective, and a quick procedure to divide the frenulum (frenotomy) may help.

The hard part is telling tongue-tie apart from the many other causes of feeding trouble. In the AAP's coverage of its 2024 report on tongue-tie, one of the authors says most breastfeeding difficulties, including pain, are not due to tongue-tie, and the AAP describes frenotomy as a surgery medical experts believe is being overused. So the first step is a skilled look at a whole feed, not just at your baby's tongue.

What is tongue-tie and how common is it?

Before birth, the frenulum normally thins and draws back. La Leche League GB explains that when it doesn't, it can limit how the tongue moves. Australia's Pregnancy, Birth and Baby says you might notice that:

• the tongue is held close to the floor of the mouth
• it can't move side to side, lift to the roof of the mouth, or poke out past the lips
• the tip looks square, heart-shaped or notched instead of round.

Estimates of how common it is vary, partly because there's no single agreed definition:

The Australian Breastfeeding Association says it's slightly more common in boys, and Pregnancy, Birth and Baby says it can run in families.

How can tongue-tie affect breastfeeding?

To breastfeed well, your baby's tongue needs to move freely to draw milk from the breast. The Australian Breastfeeding Association says a restricted tongue can lead to "nipple-feeding", which can damage your nipples and reduce how much milk your baby gets.

Signs in your baby (from the NHS tongue-tie page, Pregnancy, Birth and Baby and La Leche League GB):

• difficulty latching, or slipping off the breast
• clicking sounds as they lose suction
• feeding for a long time and very often
• dribbling milk, coughing or spluttering during feeds
• taking only small amounts, or tiring quickly
• slow weight gain, or not gaining weight.

Signs in you:

• nipple pain during feeds
• nipples that look flattened, pinched or striped after feeds, or that crack
• blocked ducts or mastitis
• milk supply that drops over time.

None of these signs is specific to tongue-tie. The Australian Breastfeeding Association says they can all have other causes, and Victoria's Better Health Channel in Australia says most breastfeeding problems aren't caused by tongue-tie and can be solved with the right support. La Leche League GB agrees that the vast majority can be fixed by adjusting positioning and attachment. Start with latch and positioning, and see sore nipples for other causes of pain.

Does every tongue-tie need treating?

No. The NHS says treatment isn't usually needed if tongue-tie isn't causing problems, and the Australian Breastfeeding Association says many babies with a visible frenulum breastfeed "just fine". NICE's guidance on tongue-tie division notes that many tongue-ties cause no symptoms, and that careful assessment is needed to decide whether the frenulum is really interfering with feeding.

Pregnancy, Birth and Baby says that for many babies the frenulum loosens as they get older. The Better Health Channel adds that tongue-tie may improve on its own by age 2 or 3, and that a small number of children develop speech problems because of it.

Who can assess tongue-tie?

If feeding is hard, the first step is getting a feed watched by someone skilled. Depending on where you live, that might be:

• a lactation consultant (IBCLC)
• your midwife, pediatrician or doctor
• a pediatrician, if your baby is referred.

The NHS suggests talking to a midwife, health visitor or doctor. Pregnancy, Birth and Baby suggests your doctor or a lactation consultant, and says a pediatrician, doctor, speech pathologist or pediatrician can also help. The AAP suggests starting with your baby's doctor, who can work with lactation consultants and other specialists as a team. Australian Breastfeeding Association counselors can support you, but they say they aren't medically trained to diagnose tongue-tie.

Drawing on Pregnancy, Birth and Baby, NICE and the AAP, a good assessment looks at:

1. How feeding is going: your pain, how your baby attaches, how long feeds take, diapers and weight gain.
2. How the tongue moves, not just how it looks: whether it can lift, extend and move side to side.
3. Other causes: positioning and attachment, your nipples and breasts, and your baby's health.
4. Whether a frenotomy is likely to help, or whether feeding support should come first.

La Leche League GB says tongue-tie can be hard to diagnose accurately, so it's worth seeing someone experienced. Ask about their training; the Australian Breastfeeding Association notes there's currently no formal accreditation for people who do tongue-tie releases. NICE says the procedure should only be done by registered healthcare professionals who are properly trained.

While you wait, keep feeding your baby, keep an eye on wet diapers and weight (see is my baby getting enough milk?), and ask your lactation consultant how to protect your milk supply.

What happens during a frenotomy?

NICE describes the procedure in young babies:

1. No general anaesthetic. In early infancy it's usually done without anaesthesia, although a local anaesthetic is sometimes used. Pregnancy, Birth and Baby says babies under 4 months may have it without anaesthetic and with little discomfort.
2. Your baby is held still. Their head is steadied, often with your baby wrapped.
3. A quick snip. The frenulum is divided with sharp, blunt-ended scissors. NICE says there should be little or no blood loss.
4. Feed straight away. NICE and Pregnancy, Birth and Baby say feeding can resume immediately. La Leche League GB says this comforts your baby and keeps the tongue moving.

La Leche League GB says the procedure takes a minute or two. In two studies NICE reviewed, 8% and 18% of babies slept through it.

Afterwards, you may see a small white patch under the tongue. Pregnancy, Birth and Baby says this is normal and heals within a couple of weeks; La Leche League GB says 24 to 48 hours. NICE says that after the early months a general anaesthetic is usually needed. The Royal Children's Hospital Melbourne aftercare sheet for this surgery in older children notes that, rarely, a second operation is needed.

NICE's list of possible problems includes bleeding, infection, ulcers, pain, damage to the tongue or the ducts under it, and the tie coming back. Few problems were reported in the studies it reviewed, its specialist advisers said adverse effects were likely to be rare, and the AAP says the procedure is safe and poor outcomes are rare.

Does frenotomy help breastfeeding?

The sources agree it's generally safe. They are more cautious about whether it improves feeding:

NICE's recommendations, first published in 2005 as IPG149, say the evidence is adequate to support the procedure with normal consent and audit arrangements, and that further controlled trials on long-term breastfeeding would be useful. Its own specialist advisers disagreed, and some said it's hard to be sure whether any improvement is due to the procedure. The Cochrane review pooled 5 small trials with 302 babies. It found less nipple pain for mothers in the short term but no consistent improvement in infant breastfeeding, and no serious complications, while noting that the trials were small and had serious weaknesses.

The AAP's clinical report says it isn't clear whether releasing a tight frenulum in newborns improves breastfeeding, and that because the signs overlap with other feeding problems, a team approach is needed. In its announcement, the AAP said:

• tongue-tie diagnoses rose almost 10-fold between 1997 and 2012 in one study, and medical experts believe frenotomy is being overused
• one of the report's authors warns that some providers and clinics promote the diagnosis and frenotomies when this isn't always in the baby's best interest
• doctors should first consider non-surgical options, and keep frenotomy for babies with significant functional problems where those options haven't worked
• no evidence supports laser over other methods
• it advises against stretching exercises after the procedure that reopen the wound.

In short, a frenotomy may help when a tie is clearly limiting feeding and skilled support hasn't solved the problem. It isn't a shortcut past that support. Ongoing help with attachment matters either way.

What about lip-tie?

The upper lip is attached to the gum by a band of tissue too. Some practitioners call a tight one a "lip-tie" and offer to release it, sometimes alongside cheek (buccal) ties. The Australian Breastfeeding Association says there isn't enough evidence yet about whether upper lip-ties or cheek ties affect breastfeeding, or whether releasing them helps. If someone recommends releasing more than one tie, it's reasonable to ask what evidence supports it and to get a second opinion.

Can tongue-tie affect bottle feeding?

It can. The NHS says babies with tongue-tie may have difficulty attaching to a bottle nipple as well as the breast. Pregnancy, Birth and Baby lists these signs in bottle-fed babies:

• dribbling or milk leaking from the mouth during feeds
• swallowing a lot of air
• feeds that take a long time.

The NHS says treatment options include bottle-feeding advice from a trained health professional, as well as surgery. NICE's guidance only looked at breastfeeding; it says bottle feeding wasn't included in the evidence it reviewed. For general bottle technique, see paced bottle feeding.

When to get help

These are on the NHS list of signs that need urgent help. For the first day after birth, see newborn first 24 hours. Also call 911 if bleeding after a frenotomy is heavy or your baby becomes pale or floppy.

Get medical help today (doctor, midwife, pediatrician or your pediatrician's after-hours nurse line) if:

• your baby has fewer wet diapers than usual, or dark, strong-smelling pee (see dehydration signs)
• your baby is refusing feeds or feeding much less than usual
• there's bleeding from the mouth after a frenotomy that doesn't settle, or your baby seems unwell afterwards (the RCH aftercare sheet lists bleeding from the mouth, ongoing fever and seeming generally unwell as reasons to see a doctor).

Arrange a feeding assessment soon (lactation consultant, pediatrician, doctor or La Leche League or a lactation consultant (IBCLC)) if:

• feeding hurts throughout, or your nipples are cracked, bleeding or misshapen after feeds
• your baby can't latch or stay on, clicks, or feeds for very long stretches
• weight gain is slow, or your baby isn't back to birth weight by about 2 weeks
• you've had a frenotomy and feeding hasn't improved.

Before your appointment, jot down a few days of feeds, wet and dirty diapers and any weights with dates, and note when pain happens during a feed. That gives whoever assesses your baby a clearer picture than a single feed can.