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Tongue tie: assessment, referral and outcomes


Key learning points:          

- Restriction of the tongue function can lead to significant infant feeding problems     

- Mothers should have concerns taken seriously and be given advice based on the best available evidence

- If a tongue-tie is suspected mothers would benefit from a referral to those who have experience in tongue-ties and frenulotomy (division of tongue-tie)

Atongue-tie is an inherited condition where the connective tissue (frenulum) under the tongue is too tight or too short. This restricts the movement of the tongue and can affect breastfeeding, weaning onto solids, speech, dental hygiene and breathing. It is estimated that 1.7% - 11% of the worldwide population are tongue tied to some degree but not all will be significant for infant feeding. One study examined 1,866 babies of which 11% had a tongue-tie; 44% of babies with tongue-tie had problems feeding and 85% of these babies were breastfed.1

A review of current literature fails to agree on the absolute definition of a tongue tie or what is the best management. As health professionals, registered with the Nursing and Midwifery Council (NMC), our Code states, “You must deliver care based on the best available evidence or best practice”.2 How do we therefore manage when evidence is controversial or scarce?

Parents frequently ask for grading of a tongue tie, by its appearance, with the expectation that this assessment alone will determine breastfeeding management. It is important to ask if feeding is affected, as that will determine the significance of the tongue tie. The feeding history and experience of the mother is crucial in this evaluation as not all babies with a tongue tie will have problems feeding at the breast. A review of medical texts demonstrates a common theme that tongue ties have no impact on breastfeeding. The conundrum is who to believe?


For the mother tongue tie can cause:

- Bruised, sore, cracked, bleeding and/or flattened nipples.

- Blanching of the nipples after feeding.

- Reduced milk supply.

- History of mastitis and/or true engorgement.

- Instinctive response that there is something wrong with feeding.

- History of previous breastfeeding failure or difficulties with older siblings.

- Emotional distress.

Effects of tongue tie on the infant include:

- Difficulty coordinating sucking, swallowing and breathing.

- Restricted movement of the tongue and jaw.

- Baby remains unsettled during and after feeding.

- Shallow latch or difficulty maintaining a deep latch.

- Baby falling asleep early while feeding due to exhaustion.

- Very frequent short feeds or excessively long feeds.

- Shallow gag reflex.

- Audible clicking while feeding.

- Dribbling while feeding.

- History of colic and wind.

- Dramatic early weight loss >10%.

- Poor weight gain.


Parents often ask why babies are not checked for tongue tie at birth. From experience, the answer is really threefold. If tongue tie was identified would there be local resources to refer to? Is it ethical to withhold a diagnosis if perception is that restriction is of no significance? Would it be beneficial to the mother to be aware that the breastfeeding may present with difficulties?

Should a parent cite some of the symptoms listed above it is the health professional's responsibility to decide if they have the competence and confidence to correctly diagnose. Some tongue ties are visible, especially when the baby cries, however, not all tongue ties are easily visible by inspection and if a shortened frenulum is present it may not be obvious, except by digital examination. If there is any uncertainty, appropriate referral is recommended. It is unethical to underplay the significance of feeding issues due to lack of knowledge or experience.

Timely provision of treatment for tongue-ties in infants varies greatly in the UK. Media awareness campaigns recently highlighted the lack of access to treatment and when there is a need to resolve issues urgently, some parents seek private treatment. Clearly this may not a suitable choice for families on lower incomes. Any delay in division of a tongue tie can lead to early and unwanted cessation of breastfeeding.3 The UNICEF UK Baby Friendly Initiative (BFI)4 and The Association of Tongue Tie Practitioners (ATP)5 provide details of NHS and private practitioners. The ATP strives to increase awareness of tongue ties, improve knowledge through education and improve access to services for mothers in the UK.


Treatment with a frenulotomy can only be justified if it is likely to lead to significant improvement in the comfort and continuation of breastfeeding, or of other longer term problems for the child.6

Where treatment is postponed or delayed it is crucial that health professionals give evidenced based advice on maintaining adequate lactation, as the success of breast-feeding relies on a robust milk supply. BFI and Department of Health advises that mothers should aim to express a minimum of 8-10 times in a 24 hour period, with at least one expression during the night.7 The mother should aim to produce over 750ml per day by two weeks in order to provide sufficient nutrition to her baby.

The mother may wish to try conservative management of the baby's tongue tie, especially if the baby's weight gain is appropriate. Mothers should be encouraged to maintain their milk supply, maintain practice contact at the breast, focus on obtaining the deepest asymmetrical latch possible and improve tongue mobility with exercises.8

One study, where tongue tied infants and mothers were given intensive breastfeeding support, demonstrated no improvement in their ability to breastfeed.

However, following division of the tongue tie, without an anesthetic, with minimal distress, and no significant complications 64% were able to breastfeed for at least three months.7 One infant feeding study recommended, “If frenulotomy is to be done, it should be performed before one week of age, when significant numbers of tongue-tied infants will have already stopped breastfeeding”.9

It should be noted that if the mother is persevering and ignoring symptoms of poor attachment - sore, bruised cracked nipples - that it is likely that the baby is struggling to effectively remove milk and weight may, in turn, falter as the hormonal influence on the breast milk production diminishes. There is typically adequate weight gain until around twelve weeks, then the weight plateaus. This effect is due to inadequate milk removal reducing the stimulus to provide adequate milk production.

The National Institute of Health and Care Excellence (NICE) Guidance advises, “There are no major safety concerns about the procedure and evidence is adequate to support the use of the procedure”.

It further recommends that only registered healthcare professionals, with proper training, perform the procedure and it would be helpful to see the results from studies looking at the effects of the procedure on long-term breastfeeding.10


In early infancy, division of the tongue tie is usually performed without anaesthesia. The baby's head is stabilised, and sharp, blunt-ended scissors are used to divide the lingual frenulum. There should be little or no blood loss and feeding may be resumed immediately. Advice may be given on optimal positioning and attachment in order to increase maternal confidence. The baby feeding at the breast usually stops any bleeding and it is very rare for any further bleeding to occur.

Parents can expect an uneventful recovery and are advised to observe for any signs of infection and seek medical advice, if concerned. Occasionally babies are unsettled post procedure, and may be fussy at the breast for up to 48 hours. Occasionally analgesia may be suggested, if age appropriate. Some babies will have a white covering of the wound within a couple of days and parents should be assured that this is part of the normal healing process.


It is apparent, from social media 'Action Groups', parents are gathering together to support each other and share information on tongue-tie services. The discrepancy in service provision is becoming more and more apparent to parents and has assisted some in successfully campaigning for the commissioning of local services. The implementation of a timely and effective NHS service is required in all areas to support all mothers with informed choice on how they feed can their babies.


The Association of Tongue Tie Practitioners

The UNICEF UK Baby Friendly Initiative


1. Hogan M, Westcott C, Griffiths M. A randomised, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health 2005;41(5-6):246-250.

2. NMC. The Code. Standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008.

3. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Fam Pract 2005;18(1):1-7.

4. The Baby Friendly Initiative. Where can tongue-ties be divided? Available at:

5. The Association of Tongue-Tie Practitioners: Finding a tongue-tie practitioner. Available at:

6. Griffiths DM. Do Tongue Ties Affect Breastfeeding? J Hum Lact 2004;20(4):409-414.

7. Off to the Best Start: Important information about feeding your baby. 2007. Unicef. Department of Health. Available at:

8. Genna CW. Supporting Sucking Skills in Breastfeeding Infants. Sudbury: Jones and Bartlett; 2008.

9. Hall DMB, Renfrew MJ. Tongue tie. Arch Dis Child 2005; 90(12): 211-1215.

10. NICE. Division of ankyloglossia (tongue-tie) for breastfeeding. NICE interventional procedures guidance [IPG149]. London: NICE; 2005.