Tongue-Tie Versus Visible Frenulum

A baby needs to be able to move its tongue well and poke it out over its lower gum with their mouth open wide in order to feed from the breast. Babies who have a tongue-tie may breastfeed well from the start and some may need support to improve their positioning and attachment to the breast.

Symptoms described below are signs that your baby is not attaching well to the breast which could be due to the tongue-tie.

Possible signs or symptoms of tongue-tie when breastfeeding your baby:

• Persistently sore or damaged nipples despite good positioning and attachment.
• The nipple may be shaped like a wedge, a bit like a new lipstick, immediately after feeding which may cause nipple pain or discomfort lasting the duration of the feed.
• Reduced milk supply due to baby not attaching well and not removing enough milk.
• Engorged breasts or blocked ducts and mastitis.

Possible signs of tongue-tie for your baby:

• Problems maintaining good attachment to the breast.
• Fussiness at the breast.
• Wind or colic symptoms due to poor attachment.
• Early weight loss and/or difficulty in gaining weight.
• Noisy feeding, for example, clicking or smacking.
• Breastfeeding constantly to get enough milk.

Where a tongue-tie is causing issues with breastfeeding, there are treatment options available that can be effective.

Adjustment to the positioning of your baby during feeding can also improve the ability of your baby to attach well to the breast, as well as ensuring your own comfort during the feed. It is essential that a midwife, health visitor or maternity support worker assess your baby’s feeding.

Your healthcare professional may suggest a number of the following ways to improve your baby’s feeding or you may wish to try this yourself.

• Breastfeed frequently so your breasts remain soft and not engorged. Your baby may find attaching to your breast easier when they are softer. If your breasts are hard you may want to remove some of the milk through hand expressing which will naturally soften your breasts. There is information and a video about hand expressing on our breastfeeding page.

• Lay your baby with their chest and tummy against you, with you semi-reclined in a slouched position. This will allow your baby to attach to the breast using its instinctive reflexes and gravity will help your baby keep their tongue forward. Positioning you both this way is also great for skin-to-skin contact and will really boost your breastmilk supply.

• Attaching to the breast effectively can be harder for a baby whose tongue movement is reduced. There are methods that you can use to support your baby to attach effectively to the breast. The La Leche League have produced some pictures, videos and descriptions on the methods you can try.

• Maintain your breastmilk supply by pumping eight to ten times in 24 hours if your baby cannot attach to your breast with its tongue-tie. You can offer your expressed breastmilk to your baby until your baby’s tongue-tie is divided. After division your baby may be able to return to feeding directly from your breast with support. The best way to maintain a good supply is by using a hospital grade pump. Speak to your midwife to find out if you can hire a pump from the hospital or if they have an agreement with a pump supplier who you can hire from directly. Please check that the flange of the pump is the correct size for your nipple as this can affect output when pumping.

• Babies with a tongue-tie may experience Aerophagia which is a term used when a baby ingests more air while feeding due to a poor latch. This can result in your baby needing to be burped more frequently to release trapped wind which can be uncomfortable. If your baby is suffering from colic type symptoms or bad wind because of the tongue-tie, you may find the ‘koala’ hold position while breastfeeding helps reduce these symptoms. This is because your baby is being held in a more upright position. The Milk Meg have provided a great description and pictures on this. Similarly, if using a bottle, feeding your baby in an upright position and ensuring you are following ‘paced bottle feeding’ can help reduce the amount of air that is ingested. Find out more about this from Unicef.

Your healthcare professional will listen to you and ask you what your feeding experience has been so far. If they feel that the frenulum is causing difficulty with feeding due to tongue-tie or you and/or your baby are experiencing symptoms, then a referral can be considered for further assessment and possible division of the frenulum.

A referral would not be considered appropriate for babies who are bottle feeding where there are no concerns with growth.

A posterior frenulum, which is at the back of the tongue, can be less easy to see and in some cases may only be felt if the professional is trained on how to assess a frenulum. If you and/or your baby are experiencing feeding difficulties an assessment of your baby’s tongue function and a feeding assessment will determine whether a division could help.

How is the procedure performed?

Tongue-tie division is a simple procedure which is carried out at the hospital on babies aged between 24 hours and 8 weeks. The person performing the division will initially discuss with you the difficulties you have been experiencing feeding your baby. They will give you more information regarding the division including potential side effects and ask you to sign a consent form. The division can only be completed if the baby is free from oral thrush and has received Vitamin K at birth. A second dose of Vitamin K is required before division if the first was given orally.

The person performing the division will swaddle your baby in a towel. The frenulum will be divided with blunt ended sterile scissors and your baby will be returned to you for a cuddle and feeding. The procedure is often very quick. They are not given an anaesthetic so can feed as soon as this is done which is a great way of stopping any bleeding and provides your baby with comfort.

Does it hurt?

Babies who do cry don’t do this for more than a few minutes and as soon as the procedure is finished the baby is brought back to you for comfort and feeding. The baby does not require any anaesthetic or medication because the frenulum is poorly supplied with nerves and blood vessels.

Does it bleed or need stitches?

Usually there is a drop of blood, which is wiped away with a gauze swab. There is a small wound which heals within approximately a week and doesn't need stitches. It can look like a whitish diamond shape under the tongue and should not interfere with feeding and will heal by itself. Please observe careful hand hygiene. If you feel healing is slow then please see your GP to rule out a bacterial or fungal infection which can prevent healing.

Benefits and potential problems

A review of research examining the benefits and potential problems associated with tongue-tie division has been undertaken by the National Institute of Health and Care Excellence, more commonly known as 'NICE'. A reduction in nipple pain and an improved ability to attach to the breast has been consistently identified and while potential problems such as bleeding, infection, ulcers, pain and damage to the tongue and surrounding area are possible, they are very rare. Very occasionally a few tongue-ties may recur as the frenulum re-fuses.

Consequently the use of tongue-tie division is supported by NICE as it is considered a safe and simple intervention which demonstrates significant improvements in feeding, particularly breastfeeding.

My baby is not breastfed or I am feeding breastfeeding comfortably, does the baby’s frenulum still need to be divided?

If you and the baby are not experiencing any feeding difficulties the frenulum does not need to be divided. Having a frenulum does not necessarily mean the baby will experience any other feeding difficulties in the future. However, should these develop before 8 weeks of age then your midwife or health visitor may refer you for a frenulum assessment. If your baby is over eight weeks old then your health visitor or GP may refer you to a specialist centre.

Was my baby’s tongue-tie missed?

It can be incredibly frustrating feeling a tongue-tie was missed if treatment is required at a later stage. It is often the case that babies cope well with having a mildly restricted tongue in the early days and weeks. This is because your breastmilk supply would have been at its highest, meaning that babies do not need to ‘work as hard’ to get milk to become full and therefore does not cause any concerns with breastfeeding. Once your breastmilk settles, usually at around four to six weeks of age, is when the tongue-tie can become more apparent. You and your baby may start to display symptoms or the symptoms may have become worse. At this point you and your healthcare professional may wish to refer your baby to be assessed for division.

What happens if it re-fuses or re-forms?

Occasionally a baby’s frenulum needs dividing a second time as the frenulum has re-fused. Your healthcare professional will assess your baby and will decide if a second division is required. They may decide to refer you to a specialist centre to get a paediatric surgical opinion.

What if the tongue-tie division doesn't resolve the issues?

Usually you will notice improvements with your baby’s attachment to the breast immediately. However that might not always be the case. In some situations it can take a week or two for your baby to learn its new tongue abilities. In this time your baby will likely work on your breastmilk supply and you may notice that your baby feeds more often whilst it does this. Occasionally a baby’s frenulum needs dividing a second time as the initial division was not quite extensive enough. Your healthcare professional will assess your baby and will decide if a second division is required. They may decide to refer you to a specialist centre to get a paediatric surgical opinion.

Do I have to wait to be seen on the NHS for tongue-tie assessment or division?

No, you don’t need to wait for NHS treatment. There are many private lactation consultants and private tongue-tie practitioners who can provide you with support. This can be as a complement to an NHS referral for tongue-tie division or you may wish to seek out your support entirely from private practice.

Find a local lactation consultant.

Find a local private tongue-tie practitioner.

How do I return to direct breastfeeding or reduce top-ups?

You should have the support of your healthcare professional to establish, or re-establish, breastfeeding directly from your breast. The most important thing to do is offer your breasts freely to your baby and respond to their feeding cues as often as they need. Building and maintaining your breastmilk supply is very important so if you still need to give top-ups of expressed breastmilk or formula, then always offer your baby your breast first. Having as much skin-to-skin contact time with your baby as possible will also help increase your breastmilk supply. Keep watching for the signs of breastfeeding well. Over time you may find you can gradually reduce the top-ups you give and this should be supported by your healthcare professional who will monitor your baby’s weight.