Are you Tongue-tie "Release-Ready"?

When a tongue-tie release, or frenulotomy, is being considered, it is understandable that families may focus on one question:

“Should we have the tongue-tie released?”

But there is another question that deserves equal attention:

“Are the baby and family ready for the procedure and the rehabilitation that follows?”

Being release ready is not simply about identifying a lingual frenulum, deciding that it appears restrictive and booking an appointment.

It is about understanding the whole clinical picture, identifying what may be contributing to the feeding difficulty, addressing modifiable factors where possible and making sure that the baby and family are as well prepared as reasonably possible for whatever decision is made.

Sometimes that decision will be to proceed with a frenulotomy.

Sometimes it will be to continue with conservative management.

Sometimes another cause needs to be investigated first.

And sometimes the right decision is to wait.

Importantly, waiting is not the same as doing nothing.

Delaying a release can be active clinical preparation.

What does “release ready” actually mean?

There is no single checklist or clinical score that can determine whether an infant is ready for tongue-tie release.

Readiness needs to be individualised.

The infant's gestational age, chronological age, corrected age where relevant, birth history, current health, weight and weight trajectory, feeding method, oral function, regulation and muscle tone may all be relevant.

The family's circumstances, feeding goals, understanding of the procedure, support network and ability to manage the feeding and rehabilitation plan afterwards are also important.

The Academy of Breastfeeding Medicine describes ankyloglossia as a functional diagnosis. The presence of a sublingual frenulum alone is not an indication for surgical intervention; restricted tongue function needs to be considered alongside the clinical feeding picture and the response to conservative management (LeFort et al., 2021).

This means that release readiness is less about reaching a particular point in time and more about asking:

Have we understood enough about this baby and family to make a sound clinical decision?

Start with the whole feeding picture

Feeding difficulties are rarely explained by one factor alone.

A baby may have difficulty attaching, staying attached, maintaining a seal, generating suction, coordinating sucking and swallowing or managing milk flow.

A breastfeeding mother may experience nipple pain, breast fullness, reduced milk supply or difficulty maintaining milk production.

A bottle-fed baby may have difficulty maintaining a seal around the teat, coordinating suck–swallow–breath, managing the flow rate or regulating during a feed.

A baby may receive expressed breast milk, formula or a combination of feeding methods, and each feeding method needs to be assessed on its own terms.

None of these difficulties automatically means that the frenulum is the cause.

Positioning and attachment, milk flow, supply, feeding frequency, bottle-teat flow, prematurity, birth experiences, infant regulation, oral-motor development and medical conditions can all influence feeding.

NICE recommends that feeding assessment considers factors such as feeding frequency and duration, swallowing, whether the baby is content after feeds, weight change, wet and dirty nappies and the condition of the mother's breasts and nipples. Where concerns continue, additional feed observation and skilled feeding support may be appropriate (NICE, 2021).

For formula-fed and bottle-fed babies, NICE also recommends responsive bottle-feeding support, observation of feeds, consideration of positioning and pacing, recognition of feeding cues and appropriate support for families (NICE, 2021).

A useful assessment therefore asks not simply:

“Does this baby have a tongue-tie?”

but:

“What is happening during feeding, why might it be happening, and what can be improved before we consider changing the structure?”

The family's feeding goals matter

There is no single correct way for a baby to be fed.

Some babies breastfeed directly. Others receive expressed breast milk, formula or a combination of feeding methods. Some families may be transitioning between feeding methods because of previous difficulties.

The aim of assessment should not be to direct a family towards a particular feeding method.

It should be to understand what the family wants to achieve and identify what support may help them achieve it safely and sustainably.

For a breastfeeding family, this may include assessing milk supply, breast drainage, nipple comfort, positioning, attachment and milk transfer.

For a bottle-feeding family, assessment may include bottle flow, teat–mouth seal, suck efficiency, pacing, coordination and regulation.

For families using combination feeding, both may need to be considered.

NICE recognises that families may breastfeed, formula feed or use a combination of feeding methods and recommends appropriate support according to the family's circumstances and choices (NICE, 2021).

A tongue-tie assessment should therefore never assume that breastfeeding is the only reason a family may be seeking help.

Maternal factors may be important

Where breastfeeding is part of the family's feeding plan, maternal physiology and wellbeing need to be considered.

This may include:

• current milk supply;

• breast drainage;

• nipple or breast pain;

• breast fullness or engorgement;

• pumping or expressing;

• supplementation;

• feeding frequency;

• maternal medications;

• relevant maternal medical conditions;

• previous feeding experience; and

• the family's feeding goals.

If milk supply is currently low, it may be important to understand why and support milk production before a procedure where possible.

A frenulotomy cannot create milk supply.

If milk transfer has been poor for some time, the mother may already have experienced reduced breast stimulation or incomplete breast drainage. Addressing these factors before a release can help ensure that there is an adequate milk supply available for the infant to access if feeding mechanics improve.

Equally, a very rapid milk flow or oversupply can contribute to feeding behaviours that may look like oral dysfunction.

The aim is not to attribute every feeding problem to the frenulum.

It is to understand the relationship between the infant, the feeding method and the person providing the milk.

Infant age, gestation and weight are important

The same feeding presentation can have very different significance depending on the individual infant.

Gestational age matters.

A premature infant may have different oral-motor skills, endurance, coordination and feeding maturity from a term infant of the same chronological age.

Chronological age matters too, as feeding patterns and compensations can change over time.

For a premature infant, corrected age may also provide useful developmental context.

Weight and weight trajectory are particularly important.

It is not enough to know a baby's current weight in isolation. A clinician may need to consider birth weight, early weight loss, whether birth weight has been regained, the infant's growth pattern and whether feeding support is having the expected effect.

A baby who is thriving and feeding comfortably presents a different clinical picture from a baby who is struggling to gain weight, becoming increasingly tired during feeds or showing signs of inadequate intake.

Weight is therefore not simply a number.

It is part of the clinical story.

Is the baby medically ready?

Before undertaking a procedure, the infant's general health needs to be considered.

This may include:

• current or recent illness;

• prematurity and neonatal history;

• current weight and growth;

• relevant medical conditions;

• medications;

• bleeding or clotting concerns;

• vitamin K status where relevant;

• congenital or craniofacial conditions;

• airway or respiratory concerns;

• neurological or developmental concerns; and

• any unexplained symptoms that require further investigation.

A baby who is unwell, whose feeding difficulty may be part of another medical problem, or whose clinical picture is not yet understood may need medical assessment before a tongue-tie pathway progresses.

This is not about creating unnecessary barriers.

It is about making sure that a potentially correctable oral restriction does not distract from another condition that needs attention.

Medication and medical conditions should not be overlooked

Medication history can be relevant for both infant and family.

The clinician should be aware of medications or supplements being taken by the infant and, where relevant, by a breastfeeding mother.

Medical conditions can also affect feeding, milk production, pain, fatigue, regulation and the family's ability to implement a feeding or rehabilitation plan.

These factors do not necessarily prevent a frenulotomy.

They simply form part of the information required to make an appropriately individualised decision.

Consider the differential diagnosis

One of the most important parts of release readiness is asking:

Could something else be causing some or all of this difficulty?

Clicking, prolonged feeds, poor attachment, maternal nipple pain, milk leakage, fatigue, unsettled behaviour and poor weight gain can occur for many different reasons.

Possible contributors may include:

• positioning and attachment difficulties;

• low or excessive milk supply;

• rapid milk flow;

• prematurity or developmental immaturity;

• high or low muscle tone;

• oral-motor or neuromuscular difficulties;

• craniofacial differences;

• nasal obstruction or airway difficulties;

• gastrointestinal problems;

• pain or illness;

• neurological or developmental conditions;

• maternal breast or nipple conditions; and

• other infant feeding difficulties.

A baby may have more than one contributing factor.

The presence of another factor does not exclude a restrictive frenulum, but neither should the presence of a frenulum become an explanation for every feeding problem.

Differential diagnosis protects families from both under-recognition and over-attribution.

Assess the tongue functionally

A frenulum can provide important anatomical information, but anatomy alone cannot tell us whether releasing it will improve feeding.

The Academy of Breastfeeding Medicine specifically states that the presence of a frenulum alone is not an indication for surgical intervention (LeFort et al., 2021).

A functional assessment may consider:

• tongue elevation;

• tongue extension;

• lateral movement;

• tongue cupping and shaping;

• suck generation;

• vacuum stability;

• oral seal;

• suck–swallow–breath coordination;

• tongue movement during feeding;

• regulation during feeding;

• body tension;

• asymmetry; and

• established compensatory feeding patterns.

The important question is not simply:

“Does this baby have a tongue-tie?”

It is:

“Is restricted tongue function contributing meaningfully to this baby's feeding difficulty, and have the modifiable contributors been addressed?”

Prepare the infant functionally

If a frenulotomy is being considered because restricted tongue movement appears to be contributing to feeding difficulty, it is worth considering the infant's function before the procedure.

Some infants may benefit from appropriate preparation to support relaxation, regulation, oral awareness and functional movement before a procedure.

This may include activities intended to support:

• comfortable positioning;

• regulation;

• reduction of unnecessary tension;

• symmetrical movement;

• oral sensory tolerance;

• tongue awareness and movement; and

• more organised feeding behaviour.

This can be thought of as prehabilitation.

However, there is currently limited evidence to establish one specific pre-frenulotomy exercise programme as necessary for every infant. Preparation should therefore be individualised rather than presented as a universal requirement.

The clinical principle is nevertheless important:

If the intended intervention is to change function, it is useful to understand and optimise function before changing the structure.

Tension and regulation matter

Some infants present with significant body tension, asymmetry or difficulty regulating during feeding.

A baby who is uncomfortable, highly tense or poorly organised may find it difficult to use oral movement efficiently, regardless of the mobility available to the tongue.

Where clinically appropriate, preparation may therefore include strategies to support comfortable positioning, regulation, reduction of unnecessary tension, symmetrical movement and oral organisation.

This is not intended to suggest that tension is caused by tongue-tie, nor that reducing tension will eliminate a functional restriction.

It is about ensuring that the tongue is not assessed in isolation from the infant who is using it.

What does the family understand about the procedure?

Readiness also includes informed decision-making.

Families should understand why a frenulotomy is being considered and what functional problem it is intended to address.

They should have the opportunity to discuss:

• the findings from the assessment;

• what conservative management has achieved;

• what other factors may be contributing;

• what the procedure can realistically be expected to change;

• the limitations of the evidence;

• possible risks;

• alternatives to intervention;

• what feeding support will be available;

• what rehabilitation may be recommended; and

• what will happen if feeding does not improve as expected.

NICE states that tongue-tie division should be performed by appropriately trained registered healthcare professionals within appropriate arrangements for consent, audit and clinical governance. NICE also recognises that the evidence for benefit is limited (NICE, 2005).

The goal is not to persuade a family to proceed.

It is to make sure they are able to make a genuinely informed decision.

A release is not the end of the feeding plan

One of the most important aspects of readiness is considering what happens after the procedure.

A frenulotomy changes the physical restriction.

It does not automatically teach an infant how to use the increased tongue mobility.

Some babies adapt quickly. Others may need time, feeding support and functional rehabilitation.

This is why a post-release plan should ideally be considered before the procedure takes place.

The plan may include:

• how feeding will be approached immediately afterwards;

• breastfeeding support where applicable;

• bottle-feeding support where applicable;

• expressing or supplementation plans where required;

• strategies to protect maternal milk supply where breastfeeding is part of the plan;

• observation of feeding effectiveness;

• monitoring infant weight;

• monitoring hydration and output;

• functional oral rehabilitation where clinically appropriate;

• support with infant regulation and tension;

• review of feeding comfort; and

• a clear plan for reassessment.

The aim is not to assume that every infant will require the same aftercare.

The aim is to ensure that there is a plan.

Rehabilitation is about using the change in function

Following a release, the infant may have greater tongue mobility.

The next question is:

Can the infant use that movement functionally?

This is where rehabilitation may form part of the care pathway.

Depending on the individual infant, this might involve continued feeding observation, oral-motor activities, functional tongue movement, regulation work or other appropriate interventions.

The precise approach should be individualised according to the infant's presentation.

There is not currently sufficient evidence to claim that one particular rehabilitation programme is required after every frenulotomy. Recommendations should therefore be based on the infant's clinical needs rather than a universal protocol.

What should not be lost, however, is the distinction between structural change and functional change.

A release changes tissue. Rehabilitation and feeding support help the infant adapt to and use that change.

Feeding after release needs to be individualised

The feeding plan after a release will depend on how the infant was feeding beforehand.

For a breastfeeding infant, the plan may include supporting effective attachment, milk transfer and breast drainage while the infant adapts.

For a bottle-fed infant, the focus may instead be on maintaining a safe and effective bottle-feeding pattern, appropriate flow, oral seal and coordination.

For an infant receiving expressed breast milk, the plan may include continued support for bottle feeding and, where appropriate, maintaining milk supply through expressing.

For combination-fed families, the plan may need to protect both milk supply and the infant's nutritional intake.

If supplementation is currently required, it should not simply be stopped because a frenulotomy has taken place.

The infant's nutritional needs remain the priority.

NICE recommends appropriate feeding support for both breastfeeding and formula feeding families, including observation of feeds and consideration of feeding technique and infant cues (NICE, 2021).

Weight should continue to be monitored

Weight monitoring is particularly important where feeding difficulties were associated with poor intake or faltering growth before the procedure.

An improvement in tongue mobility should not be assumed to equal an immediate improvement in milk transfer.

The infant may need time to adapt, and other feeding factors may still require attention.

A useful post-release review therefore considers the whole picture:

Is the baby feeding effectively?

Is milk transfer improving where relevant?

Is the baby maintaining appropriate hydration?

Is weight progressing appropriately?

Is feeding more comfortable or efficient?

Is the infant becoming more organised during feeding?

These outcomes are more meaningful than simply asking whether the tongue “looks better”.

Build the support network before you need it

Families should not be expected to navigate the post-release period alone.

Clinical support may come from the practitioner who performed the assessment or procedure, an IBCLC or other appropriately trained infant-feeding professional, midwife, health visitor, GP, paediatrician or another relevant clinician depending on the individual circumstances.

But the family's own support network matters too.

A partner, family member or trusted friend may provide practical help with meals, rest, older children, transport, expressing or simply being present.

Peer support can also be valuable.

NICE recognises the value of appropriate feeding support and peer support and recommends that families are offered information and practical support appropriate to their feeding method and circumstances (NICE, 2021).

A good care plan therefore considers:

Who will support the baby?

Who will support the family?

Who can help practically?

Who can provide feeding support?

Who should the family contact if they are concerned?

Knowing these answers before the procedure can make the post-release period much less overwhelming.

When delaying is the right decision

There is sometimes an understandable fear that delaying a frenulotomy means losing an opportunity.

But a delay can provide valuable time to prepare.

During that period, it may be possible to:

• optimise milk supply where relevant;

• improve positioning and attachment where relevant;

• address nipple or breast pain where relevant;

• establish a sustainable feeding plan;

• optimise bottle feeding where relevant;

• monitor weight;

• investigate possible medical conditions;

• review medications;

• consider differential diagnoses;

• support infant regulation;

• reduce unnecessary tension;

• develop oral and feeding skills;

• establish realistic expectations; and

• put appropriate post-release support in place.

If the decision is subsequently made to proceed, the baby and family may then be better prepared to make use of any functional change.

And sometimes that preparation demonstrates that a frenulotomy is no longer required.

That is not a failure.

It is successful clinical reasoning.

Release ready does not mean guaranteed success

Even when a baby and family have been carefully prepared, no procedure can guarantee a particular feeding outcome.

Evidence suggests that frenotomy can reduce maternal nipple pain for some breastfeeding dyads, but important questions remain regarding optimal timing and longer-term outcomes (O'Shea et al., 2017).

The FROSTTIE randomised controlled trial did not provide sufficient evidence to determine whether frenotomy in addition to breastfeeding support improves breastfeeding rates at three months, although the study was substantially under-recruited and therefore had limited statistical power (Knight et al., 2023).

A frenulotomy should therefore not be presented as a guaranteed solution for breastfeeding, bottle feeding, speech, sleep, posture, dentition or future development.

The expected outcome should relate to the specific functional problem for which the procedure is being considered.

A release may be one part of a wider plan.

It does not replace feeding support, medical care, rehabilitation or appropriate investigation of other contributing factors.

The goal is not simply to release the frenulum

A successful tongue-tie pathway is not defined by whether a procedure takes place.

It is defined by whether the baby and family have been assessed as individuals, whether contributing factors have been explored, whether appropriate preparation has taken place and whether the next step makes clinical sense.

Sometimes the best next step is a release.

Sometimes it is feeding support.

Sometimes it is investigation.

Sometimes it is rehabilitation.

And sometimes it is simply more time.

That time is not wasted.

Delaying is not doing nothing.

It may be the opportunity to optimise feeding, support infant health and development, investigate differential diagnoses, monitor weight, review medications, reduce unnecessary tension, prepare oral function and establish a realistic plan for what happens after a release.

If a frenulotomy is ultimately undertaken, preparation should not stop at the procedure.

The infant may need support to use the new range of movement functionally. The family may need continued feeding support. Weight and feeding effectiveness may need monitoring. And the family should know where to turn for both clinical and practical support.

The procedure changes structure. The care around it supports function.

The aim is therefore not simply to make a baby “ready for a tongue-tie release”.

It is to make the baby and family as ready as reasonably possible for the whole journey before, during and after it.

Prepared, supported and appropriately assessed — rather than rushed.

References

Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. doi: 10.1089/bfm.2021.29179.ylf.

Knight, M., Ramakrishnan, R., Ratushnyak, S., Rivero-Arias, O., Bell, J., Bowler, U., Buchanan, P., Carter, C., Cole, C., Hewer, O., Hurd, M., King, A., Juszczak, E., Linsell, L., Long, A.-M., Mottram, L., Murray, D., Oddie, S., Quigley, M., Stalker, V., Stanbury, K., Welsh, R. and Hardy, P. for the FROSTTIE Trial Collaborative Group (2023) ‘Frenotomy with breastfeeding support versus breastfeeding support alone for infants with tongue-tie and breastfeeding difficulties: the FROSTTIE RCT’, Health Technology Assessment, 27(11), pp. 1–73. doi: 10.3310/WBBW2302.

National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. HealthTech guidance HTG95. London: NICE. Available at: https://www.nice.org.uk/guidance/HTG95 (Accessed: 29 August 2026).

National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. London: NICE. Available at: https://www.nice.org.uk/guidance/NG194 (Accessed: 29 August 2026).

National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. London: NICE. Available at: https://www.nice.org.uk/guidance/NG75 (Accessed: 29 August 2026).

O'Shea, J.E., Foster, J.P., O'Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. doi: 10.1002/14651858.CD011065.pub2.