Breastfeeding Problems Caused by Tongue Tie?

A baby may appear to latch well and still leave their parent with grazed nipples, a breast that never feels comfortably softened, or a sense that every feed is hard work. Breastfeeding problems caused by tongue tie are often discussed in simple terms, but feeding is rarely simple. A restrictive lingual frenulum may contribute to difficulty for some breastfeeding dyads, yet its appearance alone cannot explain the whole feeding experience.

A careful, compassionate assessment considers the baby, the parent, the breast, milk supply and the feeding relationship together. Anatomy provides information. Function provides context.

What is tongue tie?

Tongue tie, clinically termed ankyloglossia, describes a lingual frenulum that restricts the tongue’s movement or function. The frenulum is a normal fold of tissue beneath the tongue, and there is considerable normal variation in how it looks. A visible frenulum is therefore not, by itself, a diagnosis of a feeding problem or a reason for treatment.

For breastfeeding, the relevant question is whether tongue function may be affecting the baby’s ability to latch, stay attached, transfer milk and feed comfortably. This needs to be considered alongside a full feeding history and direct observation of a feed where possible. The Academy of Breastfeeding Medicine and the American Academy of Pediatrics both advise that tongue tie should be assessed in the context of breastfeeding function, rather than appearance alone (LeFort et al., 2021; Thomas and Bunik, 2024).

Breastfeeding problems caused by tongue tie: what may be seen

When tongue restriction is contributing to feeding difficulty, the effects can be felt by both parent and baby. Some babies may struggle to maintain a deep, stable latch. They may repeatedly slip towards the nipple, make clicking sounds, dribble milk or take a long time to feed without seeming settled afterwards. These observations are not specific to tongue tie, but they can guide further assessment.

For the breastfeeding parent, persistent nipple pain, compression or misshaping of the nipple after feeds, recurrent damage, or concerns about milk removal can be particularly distressing. Frequent feeding is normal for young babies, especially in the early weeks, but feeding that remains painful or feels unsustainable deserves skilled support.

Milk transfer is important, but it should not be guessed from behaviour alone. A baby who feeds frequently may be growing well and regulating supply normally. Equally, a quiet or sleepy baby may not always be transferring milk effectively. Feeding history, weight pattern, nappy output, maternal comfort and observation of feeding all provide useful pieces of the picture.

Research suggests that frenotomy can reduce nipple pain in the short term for some breastfeeding dyads where tongue tie and feeding difficulty have been identified. However, the certainty of evidence is limited by small studies, inconsistent definitions and short follow-up periods. Evidence for longer-term breastfeeding outcomes remains less clear (O'Shea et al., 2017; Francis et al., 2015). This is why it is not appropriate to promise that a release will resolve every feeding concern.

Symptoms can have more than one cause

Many of the difficulties commonly linked with tongue tie also occur for other reasons. Positioning and attachment may need adjustment. A very full breast, engorgement, nipple shape, fast or slow milk flow, pain, previous breast surgery, delayed lactogenesis, prematurity, jaundice, illness or a baby’s developmental maturity can all affect feeding.

Babies may also find feeding difficult because of nasal congestion, reflux-like symptoms, neurological or muscular differences, birth-related tension, or fatigue. These possibilities do not invalidate a parent’s concerns. They are reasons to widen the clinical lens, rather than assuming that one visible feature is the answer.

Why a functional feeding assessment matters

A feeding assessment should make space for the family’s experience. Parents are the experts in what feeding feels like at 2 am, how long feeds are taking, and whether pain or worry is affecting daily life. Listening carefully is not an optional extra to clinical assessment - it is central to it.

For clinicians, a function-focused assessment may include a detailed history of pregnancy, birth and early feeding; the infant’s health and growth; maternal breast and nipple comfort; observation of feeding; and consideration of the baby’s oral movement within the wider clinical picture. Assessment tools can support structured observation, but no tool should replace clinical reasoning or be used as the sole basis for recommending treatment (LeFort et al., 2021).

It is also helpful to establish the family’s goals. Some parents want to continue exclusive breastfeeding, while others are combination feeding, expressing milk, or considering a change in feeding plan. Each route deserves informed, non-judgemental care. The purpose of support is not to impose a single outcome, but to help families make decisions that are safe, realistic and right for them.

Support can begin before any decision about release

Conservative feeding support is often valuable, whether or not tongue tie is present. Small adjustments to positioning, attachment and breast support can improve comfort and milk transfer for some dyads. Protecting milk supply may also be a priority where milk removal is reduced, particularly while assessment and follow-up are taking place.

This support should be individualised. Advice that helps one family may not suit another, and repeated generic suggestions can feel discouraging when feeds remain difficult. A skilled practitioner can observe what is happening in real time, explain the possible factors clearly and review progress rather than leaving families to manage alone.

If an infant is not gaining weight as expected, has fewer wet nappies than anticipated, is unusually sleepy for feeds, or a parent has severe breast pain, fever or worsening breast symptoms, timely assessment from an appropriate health professional is important. These concerns need attention regardless of whether tongue tie is suspected.

When might a surgical release be considered?

Surgical release of a restrictive lingual frenulum may be considered when there is a clear functional restriction alongside significant breastfeeding difficulty that has not improved with appropriate skilled support. The decision should be collaborative and informed by the potential benefits, limitations and risks for that individual baby and family.

A release is not required for every tongue tie. Some babies with a restrictive-looking frenulum feed effectively and comfortably, and may need no intervention. Others benefit from feeding support without surgery. Where a release is chosen, families should receive clear information about what to expect, appropriate aftercare and a plan for feeding follow-up. Ongoing support matters because a procedure does not automatically address established pain, feeding patterns, supply concerns or other contributors to difficulty.

The National Institute for Health and Care Excellence considers the evidence on safety acceptable when the procedure is undertaken by trained practitioners with appropriate governance, while recognising that evidence on efficacy is limited (NICE, 2005). More high-quality research with consistent definitions and longer follow-up would help families and professionals make decisions with greater certainty.

Questions families can take to an appointment

It can be useful to ask what has been observed during a feed, whether milk transfer and growth are reassuring, and what other factors could be contributing. Families may also ask what non-surgical support is available, what improvement is realistically possible, and how feeding will be reviewed afterwards.

For professionals, the same questions encourage thoughtful practice: Is the restriction functionally relevant? Have other explanations been considered? Is the proposed plan aligned with the family’s priorities? This approach avoids both dismissing concerns and over-attributing complex feeding challenges to tongue tie.

Persistent feeding pain or worry can make the early weeks feel lonely, even when others say that feeding should be natural. You deserve to be heard. A careful assessment and continuity of support can create space for clearer decisions, gentler feeds and a feeding plan that respects both your baby’s needs and your own.

References

Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466.

LeFort, Y., Evans, A., Livingstone, V., Douglas, P., Dahlquist, N., Donnelly, B. et al. (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281.

National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 149. London: NICE.

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.

Thomas, J. and Bunik, M. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 153(1), e2024067605.