Tongue-tie or Lip-tie restrictions

A visible fold of tissue beneath a baby’s tongue or upper lip can prompt understandable questions, particularly when feeding is painful, tiring or worrying. Yet a tongue-tie and lip-tie restrictions are not a simple comparison of two pieces of anatomy. What matters clinically is whether an oral structure appears to be affecting function within the wider feeding relationship.

For families, this distinction can reduce pressure to find one explanation for every feeding difficulty. For healthcare professionals, it supports careful differential diagnosis and avoids treating appearance as a diagnosis. Anatomy provides information. Function provides context.

What is a tongue-tie?

Tongue-tie, also known as ankyloglossia, describes a lingual frenulum that restricts the movement of the tongue. The lingual frenulum is the fold of tissue connecting the underside of the tongue with the floor of the mouth. It is a normal anatomical structure, but its appearance, attachment and effect on tongue movement vary considerably between infants.

Tongue-ties do not all look the same. Some frenula are thin and barely visible, while others are thicker, more prominent or attach in a different position. However, the appearance of the frenulum is not the diagnosis. The important question is what the tongue can actually do and whether any restriction is associated with meaningful functional difficulties.

This is particularly important when considering infant feeding. A visible or prominent frenulum does not automatically mean that a baby has a clinically significant tongue-tie. Equally, the appearance of the frenulum alone cannot tell us how well the tongue is functioning.

When assessing a baby with feeding difficulties, the whole feeding picture needs to be considered. In breastfeeding, this may include ongoing nipple pain or damage, difficulty maintaining attachment, clicking, milk leakage, prolonged or unsettled feeds, or concerns about milk transfer and weight gain. These signs are not specific to tongue-tie and can have many other causes, including positioning and attachment, breast fullness, milk supply, prematurity, jaundice, illness, oral or neurological differences and the normal learning process of early feeding.

For bottle-fed babies, difficulties such as losing the seal, dribbling milk or taking a long time to feed can also have many explanations. Teat flow, feeding pace, bottle angle, positioning and other medical or developmental factors should be considered rather than assuming that a frenulum is responsible.

The American Academy of Pediatrics (AAP), in its 2024 clinical report, recommends that symptomatic ankyloglossia should be considered in the context of a restrictive lingual frenulum associated with significant feeding difficulties that have not improved with appropriate support. Not every baby with a tongue-tie requires treatment, and assessment of feeding and tongue function should come before considering frenotomy. (AAP, 2024)

Most importantly, assessment should focus on what is happening now. A frenulum should not be released simply because someone believes it might cause a problem with speech, teeth, sleep or other functions years into the future. The decision should be based on demonstrable restriction and symptoms that are present and clinically relevant at the time of assessment.

What is a lip-tie?

A “lip-tie” usually refers to the maxillary labial frenulum — the band of tissue connecting the inside of the upper lip with the gum. This is a normal oral structure that is present in infants and changes naturally as a child grows.

There is considerable normal variation in the appearance and attachment of the upper labial frenulum. Some babies have a frenulum that looks prominent, thick or attaches relatively low on the gum. This does not, by itself, mean that the upper lip is functionally restricted or that treatment is required.

Importantly, the appearance of the upper labial frenulum should not be used to diagnose an infant feeding problem. The American Academy of Pediatrics (AAP) states in its 2024 clinical report that labial and buccal frenula are normal oral structures and that surgical intervention on these tissues to improve breastfeeding is not supported by evidence. (AAP, 2024)

In the UK, upper lip frenula are not routinely divided in infancy, and there is no good evidence that doing so improves breastfeeding. The biggest clinical considerations relating to the upper labial frenulum are generally associated with dental development or aesthetics later in childhood or adulthood, rather than infant feeding.

This is an important distinction. A prominent upper lip frenulum in a newborn does not mean that it needs to be treated in anticipation of a possible future dental problem. If there is a genuine dental concern as the child grows, it can be assessed in the context of the developing dentition. Where assessment or treatment is being considered, particularly once the adult teeth have erupted, an appropriately trained paediatric oral surgeon or specialist dentist is the appropriate professional to assess the anatomy and its clinical significance.

What about lower lip-ties and buccal-ties?

Lower lip frenula and buccal frenula — the tissues connecting the lips or cheeks to the gums — are also normal anatomical structures. There is no established evidence that releasing these tissues in infancy improves breastfeeding or other infant feeding outcomes.

These structures should therefore not be treated as additional “ties” that need to be identified and divided simply because they are visible. Their presence or appearance does not demonstrate a feeding problem, and routine division of multiple oral frenula in infants is not supported by good evidence.

Tongue-tie vs lip-tie: what is the difference?

Although the terms “tongue-tie” and “lip-tie” are often discussed together, they describe different anatomical structures and should not be treated as though they have the same evidence behind them.

A tongue-tie involves the lingual frenulum beneath the tongue. In some infants, a restrictive lingual frenulum can contribute to impaired tongue movement and, alongside other factors, may be associated with breastfeeding difficulties. The evidence for treatment remains limited, but there is evidence that frenotomy can reduce maternal nipple pain in carefully selected cases where significant functional problems persist despite appropriate feeding support. The AAP's 2024 clinical report therefore emphasises careful assessment and conservative management before considering surgical intervention. (AAP, 2024)

A lip-tie, by contrast, refers to the maxillary labial frenulum beneath the upper lip. This is a normal structure, and there is currently no good evidence that its appearance causes infant feeding difficulties or that releasing it improves breastfeeding. The same applies to lower lip and buccal frenula: their appearance does not establish a functional feeding problem and routine release in infancy is not evidence-based.

The key distinction is therefore not simply tongue versus lip, but function versus appearance.

Frenula naturally look different from one infant to another. Some are prominent, some are subtle, and their attachments vary. What matters clinically is not whether a frenulum looks unusual, but whether there is a demonstrable functional restriction and whether that restriction is reflected in the infant's current symptoms and feeding function.

Assessment should therefore ask:

• What does the tissue look like?

• What can the tongue or lip actually do?

• Is there a demonstrable functional problem?

• Are there feeding symptoms that are present now?

• What other explanations could account for those symptoms?

• Has appropriate non-surgical feeding support been provided where relevant?

• Is there good evidence that releasing the tissue is likely to provide a meaningful benefit?

A frenulum should not be divided simply because it looks prominent, because it has been given a particular label, or because of a theoretical concern about what it might cause years later. The child in front of us, their current function and their current symptoms should guide assessment and treatment.

Why appearance alone is not enough

Photographs of infant mouths can be compelling, especially when a parent is searching for an answer after difficult feeds. However, an image cannot show how a baby coordinates sucking, swallowing and breathing, how comfortable the feeding parent is, or whether milk transfer is effective.

A function-focused assessment considers the baby as a whole. It includes a careful feeding history, growth and wellbeing, the parent’s goals, and direct observation of a feed where possible. In breastfeeding, this may involve considering attachment, comfort, audible swallowing and breast drainage. In bottle feeding, it may involve observing coordination, seal, pacing, stress cues and the baby’s comfort.

This approach also makes room for conservative support. Sometimes a change in positioning, attachment, feeding pace, pump flange fit, milk supply support or a period of follow-up makes a meaningful difference. Sometimes concerns persist despite skilled input and a restrictive lingual frenulum appears to be contributing. Neither pathway represents failure.

Validated assessment tools can support structured observation, but they should not be used as a stand-alone decision-maker. The Academy of Breastfeeding Medicine emphasises that no published tool should be the sole basis for deciding whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). Clinical reasoning remains essential.

What does the evidence say about frenulotomy?

For infants with tongue-tie and breastfeeding difficulties, randomised trials reviewed by O’Shea and colleagues found that frenulotomy may reduce maternal nipple pain in the short term. However, evidence for longer-term breastfeeding outcomes remains less certain, partly because studies are small and use different definitions, measures and follow-up periods (O’Shea et al., 2017).

This is an important balance to communicate. Some families report a noticeable change after frenulotomy, while others need ongoing feeding support, see a more gradual change, or find that the procedure does not address all their difficulties. A frenulotomy is therefore a considered option within a broader plan, rather than a guaranteed solution.

Where a procedure is being considered, families should receive clear information about the reason for the recommendation, potential benefits and limitations, possible risks, alternatives and aftercare. Their informed preferences matter. Some families choose to continue with conservative management or to seek review later; others feel that a procedure is the right next step after assessment and support. Both deserve respectful, non-judgemental care.

There is insufficient evidence to recommend surgical treatment of an upper lip frenulum for breastfeeding concerns. It is also worth being cautious about claims that oral ties reliably explain later speech, sleep, dental, posture or developmental concerns. These issues require their own appropriate assessment and should not be predicted from infant oral anatomy alone.

When to seek further support

A further assessment may be helpful when feeding remains painful, stressful or inefficient despite appropriate support, when there are concerns about growth or hydration, or when parents feel something has not been fully understood. Urgent medical review is appropriate if a baby is very sleepy and difficult to rouse for feeds, has markedly fewer wet nappies, shows signs of dehydration, is unwell, or there are concerns about weight gain.

For professionals, it can be helpful to document both positive and negative findings. A baby may have a visible frenulum but good tongue function, comfortable feeding and appropriate growth. That information is as clinically meaningful as identifying restriction. It protects families from unnecessary intervention and keeps the focus on their actual needs.

D-Restricted Ltd® approaches infant feeding and tongue-tie care through this function-focused lens: listening carefully to each family, assessing feeding as well as anatomy, and supporting collaborative decisions about next steps.

References

Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281.

American Academy of Pediatrics (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 154(2), e2024067605.

Messner, A.H., Walsh, J., Rosenfeld, R.M., Schwartz, S.R., Ishman, S.L., Baldassari, C., Brietzke, S.E., Darrow, D.H., Goldstein, N.A., Levi, J., Meyer, A.K., Parikh, S.R., Simons, J.P., Yellon, R.F. and Mitchell, R.B. (2020) ‘Clinical consensus statement: Ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611.

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.

When feeding feels difficult, the most helpful next step is rarely a judgement based on one visible feature. It is skilled, compassionate support that considers the baby, the feeding parent and the feeding relationship together.