Breast milk production is a physiological process, and it can look very different from one breastfeeding or expressing journey to another. Some caregivers want to increase their milk production because their baby is feeding frequently, while others may be expressing because their baby cannot currently breastfeed directly, they are separated from their baby, their baby is unwell or they simply want to have more milk available. There is no single reason for wanting to increase milk production, and there is no single approach that works for everyone. Understanding how milk production works can make it easier to work out what might be happening when milk production feels lower than expected. It can also help to separate the physiology of milk production from the pressure to produce a particular volume. Breast milk production is a physiological process Milk production begins during pregnancy. During the first stage of lactation, known as lactogenesis I, the breasts develop the capacity to produce colostrum. After the placenta is delivered, hormonal changes allow lactogenesis II to begin, often described as milk "coming in". Prolactin has an important role in milk synthesis, while oxytocin helps the milk-ejection reflex that moves milk towards the nipple (Neville and Morton, 2001; Wambach and Riordan, 2021). The timing and experience of this transition can vary. Prematurity, significant blood loss, retained placental tissue and some maternal health conditions can affect the establishment of lactation. Birth by caesarean section or other interventions do not automatically prevent breastfeeding or mean that milk production will be poor. The wider picture matters, including hormonal health, breast development, previous breast surgery, feeding or expressing patterns and how effectively milk is being removed. This is why milk production is not simply a matter of "trying harder". It is a physiological process involving hormones, breast tissue, milk removal and the individual circumstances of the breastfeeding or expressing caregiver. Milk production and milk removal: use it or lose it Once established, milk production is strongly influenced by milk removal. When milk is removed from the breast, the breast receives a signal that milk is being used and that continued production is needed. When milk remains in the breast for longer periods, local mechanisms can slow the rate of milk synthesis (Wilde et al., 1995; Knight, Peaker and Wilde, 1998). This is where the familiar "use it or lose it" idea comes from. It does not mean that every feed needs to be followed by another feed or that a caregiver should spend their entire day expressing. It means that regular, effective milk removal helps maintain the physiological signal for ongoing milk production. Milk removal can happen through breastfeeding, expressing or a combination of both. If a baby is unable to remove milk effectively, or if a caregiver is separated from their baby, expressing can provide an important alternative way of maintaining that stimulation. Softer breasts after 4–6 weeks are a good thing One of the most common worries about milk production is the change that can happen during the first few weeks. Early on, breasts can feel very full, heavy or leaky, particularly as milk production is becoming established. Around four to six weeks, many caregivers notice that their breasts feel softer and that they no longer leak as much. That change does not necessarily mean that milk production has decreased. As lactation becomes more established, regulation becomes increasingly local to the breast. Milk that remains in the breast can provide signals that slow further synthesis, whereas effective milk removal signals that more milk is required (Wilde et al., 1995; Knight, Peaker and Wilde, 1998). In other words, softer breasts can be a sign that milk production has become more closely matched to what is being removed. Soft boobs can be good boobs. Can expressing too much in the early weeks cause oversupply? More milk is not always better. In the early weeks, repeatedly adding extra expressing on top of what the baby is already removing can increase milk production beyond what the feeding dyad needs. For some caregivers, this can contribute to hyperlactation, which may bring its own difficulties, including breast fullness, leaking, forceful milk ejection and recurrent inflammation (Johnson et al., 2020). This does not mean that early expressing is harmful or unnecessary. Expressing may be essential when a baby is premature, unwell, unable to breastfeed effectively or separated from their caregiver. It may also be part of an individual feeding plan for many other reasons. The important point is that expressing should have a purpose. Increasing milk production should not automatically mean adding more and more expressing sessions without considering what the breastfeeding or expressing caregiver and baby actually need. A forceful let-down on its own does not necessarily mean hyperlactation, either. Milk ejection can be powerful in people with a range of milk production levels. Ineffective milk removal needs attention If milk is not being removed effectively, simply increasing pump suction or expressing more often is not always the answer. When milk removal is poor, breasts can become increasingly full and uncomfortable, and persistent inflammation can develop. This can contribute to the mastitis spectrum, including inflammatory mastitis and, in some circumstances, breast abscess (Mitchell et al., 2022). Pain, swelling, redness, heat, a persistent tender area, fever or flu-like symptoms should not simply be managed by trying to remove more and more milk. Significant or worsening symptoms need appropriate clinical assessment, particularly if they are not improving. The same principle applies to breastfeeding. If a baby is struggling to remove milk effectively, it is worth looking at why rather than assuming that the solution is simply more frequent feeding. How a baby removes milk from the breast Effective breastfeeding is not simply about a baby attaching to the nipple. A baby needs to take a substantial amount of breast tissue into their mouth, with the nipple drawn towards the junction of the hard and soft palate. This allows the tongue and jaw to work together to create the movements and pressure changes needed for milk removal. "Nipple feeding" can therefore be quite different from effective breastfeeding. If a baby attaches primarily to the nipple rather than taking sufficient breast tissue into the mouth, milk removal may be less effective and the nipple can become compressed or distorted. This can contribute to soreness, pain and nipple trauma, including broken skin. A comfortable, deep attachment is therefore about much more than preventing sore nipples. It is part of the mechanics of effective milk removal. Breastfeeding involves suction and vacuum Breastfeeding involves coordinated tongue, jaw and oral movements, together with changes in intraoral pressure. Research using ultrasound and vacuum measurements has demonstrated that babies use complex tongue movements and vacuum during breastfeeding to help remove milk from the breast (Geddes et al., 2008; Geddes et al., 2012; Geddes et al., 2016). This is one reason why a baby who appears to be "sucking" is not necessarily removing milk effectively. A baby can make sucking movements without achieving the coordinated attachment, tongue movement and pressure changes needed for efficient milk transfer. The quality of milk removal matters more than simply counting how often a baby is at the breast. Breastfeeding and swallowing Swallowing is also a coordinated physiological process. It is commonly described in four broad phases: oral preparatory, oral, pharyngeal and oesophageal. These phases involve different structures and functions as milk moves from the mouth through the pharynx and into the oesophagus. The negative pressure or vacuum generated during sucking is part of the milk-removal process rather than one of the four swallowing phases. Sucking, milk removal and swallowing work together, but they are not the same thing. A baby may therefore need assessment of the whole feeding process rather than simply being described as a "good" or "poor" sucker. A small pumping volume does not necessarily mean low milk production The amount collected in a pump bottle is only one piece of information. It is not a direct measurement of how much milk a breast is capable of producing. Pumping is a skill, and milk ejection can be affected by many things, including flange fit, pump type, pump settings, timing of the expressing session, when milk was last removed, breast fullness, oxytocin release, comfort, stress and familiarity with the pump. Some people also respond much more easily to a baby than to a pump. The priority is effective breast stimulation and milk removal rather than chasing a number on the collection bottle. A small expressed volume can still represent useful stimulation, and a larger expressed volume does not automatically tell us that milk production is "better". There is also variation in milk composition during milk removal. Fat concentration tends to increase as the breast becomes progressively emptied, meaning that a single expressed sample does not necessarily represent the composition of all the milk available in the breast (Daly et al., 1993). This is another reason not to judge the quality or adequacy of milk production from one bottle alone. For more information about expressing, see Expressing breast milk and Breast pump flange fitting: size, shape, comfort and milk removal. Increasing milk production through milk removal When milk production genuinely needs to increase, the physiological principle is relatively straightforward: the breasts need an effective signal that more milk is required. That signal can come from a baby feeding effectively at the breast, expressing after or between feeds, or expressing instead of a breastfeed when the baby is unable to feed directly. The appropriate approach depends on why milk production needs to increase in the first place. This is why a proper feeding assessment is usually more useful than simply being given a list of things to eat, drink or buy. The question is not only "How often is the baby feeding?" but also "How effectively is milk being removed?" When someone else feeds the baby Having another caregiver give a bottle of expressed milk can be a really important part of family life. It can allow a partner, father or another caregiver to take part in feeding, and it can be particularly helpful when a breastfeeding caregiver needs rest, has to return to work or study, or simply wants someone else to feed the baby. At the same time, if a breastfeed is regularly replaced by a bottle and the lactating caregiver wants to maintain the same level of milk production, the milk that would otherwise have been removed from the breast may need to be replaced by expressing. This is not because bottles are inherently a problem. It is because the breasts respond to milk removal. If breastfeeds are replaced without another form of milk removal, the body may receive a reduced signal that milk is needed. Over time, this can contribute to a reduction in milk production for some people. The practical workload therefore remains with the lactating caregiver if maintaining milk production is the goal. That is worth recognising when families are planning how feeding will work day to day. Protecting the caregiver's health matters too Milk production does not happen in isolation from the person producing the milk. Recovery from birth, sleep deprivation, pain, illness, work, study, caring for other children and the practical demands of expressing can all affect how sustainable a feeding plan feels. Support does not have to mean telling someone to "rest more" when they have a baby who needs feeding and a life that still has to happen around them. Practical support can make a much bigger difference. A large bottle of water within easy reach can be useful for the breastfeeding or expressing caregiver, alongside easy snacks and meals that do not require much preparation. Keeping expressing equipment, muslins, tissues, a phone and charger close by can reduce the amount of getting up and down. Someone else might take responsibility for school runs, older children, shopping, cooking, laundry, cleaning, appointments or washing expressing equipment. Sometimes the most helpful support is simply reducing the number of things that the caregiver is expected to manage while feeding their baby. Rest is part of the feeding plan There is a temptation to think that everything else should continue as normal after a baby arrives, with feeding somehow fitted around it. For some families that works. For others, particularly during the early weeks or when expressing is intensive, reducing outside demands for a while can make feeding more manageable. A "babymoon" period, accepting fewer visitors, asking other people to bring food rather than expecting the caregiver to provide hospitality, or temporarily lowering household expectations can all create more space for feeding and recovery. Skin-to-skin contact can also be a useful part of the feeding relationship and may support oxytocin release and milk ejection. Babywearing or using a sling can allow some caregivers to stay close to their baby while having their hands available for other tasks, provided the baby is positioned safely and the relevant sling safety guidance is followed. The house does not need to be perfect. Feeding the baby and looking after the person doing the feeding are more important than keeping everything else running exactly as it did before. Feeding the baby is the priority When milk production is lower than expected, it can be easy to become focused on increasing supply while forgetting that the immediate priority is making sure the baby is adequately fed. If supplementation is clinically indicated, it does not mean that breastfeeding goals have to be abandoned. Depending on the circumstances, expressed breast milk, donor human milk or infant formula may all have a role while the underlying feeding issue is being assessed and supported. A feeding plan can therefore hold two things at the same time: making sure the baby receives enough milk now, while also protecting and supporting the breastfeeding or expressing relationship for the future. Begin with a feeding and health assessment Before trying to increase milk production, it is useful to understand when the concern began and what has been happening around feeding. This might include the birth history, significant blood loss, retained placental tissue, previous breast surgery, thyroid or other health conditions where relevant, separation from the baby, the baby's gestation and age, weight trajectory, feeding history and any previous supplementation or expressing. A feeding observation can also provide valuable information. Looking at positioning, attachment, comfort, swallowing, pauses, milk flow, breast softening and the baby's behaviour during and after feeding can help identify whether milk is being removed effectively. The baby's overall health matters too. A baby who is difficult to wake for feeds, increasingly sleepy or unwell, developing worsening jaundice, having fewer wet nappies or not gaining weight as expected needs prompt assessment. The aim is not to find someone to blame. It is to understand what is happening so that the feeding plan can be adjusted appropriately. When milk transfer needs closer attention Painful feeding, clicking, slipping off the breast, repeated loss of suction, very long feeds, frequent feeding without signs of effective milk transfer or concerns about weight gain can all be reasons to look more closely at feeding. There can be many possible explanations. Positioning and attachment, milk flow, oral function, prematurity, illness, fatigue, neurological or developmental factors and other health issues can all affect feeding. A restrictive lingual frenulum can sometimes be one factor, but its presence alone does not establish that it is causing a feeding problem or that a procedure is required. Assessment needs to consider the whole feeding dyad and the baby's function rather than focusing on anatomy in isolation. Anatomy provides information. Function provides context. The tongue does not function in isolation, and conservative feeding support can be appropriate. If a frenulotomy is being considered, families should be given balanced information about the potential benefits, limitations, alternatives and risks so that they can make an informed decision based on their individual circumstances. Foods, drinks and galactagogues There is a huge amount of advice online about foods and drinks that are supposed to increase milk production. Some foods may be comforting, culturally important or simply enjoyable, but there is not good evidence that drinking excessive amounts of water, eating special biscuits or following restrictive diets reliably increases milk production. Drinking according to thirst and eating nourishing, varied meals is generally more useful than trying to follow a special milk-making diet. Galactagogues are another area where the evidence needs to be handled carefully. Some caregivers may not be able to produce or remove the volume of milk they would ideally like, despite doing everything they can within the realities of their lives. Work, study, caring responsibilities, separation from a baby, neonatal care and individual medical or physical circumstances can all affect what is practically possible. Galactagogues may help some people, but they are not a substitute for assessing why milk production is lower than desired. The evidence for different agents varies, and not everyone responds. The Academy of Breastfeeding Medicine has published guidance on galactagogues, while UK prescribing guidance provides specific information about domperidone, including the need to consider underlying causes, potential contraindications, interactions and cardiac risks before it is prescribed (Brodribb, 2018; Foong et al., 2020; Specialist Pharmacy Service, 2024). Domperidone is used off-label in the UK for low milk supply in some circumstances. It should be considered on an individual basis with an appropriate healthcare professional rather than treated as a universal solution. Donor human milk may also be an option in some circumstances, particularly within neonatal care. Availability and eligibility vary, so families should discuss this with their clinical team or local milk bank. When expressing becomes part of everyday life Expressing can work very well for some caregivers and become a comfortable, familiar part of everyday life. For others, particularly when frequent expressing is needed alongside recovering from birth, caring for other children, travelling to neonatal services, working, studying or managing their own health needs, the practical workload can become demanding. Supporting milk production therefore needs to include supporting the caregiver too. If expressing is becoming a significant part of everyday life, it can help to make the routine as comfortable and sustainable as possible. The right flange size and shape, comfortable pump settings, accessible equipment and a realistic expressing schedule can all make a difference. It is also worth thinking about what can be removed from the rest of the day. Someone else may be able to take over meals, laundry, shopping, school runs, cleaning or caring for older children. Friends and family may be able to bring food rather than expecting a visit to be hosted. Workplaces and educational settings may be able to provide suitable time and space for expressing. There is no prize for making an already demanding feeding plan harder than it needs to be. Feeding support should reduce pressure, not add to it Breastfeeding, combination feeding, exclusive expressing, donor human milk and formula feeding can all be part of a responsive feeding plan, depending on the circumstances of the baby and caregiver. Milk production is physiological. Milk removal provides the signal. Pump yield is one piece of information, not a verdict on someone's ability to produce milk. If milk production needs to increase, the most useful place to start is usually with understanding what is happening: how milk is being removed, how effectively the baby is feeding, whether expressing is comfortable and effective, and whether there are health or practical factors that need attention. Supporting feeding should make things clearer and more manageable, not leave families feeling that they need another product, another target or another thing to achieve. References Brodribb, W. (2018) ‘ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018’, Breastfeeding Medicine, 13(5), pp. 307–314. Daly, S.E.J., Di Rosso, A., Owens, R.A. and Hartmann, P.E. (1993) ‘Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk’, Experimental Physiology, 78(6), pp. 741–755. Foong, S.C., Tan, M.L., Foong, W.C., Marasco, L.A., Ho, J.J. and Ong, J.H. (2020) ‘Oral galactagogues for increasing breast milk production in mothers of non-hospitalised term infants’, Cochrane Database of Systematic Reviews, 5, CD011505. Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. Geddes, D.T., Sakalidis, V.S., Hepworth, A.R., McClellan, H.L., Kent, J.C., Lai, C.T. and Hartmann, P.E. (2012) ‘Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only’, Early Human Development, 88(6), pp. 443–449. Geddes, D.T., Kent, J.C., Mitoulas, L.R. et al. (2016) ‘Vacuum characteristics of the sucking cycle and relationships with milk removal from the breast in term infants’, Early Human Development, 96, pp. 1–6. Johnson, H.M., Eglash, A., Mitchell, K.B. et al. (2020) ‘ABM Clinical Protocol #32: Management of Hyperlactation’, Breastfeeding Medicine, 15(3), pp. 129–134. Knight, C.H., Peaker, M. and Wilde, C.J. (1998) ‘Local control of mammary development and function’, Reviews of Reproduction, 3(2), pp. 104–112. Mitchell, K.B., Johnson, H.M., Rodríguez, J.M. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’, Breastfeeding Medicine, 17(5), pp. 360–376. National Health Service (2021) Breastfeeding: the first few days. London: NHS. National Institute for Health and Care Excellence (2021) Postnatal care. NICE guideline NG194. London: NICE. Neville, M.C. and Morton, J. (2001) ‘Physiology and endocrine changes underlying human lactogenesis II’, Journal of Nutrition, 131(11), pp. 3005S–3008S. Specialist Pharmacy Service (2024) ‘Using domperidone for low milk supply’. London: NHS Specialist Pharmacy Service. Uvnäs-Moberg, K., Ekström-Bergström, A., Berg, M. et al. (2020) ‘Maternal plasma levels of oxytocin during breastfeeding—a systematic review’, PLOS ONE, 15(8), e0236792. Wambach, K. and Riordan, J. (2021) Breastfeeding and Human Lactation. 6th edn. Burlington, MA: Jones & Bartlett Learning. Wilde, C.J., Addey, C.V., Boddy, L.M. and Peaker, M. (1995) ‘Autocrine regulation of milk secretion by a protein in milk’, Biochemical Journal, 305(1), pp. 51–58. World Health Organization (2009) Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals. Geneva: WHO.

Your baby’s mouth is made up of several structures that work together for feeding, swallowing, breathing and early oral development. The lips, cheeks, gums, palate, tongue and the structures around them all have different roles, but they do not work independently. There is also considerable normal variation in infant oral anatomy. The appearance of one structure does not necessarily tell you how well it is functioning. Anatomy provides information. Function provides context. Understanding the different parts of your baby’s mouth can help you recognise what is normal, what may vary between babies, and when a feeding or oral assessment may be helpful. The lips Your baby’s lips are muscular structures that help create a seal around the breast or bottle during feeding. They also contribute to sucking, controlling milk flow and coordinating movements of the mouth. The appearance and tone of the lips can vary between babies. You may notice differences in lip colour, posture or how tightly or loosely the lips rest together. These observations need to be considered alongside feeding and oral function rather than interpreted in isolation. Some babies develop a small sucking blister or callus on the upper lip. This can occur as a result of repeated friction or pressure during feeding and is often a normal finding. There is also a fold of tissue called the upper labial frenulum, which connects the inside of the upper lip with the gum. Its appearance varies considerably between babies. A prominent upper labial frenulum is not, by itself, evidence that it is causing a feeding problem. The term “lip-tie” is sometimes used when the upper labial frenulum appears to restrict movement of the lip. However, the appearance of the frenulum alone does not establish that feeding is being affected, and the evidence regarding lip-tie as a cause of breastfeeding or bottle-feeding difficulties remains limited. For more information, see Lip-tie: what does it actually mean? The cheeks Your baby’s cheeks provide support and stability during feeding. The cheeks contain specialised fat pads, sometimes referred to as buccal fat pads, which are particularly prominent in young infants. These structures help maintain the shape and stability of the cheeks while your baby sucks. The cheeks also work with the lips, jaw and tongue to help create and maintain an effective oral seal. You may come across the term “buccal tie”, referring to a fold of tissue within the cheek. This is an emerging term and there is currently no published evidence establishing that a so-called buccal-tie causes breastfeeding or bottle-feeding problems. The Association of Tongue-tie Practitioners currently states that there is no published evidence supporting a link between lip-tie or buccal-tie and breastfeeding or bottle-feeding difficulties (ATP, 2026). The gums and developing teeth A newborn baby’s gums are covered by soft gum ridges. Beneath these are the developing primary teeth, which are also called deciduous or milk teeth. Although most babies begin to show their first teeth at around six months, there is considerable normal variation. Occasionally, a baby is born with a tooth already present. This is called a natal tooth. A tooth that erupts during the first 30 days after birth is generally described as a neonatal tooth. These teeth are usually part of the normal primary dentition. Most do not require treatment, but a dental or medical assessment may be appropriate if a tooth is very mobile, creates a risk of aspiration, or causes injury to the baby’s tongue or difficulty with feeding. The palate: the roof of the mouth and floor of the nose The palate forms the roof of your baby’s mouth. The front portion is the hard palate, which is formed from bone. The posterior portion is the soft palate, which contains muscle and can move during swallowing. The palate also forms much of the floor of the nasal cavity, so the mouth and nose are anatomically very closely related. Palate shape varies between babies. Some babies have a relatively broad and shallow palate, while others have a higher or narrower palate. A high or narrow palate does not automatically mean that a baby will have feeding or breathing difficulties. However, palate shape can influence the space available for tongue movement and the relationship between the tongue, palate, jaw and other oral structures. The tongue also changes position as babies develop, and its resting position and movement need to be considered alongside the shape of the palate and the overall pattern of oral function. For more information, see Understanding your baby’s resting tongue posture. The tongue The tongue is a highly specialised muscular structure made up of intrinsic and extrinsic muscles. These muscles allow the tongue to change shape, move forwards and backwards, elevate, depress and move from side to side. The tongue is involved in sucking, swallowing, early oral development and the management of milk within the mouth. The tongue does not function in isolation. Its movement and resting position are influenced by the palate, jaw, lips, cheeks and surrounding soft tissues. During early infancy, breathing is predominantly nasal. The tongue, jaw and surrounding oral structures have a close relationship with the upper airway, but a particular tongue resting position should not be interpreted as a simple test of whether a baby can breathe effectively through their nose. As babies grow and develop, their oral structures and motor skills also change. What is seen in a newborn should therefore be considered within the context of their age and developmental stage. The floor of the mouth and lingual frenulum The floor of the mouth contains several important structures, including muscles, glands, nerves and connective tissues. A fold of tissue called the lingual frenulum can be seen beneath the tongue. Frenula are normal anatomical structures and their appearance varies considerably between individuals. Seeing a frenulum does not mean that a baby has a tongue-tie. The term ankyloglossia, commonly called tongue-tie, is generally used when a restrictive lingual frenulum limits tongue movement and affects function. This means that the presence and appearance of a frenulum should not be assessed separately from what the tongue can actually do. For more information, see What is a tongue-tie?. Other oral frenula Frenula are folds of tissue found at several locations in the body. Within the mouth, you may see or feel frenula connecting the lips or cheeks with the surrounding oral tissues. The upper and lower labial frenula are visible between the lips and gums. Small buccal frenula may also be visible within the cheeks. The appearance of these structures varies naturally between babies. Terms such as “lip-tie” and “buccal-tie” are increasingly used to describe particular appearances or perceived restrictions. However, terminology does not establish function, and current evidence does not demonstrate that these findings cause breastfeeding or bottle-feeding difficulties. The ATP’s 2026 position statement specifically notes that there is currently no published evidence supporting a link between lip-tie or buccal-tie and breastfeeding or bottle-feeding issues (ATP, 2026). Other things you may see inside your baby’s mouth There are several normal or relatively common findings that may be seen when looking inside a newborn or young baby’s mouth. Epstein pearls Epstein pearls are small white or yellowish cysts that can appear along the gums or roof of the mouth. They are common in newborn babies and are harmless. They usually disappear without treatment. Bohn’s nodules and dental lamina cysts Other small cysts can occur around the gums or palate. Bohn’s nodules and dental lamina cysts are benign developmental findings and generally resolve naturally. The terminology used to describe these cysts can sometimes overlap, which is why they may be given different names depending on their location and appearance. Tonsillar tissue Tonsillar tissue is part of the immune system and forms part of the tissues surrounding the entrance to the throat. It is normal for these structures to be present, although their appearance changes as children grow. Cleft lip and palate A cleft lip or cleft palate occurs when structures of the lip and/or palate do not join together completely during development before birth. The presentation varies considerably. Some clefts are immediately visible, while others may involve only part of the palate. Babies with a cleft affecting the palate may require additional feeding support because the separation between the mouth and nasal cavity can affect their ability to create the pressure needed for feeding. Other unusual findings Occasionally, a baby may have a lesion, swelling or other finding that is not part of normal oral variation. Anything that is persistent, enlarging, bleeding, painful, associated with feeding difficulties, or affecting breathing or swallowing should be assessed by an appropriate healthcare professional. Facial shape, birth and developing muscle tone The appearance of a baby’s face and mouth is influenced by many factors. Before birth, a baby’s position within the uterus can influence temporary shaping of the head and face. Birth itself can also be associated with temporary moulding, swelling or asymmetry. These changes usually settle as the baby adapts after birth. Genetics, growth and development also influence facial shape. Muscle tone and soft-tissue tension can affect how the jaw, lips, cheeks and tongue are positioned and how they move. This does not mean that a particular mode of birth causes oral dysfunction. Birth history is simply one part of the wider picture that may be considered when looking at a baby’s early oral function. How does a baby swallow? Feeding requires the baby to coordinate several systems at the same time. During breastfeeding or bottle feeding, a baby needs to coordinate sucking, swallowing and breathing. Milk must be collected and managed within the mouth before the swallow is initiated, while the airway is protected as the swallow occurs. This coordination develops rapidly during infancy and is influenced by neurological maturity, oral motor skills, milk flow and the physical characteristics of the feeding method. Some signs that may indicate that a feeding and swallowing assessment would be helpful include: repeated coughing or spluttering during feeds repeated choking episodes changes in breathing during feeding colour changes during feeds persistent wet or noisy breathing after feeding significant difficulty coordinating sucking, swallowing and breathing becoming excessively tired during feeds consistently prolonged feeds These signs are not specific to one particular condition. They should be considered alongside the baby’s age, development, feeding history, growth and overall presentation. Oral anatomy, feeding and breathing Breastfeeding and bottle feeding both require coordinated use of the lips, cheeks, jaw and tongue. The palate provides a stable surface against which the tongue can move, while the lips and cheeks contribute to the oral seal. The tongue helps manage milk within the mouth and participates in the movements required for swallowing. Breathing also has to be coordinated with feeding. This is why looking at one anatomical structure in isolation can sometimes give an incomplete picture. A visible difference does not necessarily indicate a functional problem, and an apparently typical structure does not guarantee that feeding will be comfortable or efficient. For more information about oral function and feeding, see A guide to understanding your baby’s oral function. When might your baby benefit from an oral or feeding assessment? If you have concerns about your baby’s feeding, swallowing, oral movements, breathing or the appearance of their mouth, an assessment can help put the findings into context. Assessment may include looking at: how your baby feeds at the breast or from a bottle positioning and attachment milk transfer the movement and function of the lips, cheeks, jaw and tongue oral tone and coordination swallowing and suck–swallow–breathe coordination resting oral posture palate shape your baby’s growth and development your experience of feeding and any difficulties you are noticing An IBCLC can assess breastfeeding and feeding mechanics and can identify when further assessment or referral may be appropriate. Other healthcare professionals may also be involved depending on the concern. It is not recommended to try to diagnose an oral restriction or other oral condition from photographs or by comparing your baby’s mouth with pictures online. For more information, see Who can assess a baby’s feeding and oral function?. Looking at the whole picture Your baby’s mouth is a connected system rather than a collection of separate structures. The lips, cheeks, jaw, palate, tongue, gums and developing teeth all have their own anatomy and roles, but they also interact during feeding, swallowing, breathing and development. When considering whether something is significant, it is therefore helpful to look beyond what a structure looks like and consider how your baby is functioning. This includes feeding, breathing, oral movement, resting posture, muscle tone, symmetry, growth, development and, importantly, the experience of the feeding dyad. A finding can be anatomically interesting without being a problem. Equally, a baby can have an apparently uncomplicated oral examination while still experiencing feeding difficulties that deserve further assessment. The aim is not simply to identify differences. It is to understand what those differences mean in the context of the individual baby. References Association of Tongue-tie Practitioners (ATP) (2026) Lip-tie and Buccal-tie Position Statement. Available at: https://www.tongue-tie.org.uk/position-statements (Accessed: 19 September 2026). Bode-Johnson, F. et al. (2020) ‘Neonatal oral findings and their significance’, Journal of Paediatrics and Child Health. MedlinePlus (2026) ‘Epstein pearls’. U.S. National Library of Medicine. Messner, A.H. et al. (2020) ‘Ankyloglossia in children: a multidisciplinary approach to diagnosis and management’, Otolaryngology–Head and Neck Surgery, 162(5), pp. 597–611. Mills, N. et al. (2019a) ‘What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum’, Clinical Anatomy, 32(6), pp. 749–761. Mills, N. et al. (2019b) ‘Defining the anatomy of the neonatal lingual frenulum’, Clinical Anatomy, 32(6), pp. 824–835. Neville, B.W. et al. (2016) Oral and Maxillofacial Pathology. 4th edn. St Louis: Elsevier. Stanford Medicine Newborn Nursery (n.d.) ‘Mouth’. Stanford University School of Medicine.

Assessment comes first Seeing a frenulum under a baby’s tongue does not, by itself, tell you whether treatment is needed. The important question is how your baby’s tongue and mouth are functioning during feeding, and whether this is affecting breastfeeding, bottle feeding or both. A feeding assessment can look at your baby’s oral function alongside the feeding itself, including attachment, milk transfer, swallowing, suction, comfort and your baby’s ability to maintain an effective feed. It can also help identify other factors that may be contributing to feeding difficulties. If a tongue-tie is identified, there is not one treatment pathway that is right for every family. Some babies and caregivers benefit from conservative management, while others may be considered for infant frenulotomy, also known as tongue-tie division or tongue-tie release. The decision can be made after assessment and discussion of the available options, rather than simply because a frenulum is visible. Conservative management Conservative management is an active approach to supporting feeding without dividing the frenulum. For some families, this may be the preferred option, particularly when feeding difficulties can be addressed through feeding support and other practical measures. Depending on your individual circumstances, support may include: skilled breastfeeding or infant feeding support positioning and attachment adjustments support with milk supply where needed expressing and maintaining milk supply when direct feeding is difficult paced and responsive bottle feeding strategies to support oral function where appropriate addressing factors such as reflux symptoms, colic or nasal congestion when these are present consideration of appropriately qualified bodywork or osteopathic support where this may be helpful as part of wider care These approaches can support feeding and address contributing factors, but they do not divide or remove a restrictive frenulum. If a structural restriction is present, it remains present unless the frenulum is divided. It is also important not to assume that reflux, colic, congestion or other infant behaviours are caused by tongue-tie. Babies can have several overlapping factors affecting feeding, and a good assessment considers the whole feeding picture. You can read more about supporting feeding when a tongue-tie is not divided in Untreated Tongue-Ties. Infant frenulotomy Infant frenulotomy is a procedure in which the lingual frenulum is divided. You may also hear it described as tongue-tie division, tongue-tie release or tongue-tie surgery. For carefully selected infants with documented functional difficulties, frenulotomy may improve some aspects of feeding. However, it is not an instant fix and it does not guarantee that every feeding difficulty will resolve. The evidence is also not equally strong for every outcome. O’Shea et al. (2017) found that frenotomy may reduce maternal nipple pain in breastfeeding, but evidence for improvements in infant feeding outcomes was limited. Other reviews have similarly found uncertainty around many longer-term feeding outcomes (Francis, Krishnaswami and McPheeters, 2015). More recent evidence continues to support a cautious and individualised approach. Dhar et al. (2026) found evidence of a reduction in maternal nipple pain and improvements in maternal perception of breastfeeding. However, evidence for some objective feeding measures was less consistent, particularly when frenotomy was compared with control groups. This means that the decision should consider your baby’s individual feeding difficulties, the assessment findings, the potential benefits and limitations of the procedure, and your family’s priorities. What does the evidence say about breastfeeding? The strongest evidence for frenotomy relates to short-term maternal nipple pain in breastfeeding dyads. For example, Buryk, Bloom and Shope (2011) found that frenotomy was associated with improvements in maternal nipple pain and breastfeeding effectiveness compared with a sham procedure. Emond et al. (2014), however, found no significant improvement in breastfeeding scores at five days, although mothers in the early-frenotomy group were more likely to report improvement in breastfeeding difficulties. The Cochrane review by O’Shea et al. (2017) concluded that frenotomy may reduce breastfeeding mothers' nipple pain in the short term, but there was insufficient evidence to determine whether the procedure improves longer-term breastfeeding outcomes. Dhar et al. (2026) similarly found a substantial reduction in maternal nipple pain and an improvement in maternal perception of breastfeeding, while noting that evidence for other feeding outcomes remains limited or uncertain. This is why a feeding assessment remains important. Nipple pain or difficulty maintaining a latch can have several causes, and dividing a frenulum will not necessarily address every contributing factor. For practical support with bottle feeding, see How to Pace Bottle Feeds: A Calm, Practical Guide. What about bottle feeding? There is less research specifically examining frenotomy for babies who are exclusively bottle fed or who have significant bottle-feeding difficulties. This does not mean that a baby who bottle feeds cannot have functional difficulties associated with tongue movement. It means that the evidence base is smaller, so decisions should be based on an individual assessment rather than assuming that frenulotomy will improve bottle feeding. Bottle feeding can also be affected by teat flow, positioning, pacing, coordination, oral-motor skills, airway or nasal factors and the baby’s individual feeding pattern. A responsive feeding approach can sometimes make a significant difference without surgery. You can read more in How to Pace Bottle Feeds: A Calm, Practical Guide. Do you have to decide quickly? There is no universal deadline by which a tongue-tie must be divided during infancy. Some providers and services have age or weight limits for infant procedures, while others may assess older babies and children. If you are considering frenulotomy, ask the provider you are considering about their own age limits and arrangements. If you are unsure, it is reasonable to take time to understand what is happening with feeding, consider conservative management and discuss the potential benefits and limitations of frenulotomy before making a decision. A visible frenulum does not mean that a procedure has to happen immediately. What should you know about the procedure? Frenulotomy is a surgical procedure and, like any procedure, it has potential risks. These can include: bleeding pain or discomfort infection oral aversion or feeding reluctance injury to nearby structures problems associated with the healing process Serious complications appear to be uncommon, but they cannot be completely excluded. Dhar et al. (2026) reported a pooled adverse-event frequency of approximately 4%, with bleeding the most commonly reported adverse event, although the certainty of this evidence was very low. The provider should explain the potential benefits and risks before you decide whether to proceed, including what you should do if bleeding, feeding difficulties or other concerns occur after the procedure. You can read more about potential complications in YOUR TONGUE-TIE RISKS BLOG. What technique is used? Different techniques are used for infant frenulotomy, including scissors and laser. In the UK, scissors are commonly used for infant tongue-tie division, and NICE guidance describes division using scissors. However, this does not mean that scissors are universally better than laser. Dhar et al. (2026) found that scissors and laser appeared to have comparable effectiveness, although the evidence comparing techniques was limited. There is currently not good evidence to suggest that one technique is universally superior for every baby. The technique is therefore only one part of the decision. The assessment, experience of the practitioner, understanding of infant feeding, informed consent and aftercare arrangements are also important. Aftercare matters too Frenulotomy is not simply a procedure followed by an immediate return to normal feeding. Your baby may need time to adjust to changes in tongue movement and feeding, and the healing process needs to be considered. Your provider should explain what to expect after the procedure, how to recognise problems and who to contact if you have concerns. Feeding support may still be needed after frenulotomy. Improving tongue movement does not automatically mean that a baby immediately develops a new feeding pattern, particularly if they have been compensating for restricted movement for some time. You can read more about this in Beyond the Tongue-Tie Release: Why Aftercare Matters. Choosing a practitioner or service If you are considering frenulotomy, look for a practitioner or service that can explain both the procedure and the alternatives. You may want to ask: Are you professionally registered with an appropriate UK regulator? What training and experience do you have in assessing and treating infants? Will my baby have a feeding assessment as part of the assessment? What other factors could be contributing to the feeding difficulty? What are the potential benefits and limitations of frenulotomy for my baby? What are the risks and possible complications? Which technique do you use and why? What aftercare do you recommend? What happens if my baby has a problem after the procedure? What feeding support is available afterwards? What happens if we decide not to proceed? A practitioner who also has appropriate infant feeding expertise, such as an IBCLC or another suitably qualified infant feeding specialist, may be able to consider the procedure alongside the wider feeding picture. You can also read How Is Tongue-Tie Assessed in Babies Safely? before choosing a practitioner. Neither option is the “easy” option It can be tempting to think of conservative management as doing nothing, or frenulotomy as a quick solution. Neither description reflects the reality for many families. Conservative management can involve ongoing feeding support, repeated adjustments, observation and review. Frenulotomy involves a procedure, a period of healing and potentially further feeding support while your baby adapts. The important question is not which option sounds easiest. It is which information, support and approach fit your baby’s individual feeding assessment and your family’s circumstances. There is also no requirement to choose a procedure simply because a frenulum is visible, and choosing conservative management does not mean that you are ignoring a problem. Equally, choosing frenulotomy does not mean that you have failed to try other approaches. The aim is to understand what is affecting feeding, consider the available evidence and uncertainties, and make an informed decision with appropriate support. References Buryk, M., Bloom, D. and Shope, T. (2011) ‘Efficacy of neonatal release of ankyloglossia: a randomised trial’, Pediatrics, 128(2), pp. e280-e288. doi: 10.1542/peds.2011-0077. Dhar, V., Marghalani, A.A., Amini, H., Brickhouse, T., Caffrey, E., Jayaraman, J., Keels, M.A., Messner, A., Patterson, K.K., Raol, N., Shrestha, P., Stark, C.M., Susarla, H.K. and Thomas, J. (2026) ‘Frenotomy for Ankyloglossia Associated With Feeding Challenges in Infants: Effectiveness, Technique, and Safety—A Systematic Review and Meta-Analysis, Part 2’, Pediatric Dentistry, 48(2), pp. 33E-68E. PMID: 42050812. Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., Sutcliffe, A., Emmett, P. and Salisbury, C. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 99(3), pp. F189-F195. doi: 10.1136/archdischild-2013-305031. Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. doi: 10.1542/peds.2015-0658. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. HealthTech guidance 95 (formerly IPG149). London: NICE. Available at: https://www.nice.org.uk/guidance/htg95/ (Accessed: 18 September 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.

FOLLOW-UP SUPPORT AND AFTERCARE I remember what it was like. My daughter had a division on the same day that I found out what a tongue-tie restriction was! I was overwhelmed. I even cried! Looking back this is exactly the same as how I see many of you feel. In the beginning….. So, when D-Restricted Ltd was born in 2014 it was important to me that follow-up support was inclusive within the original fees. I did my research and found that up and down the country the level of support post-division was variable, and yet we know a division is not an instant fix! There are 8 muscles that make up the tongue and so it needs to go to the gym for a bit of a work-out to gain a bit of strength and coordination, not to mention the surrounding oral structures that need to relax! I was in that place, I felt alone and lost as my journey was “unique”. The D-Restricted Post-Division Care Plan At D-Restricted I individualise your care, and back-it up with evidence based research. I appreciate that all journeys are different and change to meet the challenging needs of family life, finding it’s own, new rhythm. At the end of your consultation with myself, I give you detailed written Information on what to expect moving forwards. I then include a 6 week period from day of division where I will send you a weekly message to check-in with yourself and see how your feeding journey is progressing as this will be very different for each family. You may also text/email/call me with any queries, questions or concerns you may have during this period at any point (within daylight hours!!)-I will be there every step of the way with you 😊. What happens after 6 Weeks? At the 6 week mark feeding should be well and truly on the road to being efficient and effective if it isn’t already, and so your final week 6 text communication from myself is your formal discharge. This text will also request Feedback from yourself which will allow me to continuously review, update, and improve upon the service I give you, which can be done by following the link, or clicking on the “Feedback” tab above. Feedback is important on a personal level which may help other families in making decisions or on service providers but also on national and professional levels through audit and CQC regulation. If, after 6 weeks you feel things are not going as you had hoped, I would strongly suggest to book-in for a face-to-face follow up review where I may review feeding techniques and reassess tongue function, this opens up a further 6 weeks of ongoing support, care-planning working towards your individual goals-I am a Lactation Consultant (IBCLC) and infant feeding specialist so rest assured together we can set goals to get your little one feeding effectively (this does incur an additional charge). https://www.lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/ Additionally…. As many of you already know, I manage a tongue-tie peer support group. This has developed over the years to become a great additional resource! You may choose to start a thread to ask questions or just sit quietly in the background, it’s your call. It is a closed group so rest assured you have privacy and confidence in posting into a safe space to voice any concerns-I also have to “approve” any new posts too so you will always get my qualified opinion first! The most amazing part though is that you can use the search bar tool at the top of the page. I frequently add articles of interest, hints, tips and support videos too so if there is something specific you are looking to know-just tap on the key words in the search bar and any related posts added to the page since it began in 2014 will appear-and its “appropriateness” has already been vetted by myself so you can be confident that it is of relevance, validated and reliable-so very different from an unregulated google search! To join this group if you haven’t already, please follow this link: https://www.facebook.com/groups/219881955258950/ I hope this helps to explain the aftercare support I offer. However if you do have further question please just hollah! diana@tongue-tie.info 07910608179 © Diana Warren IBCLC, RGN D-Restricted Ltd

Post-Procedure Tongue Function Exercises (tongue function exercises, disruptive wound management, active wound management) Now that you have began to research 'restrictive tongue tie' and its implications, you will undoubtedly have noticed the conversations surrounding 'exercises'. Now, this is a very controversial topic and highly emotive. The biggest problem lies in the lack of definition between the differences between 'Wound Massage', 'Tongue Lifts/Sweeps', 'Active or Disruptive Wound Management', whether the parent or the practitioner does this and who is accountable?, How long for? and What the benefits actually are?! - This is because it is poorly backed up by a robust medical evidence base. As you can see, the terms alone are confusing and "dress-up" the 'act' using calming and gentle wording, and yet this may be painful. Examples of DWM, stretches or AWM may include: actively breaking the wound open multiple times a day and rubbing it, lifting the tongue to 'stretch' the wound, or sweeping a finger on the underside of the tongue to re-open the wound to delay healing, thus preventing reformation. These are practices that I DO NOT advocate. The stages of wound healing tells us that interfering with the wound healing process may cause further complications. Thickening of the wound causing further restriction, bleeding, infection or pain causing a feeding aversion all spring to mind, and yet internationally this is common-place routine post procedural care. ATP Position Statements - Lip tie (2014) and Disruptive Wound Management (2021) - Association of Tongue-tie Practitioners (The above link is from the Association of Tongue Tie Practitioners UK, and is the formal link for the 'Position Statements' they uphold!). Body Therapy To clarify, Body therapies such as osteopathy, chiropractic, cranial-sacral, orofacial myofunctional and physiotherapy are all specialties that are regulated by councils and governing bodies and this is not the same as 'disruptive/active wound management'. They do not advocate touching an open wound. Wound management suggestions, unless they are dual trained in a relevant speciality, is out of their remit. In the same way that I would not dream of trying to diagnose torticollis, as its not my speciality. Even if I was to suspect it-I'd refer to the professional in that field. Body therapies are very useful at addressing the tensions in the whole body caused by a variety of factors (such as a traumatic birth, birth presentation, or a restrictive tongue-tie are just a few examples) all of which can all interfere with efficient, effective infant feeding and overall health and well being. Interestingly, the nerve endings from the frenulum finish in the toes. I have most definitely seen improvements in the infants I treat who have also had a body therapy to relax, have less wind/reflux, sleep better and improved efficiency in feeding-especially if the jaw is taught from a restrictive frenulum! Please also see this link: Manual Therapy and Infant Feeding - Association of Tongue-tie Practitioners How I can help I have trained in the speciality of Orofacial Myofunctional techniques which is a relatively new concept in the world of body-therapy. It specifically looks at the tongue and surrounding oral muscles and structures and links how these can impact on other bodily function such as eating, drinking, breathing and sleeping. At your tongue-tie consultation with me, I will give you specific gentle exercises to help assist your little one in reducing any tension of the face and tongue strengthening exercises too. These are optional of course but will give your little one a 'head-start' to effective feeding. Additionally to this I have developed some online presentations that will guide you through techniques to help with relaxation, bonding and wind/colic symptoms through baby massage and infant and toddler yoga. If you are interested in these presentations please visit www.d-restricted.co.uk or click onto the link below. Ultimately, your chosen provider is accountable for their suggestions and actions so please do refer to that practitioner and follow their advice. This blog is my opinion only and is aimed for the families of the infant's I treat. As always, please feel free to contact me with any questions or queries that you may have at: diana@tongue-tie.info © Diana Warren IBCLC, RGN D-Restricted Ltd

Posterior Tongue-tie (the one that is easily missed!). Traditionally, the only ties that were thought to cause any problems were the anterior ties. Visually obvious, all the way to the tip of the tongue and attached to the alveolar ridge (gum line) at the bottom-who could get that wrong?! We now know that it really isn't about what the tongue looks like, its about its function. What it can and can not do that counts. Certainly in practice I have seen anterior ties that have a good height, thin and stretchy and do not pose any restriction on tongue function at all. Similarly, I have seen very short, and thick posterior ties that cause every feeding problem known to (wo)man. and lets face it, its not like behind an anterior tie there is a gap!-it continues through to the posterior area of the tongue. Posterior Tongue Tie Restriction Definition: There is no universally agreed definition of the area that I refer to as 'a posterior restrictive tie'. Unfortunately, this leads to much confusion, as a medical professional may conclude that the posterior element is buried deep within the tongue muscles (geniogolossus) itself, which fuels the advice that 'posterior ties do not need dividing', whereas another would not include the area in the muscle itself, and another believes only the restrictive element would warrant a division (how can that even be determined?). Now I agree that we do not need to go furkleing deep within the muscle itself-that may cause more damage, including potentially in the longer term too! When I suggest a posterior restriction, I am referring to the frenulum that protrudes forwards of the tongue muscle. The posterior element of this would be the final 25% of the frenulum before the area that attaches to the root muscle (geniogolossus). So an anterior tie is 100% of the way/length forward, and a posterior just the final quarter. Not all healthcare professionals assess in this way, there are differences, but as I say its more the function and symptoms that count rather than appearance. Many qualified professionals would also use a scoring tool to help reduce the chance of over-diagnosis. A tool combined with a feeding assessment, tongue motility assessment and noting of adverse symptoms would provide an holistic approach to the matter in hand. What to look out for? Well, the short answer to this, is to look for exactly the same as you would in an anterior tie-look at the feeding symptoms and try not to focus on the visual appearance. Symptoms for any restrictive tie may include: (*Feeding symptoms may not associated with a restrictive tie at all, it may be another issue, it really is about seeking professional support and assessment of tongue function) Weight gain/loss Breast milk supply issues Painful feeds Dribbling milk Tiring during an active feed Not maintaining a seal/latch (teat or breast) Noisy feeding Crushing teat with gums Piston action on a dummy/bottle (like Maggie Simpson!) Poor flow control of the milk Sensitive gag reflex Shallow latch onto breast or teat Frustration or anger to feed Feeding aversion Breast duct blockages/ blebs/ mastitis Thrush Trapped wind / colic Reflux/Silent reflux Who Can assess for a tongue tie restriction? This is where it gets complicated. Very few medical professionals in the grand scheme of things are trained in the diagnosis and division of a tongue tie. In the UK, there are currently 2 main training centres only. Practitioners have to be registered with CQC England, and be regulated as a nurse, doctor, dentist or health visitor. Unfortunately, many are giving diagnosis such as 'mild' , 'slight' or 'severe' which is an opinion NOT a diagnosis-and very ambiguous terms too-what does 'mild' even mean? thin? short? posterior? it s all very confusing for the caregiver. It is not part of routine midwifery, health visitor, or GP training. There are many healthcare professionals who are experienced in recognising a tongue tie restriction, and very often get it correct-but they are not trained to provide that diagnosis. Instead, my preference would be that they tell you it is suspected, and then refer to someone that may be able to assess, such as an IBCLC (International Board Certified Lactation Consultant) or a member of your local infant feeding team. Many UK based tongue-tie practitioners are members of The ATP (Association of Tongue Tie Practitioners) and many choose to list their services with them, so you as a parent then also know that they are trained professionals, and can locate where they are based based on a postcode search www.tongue-tie.org.uk. (The ATP are not regulators, so it remains within the caregiver's responsibility to check an individuals credentials). Similarly, you can check with their individual regulators on an online search or through CQC England too www.cqc.org.uk. To conclude: If you suspect, or you're not sure-seek a trained professional who can assess. If it is not a restriction, then they should still be able to support you to achieve your feeding goals and work towards rectifying any other causes of feeding complications. © Diana Warren IBCLC, RGN D-Restricted Ltd

A baby may have a visible piece of tissue beneath their tongue and feed beautifully. Another may have a less obvious restriction but struggle with every feed. That is why parents asking, “how is tongue tie assessed in babies?” deserve more than a quick look in their baby’s mouth. A careful assessment considers what the tongue looks like, how it moves and, crucially, how feeding is working for both baby and parent. Tongue-tie assessment should feel calm, unhurried and respectful. There is no need to force a baby’s mouth open or judge a feeding journey. Whether you are breast-feeding, body-feeding, bottle-feeding, combination feeding or pumping, the aim is to understand the challenges you are experiencing and identify the support most likely to help. How is tongue tie assessed in babies? A clinical tongue-tie assessment brings together a detailed feeding history, observation of your baby at rest and during movement, and an examination of the tissue beneath the tongue. When possible, watching a feed is an especially valuable part of the picture. A tongue tie, clinically called ankyloglossia, is a restriction caused by the lingual frenulum, the band of tissue that connects the underside of the tongue to the floor of the mouth. Frenula vary greatly. Some are easy to see near the tip of the tongue, while others are less immediately visible. Appearance alone cannot tell us whether a restriction is affecting function. A skilled clinician therefore does not diagnose or recommend treatment from a photograph, a single symptom or the shape of a tongue alone. The relevant question is whether the tongue has enough mobility for your particular baby to feed comfortably and effectively. The conversation comes first Before examining your baby, the clinician should listen to your experience. Early parenthood can be exhausting, particularly when feeds are painful, lengthy or worrying. A full history helps separate concerns that may relate to tongue function from those with other possible causes. You may be asked about pregnancy and birth, your baby’s gestation and health, weight patterns, nappies, jaundice or reflux symptoms, and any previous feeding support. The conversation will also cover how feeds feel and function. For breast or body-feeding, this may include nipple pain or damage, shallow or slipping latch, clicking, frequent feeding, breast fullness after feeds, or concerns about milk transfer. For bottle-feeding, it may include leaking milk, dribbling, clicking, coughing, gulping, tiring during feeds, taking very long to finish, or difficulty maintaining a seal around the teat. None of these signs proves there is a tongue tie. They are prompts to assess more closely. Positioning, flow rate, breast anatomy, milk supply, prematurity, illness, muscle tone and normal newborn adjustment can all influence feeding too. Observing your baby’s feeding and behaviour When practical, a clinician may ask to observe a feed. This is not a test that you or your baby can fail. Babies can be unsettled, sleepy or simply not hungry at an appointment, and a good assessment adapts to the situation. A video from home can sometimes add useful context, although it cannot replace an in-person examination when one is needed. During a breast or body-feed, the clinician looks at how your baby approaches the breast, opens their mouth, attaches, maintains the latch and coordinates sucking, swallowing and breathing. They will listen for swallowing and clicking, while also checking whether you are comfortable. They may observe whether the cheeks draw in, whether the lips maintain a seal and whether your baby repeatedly comes on and off the breast. During bottle-feeding, the assessment considers the baby’s position, teat type and flow, the seal around the teat, milk loss, pacing and signs of stress. Bottle-fed babies can be affected by restricted tongue movement, but bottle-feeding difficulties do not automatically mean that a release is needed. Practical feeding adjustments may be the most appropriate first step for some families. Away from feeding, the clinician may also note whether your baby can lift their tongue, extend it forwards, move it from side to side and form a seal. A baby’s cry, rooting behaviour and oral reflexes can offer further information, but they are only part of the assessment. The mouth examination: looking and feeling The examination itself is gentle and usually brief. With clean, gloved hands, the clinician looks beneath the tongue and may use a finger to assess its movement and the tension of the frenulum. This tactile assessment matters because some restrictions are not clearly visible without lifting the tongue and feeling how the tissue affects movement. The clinician will consider where the frenulum attaches, its thickness and elasticity, and whether it appears to limit elevation or forward movement of the tongue. They will also examine the palate, gums, lips and inside of the cheeks, as other oral features can affect feeding. Babies commonly protest at having their mouth examined, particularly if they are tired or hungry. Crying does not necessarily mean the examination is painful. Parents should be kept informed throughout, invited to pause if needed and supported to comfort their baby straight away. Function matters more than a label Assessment tools and scoring systems can help clinicians record tongue appearance and movement consistently. However, a score should never replace professional judgement or a full feeding assessment. A score alone does not tell a family whether feeding support, monitoring, a tongue-tie release or no treatment is right for their baby. Equally, terms such as “posterior tongue tie” can cause understandable confusion online. Rather than relying on a label, a function-focused assessment asks what the tongue can do and whether there is evidence that restricted movement is contributing to a current feeding problem. What happens after the assessment? The outcome should be explained in clear, balanced language. If the assessment finds no clinically significant restriction, this does not mean your difficulties are dismissed. It means attention can turn to other factors, such as latch and positioning, bottle-feeding technique, paced feeding, milk supply, pump flange fit or another health concern. Many families benefit from feeding support without a surgical procedure. If a restrictive frenulum appears to be affecting feeding, a clinician may discuss tongue-tie release, also known as frenulotomy. The decision should be individual to your baby and family. It should take account of feeding symptoms, growth and wellbeing, the degree of functional restriction, likely benefits and the limits of what a release can achieve. A release is not a guaranteed answer to every feeding challenge. Some babies improve quickly, while others need time, guided feeding support or further assessment. Parents should receive a clear explanation of the procedure, possible risks, aftercare and when to seek advice. They should never feel pressured into treatment. For families choosing a release, support afterwards is a vital part of care. Babies are learning a new range of tongue movement, and parents may need help with attachment, positioning, bottle-feeding or protecting milk supply. At D-Restricted Ltd, continuity-focused aftercare provides the opportunity to review feeding progress and raise concerns over the weeks that follow, rather than leaving families to manage alone after one appointment. When to arrange an assessment It is sensible to seek timely feeding support if feeds are persistently painful, your baby is struggling to stay attached, bottle feeds are stressful or unusually long, weight gain is a concern, or you feel something is not working despite trying common adjustments. Earlier support can reduce the strain on both parent and baby, but there is still value in assessment later on if difficulties continue. If your baby is very sleepy and difficult to rouse for feeds, has fewer wet nappies than expected, is not gaining weight, has signs of dehydration, or you are worried they are unwell, contact your midwife, health visitor, GP, NHS 111 or urgent care service promptly. Feeding concerns can have causes that need medical assessment beyond tongue tie. A thoughtful tongue-tie assessment is not about finding a procedure to perform. It is about listening carefully, examining gently and giving you an honest, evidence-informed plan for your baby’s feeding. You know your baby best, and a good clinical appointment should leave you feeling heard, clearer about the next step and supported in the feeding journey that works for your family.

A baby can have a visible lingual frenulum - the band of tissue beneath the tongue - and feed comfortably. Equally, a family may be asking, “does my baby have tongue tie?” because feeding has become painful, exhausting or worrying. Both experiences deserve to be taken seriously. The key question is not simply what the tissue looks like, but how your baby’s tongue is functioning during feeding and how feeding feels for you both. Tongue-tie, also called ankyloglossia, is a variation in which the lingual frenulum may restrict some tongue movement. It is not possible to confirm or rule out tongue-tie from one photograph, one symptom or a quick look in a baby’s mouth. A careful assessment considers oral anatomy alongside feeding observation, milk transfer where relevant, your baby’s health and development, and your own experience. Does my baby have tongue tie, or is feeding difficult for another reason? Feeding difficulties are often multifactorial. A tongue restriction may be relevant for some babies, but it is not automatically the only explanation for a painful latch, unsettled feeds or slow weight gain. Positioning and attachment, milk supply or flow, breast and nipple anatomy, bottle teat flow, reflux-like symptoms, allergies, illness, prematurity, birth experiences and a baby’s general feeding skills can all contribute. This does not mean you should wait quietly if feeding is difficult. It means you deserve support that looks at the whole picture rather than making assumptions based on appearance alone. Anatomy provides information. Function provides context. What you might notice when breastfeeding or chestfeeding Some families report pain that persists despite support with positioning and attachment. Nipples may look compressed, creased or misshapen after a feed, or become damaged. Your baby may struggle to maintain a deep latch, make repeated clicking sounds, feed for a long time without seeming settled, or come on and off the breast frequently. These signs can occur for many reasons, so they are prompts for a fuller feeding assessment rather than proof of tongue-tie. It can also be helpful to consider whether feeding has always felt difficult or whether it has changed over time. A baby who is growing well can still be having an uncomfortable or inefficient feeding experience, and a parent’s pain matters. What you might notice with bottle feeding Tongue function can matter in bottle feeding too, although the signs may look different. A baby may dribble milk, cough or splutter, lose their seal around the teat, take very long feeds, tire quickly or seem distressed during feeding. Some may feed frequently but appear unsettled afterwards. Teat shape and flow rate, paced feeding, positioning, coordination and medical factors also need consideration. Switching bottles repeatedly in search of an answer can feel stressful and expensive. Before changing everything at once, skilled feeding support can help identify what is happening during a feed and suggest proportionate adjustments. Signs that warrant timely feeding support It is reasonable to seek help whenever feeding is painful, worrying or not working as you hoped. Prompt support is particularly valuable if your baby is not gaining weight as expected, has fewer wet or dirty nappies than anticipated, is very sleepy for feeds, repeatedly cannot stay latched, or you are concerned about your milk supply. If your baby seems unwell, is difficult to wake, has signs of dehydration, green vomit, breathing difficulty, a fever, or you have immediate concerns about their wellbeing, seek urgent medical advice. Tongue-tie assessment is not a substitute for medical review when a baby may be unwell. You do not need to prove that there is a tongue-tie before asking for support. Bringing a short record of feeds, nappies, weight information and the challenges you are noticing can be useful, but it is not a test you need to pass. Why appearance alone cannot give the answer Many people look beneath their baby’s tongue and see a band of tissue. This is normal anatomy. Frenula vary in thickness, attachment and visibility, and a visible frenulum does not by itself tell us how freely or effectively a baby can use their tongue. Likewise, a restriction that is less obvious at rest may be relevant when a baby is trying to seal, elevate, extend or coordinate their tongue during feeding. This is why an assessment should include more than an oral examination. It should explore how your baby feeds in real time, alongside their history and your feeding goals. Online images and social-media checklists can be useful for helping parents find language for their concerns, but they cannot diagnose a functional feeding difficulty. They can also create unnecessary worry by presenting normal variations as problems. If you are unsure, a calm, individual assessment is more useful than trying to compare your baby with photographs online. What a skilled tongue-tie and feeding assessment should include A thoughtful consultation starts by listening. Your clinician should ask about pregnancy and birth history where relevant, your baby’s health, feeding pattern, weight trajectory and what you would most like to improve. There should be space for you to describe pain, anxiety, exhaustion, previous advice and the parts of feeding that are going well too. The clinician may observe a breast, chest or bottle feed, depending on how your baby is fed. They will consider your baby’s positioning, latch or seal, sucking pattern, swallowing, comfort and ability to sustain the feed. An oral examination may then provide information about tongue movement and other aspects of oral function. A good assessment also includes differential diagnosis. For example, a shallow latch may be influenced by positioning; clicking may relate to flow or coordination; and unsettled behaviour after feeds can have several possible causes. The aim is not to attach every difficulty to one finding, but to make sense of the pattern and agree sensible next steps. If a tongue-tie is identified, what happens next? Identifying a tongue-tie does not mean a procedure is inevitable. Some babies feed effectively and comfortably with a restriction present. Others may benefit from targeted feeding support, time and review, adjustments to feeding management, or discussion of a surgical release procedure where this is clinically appropriate. The best option depends on function, feeding impact, your baby’s wider health, your circumstances and your preferences. Families should have clear information about potential benefits, limitations and uncertainties, as well as the practicalities of any proposed treatment. No intervention can guarantee a particular feeding outcome, especially when difficulties have more than one contributing factor. If a surgical release is chosen, it should form part of a wider plan rather than be treated as a stand-alone solution. Feeding support before and after treatment can help families adapt, assess progress and respond to any ongoing challenges. If conservative management is chosen, that is also an active plan: it may include skilled feeding support, monitoring and review if circumstances change. Questions you can ask at an appointment You may find it helpful to ask what the clinician observed during the feed, what else could be contributing, and whether your baby’s tongue function appears to be affecting feeding. You can also ask what support is available if you decide not to pursue a procedure now, what follow-up looks like, and when to seek review sooner. It is appropriate to want clear explanations and time to make a decision. A family-centred clinician will respect breastfeeding, chestfeeding, bottle feeding, combination feeding and pumping as valid feeding journeys, and will work with the goals that matter to you. Feeding can be deeply personal, and uncertainty can feel heavy when you are tired. Whether your baby has a tongue-tie or not, persistent pain or concern is a good enough reason to seek compassionate, skilled support. You and your baby deserve to feel heard, informed and cared for as you decide what comes next.

A baby may have a visible lingual frenulum and feed comfortably. Another may be experiencing painful feeds, unsettled bottle feeds or concerns about milk transfer, yet have several contributing factors beyond oral anatomy. That is why high-quality tongue-tie training must start with curiosity rather than assumptions. Anatomy provides information. Function provides context. For professionals supporting infants and families, education in this field should build confidence without encouraging overconfidence. It should help learners recognise the limits of what they know, consider the whole feeding picture and work collaboratively with families and other practitioners. Tongue tie training begins with anatomy and function A lingual frenulum is a normal structure. Its appearance varies considerably between infants, and appearance alone cannot establish whether it is affecting feeding. Meaningful training therefore moves beyond visual descriptions or classifications and explores the relationship between oral anatomy, movement, stability, sensation and feeding function. Learners need a sound understanding of the infant oral cavity and the wider structures involved in feeding. This includes the tongue, floor of the mouth, lips, cheeks, palate, jaw and the coordinated work of sucking, swallowing and breathing. It also includes an appreciation that these systems develop over time, and that a newborn’s feeding skills can change with maturity, support and experience. This matters because a single anatomical finding can be interpreted very differently when separated from function. A visible frenulum may be clinically unremarkable for one infant. For another, it may form part of a wider pattern that deserves skilled exploration. Good education teaches practitioners to hold those possibilities carefully rather than reaching for a quick conclusion. Function must be considered in the feeding relationship Feeding is not simply an oral task. It is a relationship between an individual baby, their parent or caregiver, the feeding method, the feeding environment and the support available to the family. Breastfeeding, chestfeeding, bottle feeding, combination feeding and expressing all bring different practical considerations. A thoughtful practitioner considers what is happening over a full feed, alongside the family’s account of their experience. They may explore comfort, the baby’s feeding behaviour, growth and milk transfer concerns, feeding frequency, parental wellbeing, positioning, supply, bottle and teat choice, and any relevant birth or health history. This is clinical reasoning in practice: gathering context before deciding what may be relevant. Training should also acknowledge that no assessment tool replaces professional judgement. Tools can support structured observation and communication, but they are not a diagnosis in themselves. Their findings need to be interpreted alongside the infant’s function, the feeding history and the goals of the family. Why differential diagnosis belongs in tongue tie education Feeding difficulties are often multifactorial. A baby who finds feeding challenging may be affected by positioning, flow preference, feeding pressure, early birth, jaundice, illness, reflux-like symptoms, muscular tension, neurodevelopmental differences or difficulties with milk supply, among many other possibilities. Sometimes more than one factor is present. For this reason, tongue tie training should equip learners to think differentially. The aim is not for every professional to diagnose every possible cause, but to recognise when a concern may sit outside their scope, when further support is needed and when referral is appropriate. This protects families from an overly narrow explanation for a complex problem. It can also prevent a visible frenulum becoming the focus when practical feeding support, time, medical review or another specialist perspective may be more helpful. Families deserve clear information that does not minimise their difficulties, while remaining honest about uncertainty. Conservative support is a valid part of care Not every infant with a tongue-tie requires a surgical release. Equally, choosing conservative management is not the same as doing nothing. Skilled feeding support may include observing feeds, making individualised adjustments, supporting milk supply where relevant and helping parents understand their options. For some families, this approach may bring sufficient improvement. For others, persistent functional concerns may lead them to seek a specialist tongue-tie assessment and discuss treatment considerations. The appropriate pathway depends on the individual infant, the feeding situation, clinical findings and the family’s priorities. Training should prepare professionals to explain this without judgement. Parents and caregivers should never feel pressured towards a procedure, nor made to feel that they have failed if feeding remains difficult. Informed choice requires balanced discussion, realistic expectations and time for questions. Treatment considerations need balanced discussion Where treatment is being considered, professionals need enough knowledge to support informed conversations within their role and professional boundaries. This includes understanding the purpose of a specialist assessment, potential benefits and limitations, possible risks, alternatives and the importance of aftercare and feeding support. It does not mean that every learner should perform procedures or assess using a particular tool. Responsible education is clear about scope of practice. It teaches practitioners when to observe, support, document, refer and collaborate, rather than implying that a short course confers expertise in every aspect of tongue-tie care. Families benefit when the professionals around them communicate consistently. A parent may speak with a midwife, health visitor, GP, infant feeding practitioner, lactation consultant and specialist clinician within a short period. Training that develops shared language and respectful collaboration can make that journey feel less fragmented. Aftercare is more than a follow-up appointment A procedure, where clinically appropriate and chosen by the family, is one point within a wider care pathway. Feeding patterns may not change immediately, particularly if a baby has developed compensatory habits or if other factors remain present. Some families need ongoing feeding support; others may need reassurance, review or onward referral. High-quality education should therefore address aftercare as a period of listening, observation and practical support. Practitioners need to know how to respond appropriately to parental concerns, recognise when a baby needs clinical review and avoid making guarantees about outcomes. This approach also respects the emotional reality of infant feeding. Families may arrive exhausted, worried or carrying difficult previous feeding experiences. Clear explanations and reliable follow-up can matter as much as technical knowledge. Compassion is not separate from clinical care - it is part of safe, family-centred practice. What to look for in a professional course A worthwhile course should be evidence-informed, transparent about its learning outcomes and explicit about what it does not teach. It should include infant oral anatomy and physiology, tongue function, feeding context, assessment tools as part of wider clinical reasoning, differential diagnosis, conservative management, treatment considerations and aftercare. It should encourage learners to question simple narratives. Ask whether the course distinguishes anatomy from function, addresses uncertainty and acknowledges the limits of the evidence. Consider whether it promotes referral and multidisciplinary working where needed, rather than presenting one pathway as the answer for every family. Professional education should also create space for reflection. Learners bring different roles, experiences and local referral routes. The most useful training helps them translate knowledge into safer conversations and better decisions within their own setting. Tongue-tie School’s Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations programme is designed around these principles. It supports healthcare professionals and infant feeding practitioners to strengthen their understanding while maintaining clear professional boundaries around assessment and surgical treatment. The aim of tongue tie education is not to make every feeding concern fit one explanation. It is to help professionals notice more, assume less and ensure that each family feels heard, informed and supported in the next appropriate step for their baby.

A search for a private tongue-tie release in the UK often begins after a difficult feed: sore nipples, a baby who slips from the breast or bottle teat, long and unsettled feeds, concerns about milk transfer, or simply a feeling that feeding should not be this hard. Those experiences deserve to be taken seriously. They do not, however, automatically mean that a tongue-tie is the cause or that a frenulotomy is the right next step. A private appointment can offer timely access to a specialist assessment and continuity of support. The value lies not simply in how quickly a procedure can be arranged, but in whether the service takes time to understand feeding, assess tongue function in context, discuss alternatives and provide appropriate aftercare. What private tongue tie release in the UK should involve In the UK, the infant procedure is called a frenulotomy. It involves dividing a restrictive lingual frenulum when, following assessment and discussion, this is considered an appropriate option. A tongue-tie is an anatomical variation, but anatomy alone cannot establish that it is affecting feeding. The key clinical question is functional: how is the tongue moving during feeding, and what is happening for this particular baby and family? A careful private assessment should look beyond the mouth. It should include a feeding history, the family’s goals, relevant pregnancy and birth history, the baby’s general health and growth, and direct observation of a feed where possible. This applies whether the baby is breastfed, chest/body fed, bottle fed, combination fed or receiving expressed milk. Feeding difficulties are often multifactorial. Positioning and attachment, milk supply, breast or nipple pain, flow preferences, prematurity, jaundice, reflux-like symptoms, neurodevelopmental differences, bottle-feeding dynamics and family circumstances may all be relevant. Sometimes a restrictive frenulum appears to be an important contributor. Sometimes it is present but not causing a functional concern. Sometimes skilled feeding support or a period of observation is the most useful first approach. This is why a service that offers only a quick visual check or a pre-determined procedure can leave families without the full picture. Anatomy provides information. Function provides context. What does the evidence say about frenulotomy? The evidence base is helpful, but it has limitations. Randomised trials and systematic reviews suggest that frenulotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads. Evidence for longer-term breastfeeding outcomes, infant weight gain and the best timing of intervention is less certain, partly because studies are small and families allocated to comparison groups often later choose treatment (O'Shea et al., 2017; Francis et al., 2015). In a UK randomised trial involving infants with mild to moderate tongue-tie, early frenulotomy did not show a difference in the primary objective breastfeeding outcome at five days, although maternal breastfeeding self-efficacy improved. The study also illustrated the practical challenge of researching this subject: many families in the comparison group subsequently requested frenulotomy (Emond et al., 2014). NICE concludes that there is limited evidence of efficacy and no major safety concerns when division of ankyloglossia for breastfeeding is undertaken with appropriate arrangements for consent, audit and clinical governance (NICE, 2005). That guidance remains useful, although it should not be interpreted as meaning every identified tongue-tie needs treatment. For bottle-feeding families, the research is more limited. A functional assessment and responsive feeding history still matter, but claims that frenulotomy will resolve wind, reflux-like symptoms, sleep, speech, dental development or later posture are not supported by sufficiently strong evidence in an individual infant assessment. A clinician should be clear about what is known, what remains uncertain and what outcome is realistically being considered. Choosing a private provider thoughtfully Private care varies considerably. Families are entitled to ask practical questions before booking, particularly when they are feeling tired, worried or under pressure to make a quick decision. Clear answers are a sign of respectful, family-centred care. It can be useful to ask whether the clinician has recognised infant feeding and tongue-tie expertise, whether they observe feeding as part of assessment, and how they consider other explanations for the difficulties. Ask who performs the frenulotomy, what consent process is used, what happens if the assessment suggests conservative management instead, and whether the provider is appropriately registered and insured for the care they deliver. You may also wish to understand the full cost before attending. This should include the assessment, the procedure if it is clinically appropriate and chosen, follow-up arrangements, and any separate feeding support. A transparent service should explain its fees and what is, and is not, included without making families feel that they have to proceed. For healthcare professionals supporting families, referral language matters. It is usually more helpful to describe the feeding concerns and observed function than to state that a baby ‘needs a release’. This preserves clinical curiosity and supports informed decision-making. Consent is a conversation, not a signature Before an infant frenulotomy, parents or those with parental responsibility should have an opportunity to discuss the anticipated benefit for their baby’s specific feeding situation, the limits of the evidence, potential risks and reasonable alternatives. Those alternatives may include skilled lactation or feeding support, adjustments to positioning and attachment, paced bottle feeding where appropriate, monitoring, or choosing not to intervene. Frenulotomy is generally a brief procedure, but brief does not mean insignificant. Bleeding, pain, distress, infection and the possibility that feeding may not improve are among the issues that should be discussed. Families should also be told how to seek advice if they have concerns after the appointment. It is reasonable to take time to decide unless there is a clinical reason not to. Equally, some families feel that the feeding impact is significant and wish to proceed after balanced discussion. Neither response is inherently more committed, informed or loving. The appropriate decision is the one made with clear information, appropriate support and attention to the individual baby. Aftercare should support feeding, not create pressure The days after a frenulotomy can be emotionally intense. Some babies feed differently straight away; others need time, and some continue to need feeding support because tongue movement is only one part of a learned feeding pattern. An honest provider will avoid guaranteeing an immediate outcome. Aftercare should include clear safety-netting, a way to access advice and support with feeding goals. It should not rely on families being told that they have failed if feeding remains difficult. Persistent pain, concerns about intake or hydration, poor weight gain, fever, unusual bleeding, or a baby who seems unwell should always prompt timely clinical advice. There is currently insufficient high-quality evidence to support routine post-procedure wound stretching or massage, and families should not be encouraged to undertake interventions that cause distress without a clear, individualised clinical rationale. Please see www.tongue-tie.org.uk/position-statements. Follow-up should focus on the baby’s wellbeing, feeding function and the family’s experience. Questions worth taking to an appointment When emotions are high, it can help to write down what you want to know. Consider asking: What feeding factors have been assessed alongside tongue function? What improvement is realistic in our baby’s circumstances, and what may not change? What are the benefits, uncertainties and risks of frenulotomy for us? What support is available if we choose to wait or decide against a procedure? How will feeding and wellbeing be reviewed afterwards? These questions are equally relevant whether care is accessed privately or through NHS pathways. The setting does not replace the need for skilled assessment, shared decision-making and continuity of care. References Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., Drewett, R., Woolridge, M. and Beddow, J. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie’, Archives of Disease in Childhood - Fetal and Neonatal Edition, 99(3), pp. F189-F195. Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., McPheeters, M. and Krishnaswami, S. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional procedures guidance IPG149. 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. A private assessment should leave you feeling heard rather than hurried. Whether the next step is feeding support, observation, frenulotomy or a different clinical opinion, your baby’s wellbeing and your family’s feeding goals deserve compassionate, evidence-informed care.

A frenulotomy is a moment in a feeding journey, not a verdict on it. A thoughtful tongue-tie reassessment after release creates space to understand what has changed for the baby and family, what remains difficult, and what support may now be most helpful. It should never be used to imply that a baby ought to feed in one particular way, or that a family has failed if improvement is not immediate. For some families, feeding feels more comfortable or efficient soon after the procedure. For others, change is gradual, mixed or absent. This variation is not surprising: infant feeding reflects anatomy and tongue function, but also milk production, positioning and attachment, bottle-feeding technique, infant maturity, birth history, sensory regulation, health and the feeding relationship. Anatomy provides information. Function provides context. What reassessment after tongue-tie release is for Reassessment is a clinical conversation and observation, rather than simply a check of the mouth. It brings together three areas: the baby’s recovery, feeding function and the family’s experience. The early review provides an opportunity to discuss whether the baby is comfortable and feeding as expected, and whether there are concerns that need medical attention. It also allows the clinician to consider healing in the context of the individual baby. Healing appearance alone cannot tell us whether feeding is working well, nor can it predict all longer-term outcomes. A function-focused feeding review may explore what happens across a feed or bottle feed: the baby’s ability to settle, sustain feeding and transfer milk, alongside parental comfort and confidence. Where breastfeeding is part of the family’s plan, discussion may include breast comfort, perceived milk transfer, nappy output, growth information and any existing plan from the maternity, health visiting or infant feeding team. For bottle-feeding families, the review should be equally respectful and practical, considering comfort, coordination, pacing and whether feeds are manageable. The aim is not to look for a perfect feed. It is to identify meaningful change, remaining concerns and sensible next steps. Why feeding may not change straight away Research suggests that frenulotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains uncertain. Trials have been relatively small, outcomes vary, and feeding support is often an important part of care in both study groups (O’Shea et al., 2017; Francis et al., 2015). The FROSTTIE trial, which compared frenulotomy plus breastfeeding support with breastfeeding support alone, closed early because recruitment was affected by the COVID-19 pandemic and other challenges. Its findings therefore do not provide a simple answer about longer-term breastfeeding continuation (Knight et al., 2023). This is a useful reminder to avoid promises based on a procedure alone. In clinical practice, babies may also need time to adapt to a different range of movement and to new feeding patterns. A parent may be recovering from pain, engorgement, worry or a difficult start. Some babies have developed compensatory ways of feeding that do not resolve immediately. Conversely, an ongoing difficulty may have another primary explanation that was present before the release. This is why reassessment needs careful clinical reasoning. Persistent clicking, leaking milk, unsettled feeds, breast discomfort or slow weight gain are not, by themselves, proof of a remaining tongue restriction. They are signs that deserve skilled, whole-feeding assessment. What a skilled review may consider A clinician should listen first. Families’ observations matter: perhaps feeds are shorter but still uncomfortable; perhaps the baby is calmer at the breast but bottles remain tiring; perhaps nothing appears different, despite everyone’s hopes. These details help shape a proportionate plan. Depending on the concerns, reassessment may consider the baby’s general health and growth, feeding history, oral function during feeding, maternal lactation factors and the wider practical circumstances around feeding. It may also identify when liaison with a GP, midwife, health visitor, paediatric clinician, speech and language therapist or another appropriate professional would be useful. The Academy of Breastfeeding Medicine advises that tongue-tie assessment should be based on a skilled breastfeeding assessment and that the presence of a frenulum alone is not an indication for intervention (Academy of Breastfeeding Medicine, 2021). The same principle remains relevant after release: a visible finding must be interpreted alongside function and the family’s goals. It is also reasonable for reassessment to conclude that no further tongue-tie intervention is indicated. That outcome can be reassuring when it is paired with a clear explanation, responsive feeding support and a plan for reviewing progress where needed. Healing and aftercare conversations Families often have understandable questions about how the mouth looks as it heals. A clinician can explain what they are seeing, answer questions and advise on routine care within the service’s aftercare arrangements. Families should not feel they must interpret healing alone from online images or compare their baby’s mouth with another infant’s. There is currently limited high-quality evidence to establish that post-procedure oral exercises improve feeding outcomes or prevent reattachment, and approaches vary. Families should be given clear, individualised advice by their treating clinician rather than feeling pressured to undertake techniques that are uncomfortable, distressing or beyond their confidence (Academy of Breastfeeding Medicine, 2021). Urgent medical advice is appropriate if a baby has ongoing bleeding, appears unwell, is feeding markedly less than usual, has significantly fewer wet nappies, or a parent is worried about dehydration or their baby’s responsiveness. Parents know their baby best; concern itself is a valid reason to seek help. Timing should follow need, not a rigid rule A planned early follow-up can offer reassurance and continuity, particularly where there were significant feeding difficulties before release. However, the most useful timing depends on the baby’s age, feeding circumstances, the family’s concerns and local clinical arrangements. A reassessment may be especially valuable when pain has not improved, milk transfer or weight gain remains a concern, feeds are becoming more stressful, or the family is unsure how to interpret changes. It can also be helpful when things are going well. A brief review can affirm progress and ensure parents know where to seek support should circumstances change. For healthcare professionals, the key is to avoid treating follow-up as a binary check for success or failure. Good reassessment combines observation, history and collaboration. It acknowledges uncertainty where evidence is limited, records outcomes that matter to the family, and avoids attributing every feeding difficulty to the lingual frenulum. A compassionate plan after reassessment The next step may be as simple as continuing responsive feeding with reassurance. It may involve targeted lactation support, a review of milk supply and breast comfort, practical bottle-feeding support, weight monitoring, or referral to another practitioner. In some circumstances, further specialist opinion may be appropriate. The plan should be clear, realistic and agreed with the family. Families do not need to wait until feeding feels impossible to ask for support. Equally, they do not need to pursue more intervention simply because a feeding journey looks different from someone else’s. A good tongue-tie reassessment after release leaves parents better informed, listened to and supported to make decisions that fit their baby and family. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Francis, D.O., Chinnadurai, S., Morad, A., Krishnaswami, S., McPheeters, M. and Walsh, J. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: A systematic review’, Pediatrics, 135(6), pp. e1458-e1466. Knight, M., Ramakrishnan, R., McCourt, C., Tuffnell, D., Shakespeare, J., Kinsella, M. and FROSTTIE Trial Team (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. 1-80. 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.

Pumping should not routinely leave you dreading the next session. If you are looking for how to relieve engorgement discomfort, begin by noticing exactly where, when and how the discomfort occurs. Pain during pumping can arise from flange fit, suction settings, friction, swelling, nipple damage, breast fullness or an underlying feeding concern. A calm, function-focused review is usually more helpful than simply turning the suction up or persevering through pain. Some sensitivity when pumping begins may occur, particularly in the early postnatal weeks. Persistent, sharp, burning, pinching or worsening pain, however, deserves attention. Every feeding journey is different, and comfort matters whether you are expressing occasionally, exclusively pumping, combination feeding or building a milk supply alongside direct feeding. How to relieve engorgement discomfort: start with the pump set-up A pump flange, sometimes called a breast shield, needs to allow the nipple to glide within the tunnel whilst not drawing in the areolar tissue. The breast should not be pulled excessively into the tunnel, and the nipple should not rub against its sides. A flange that is too large, too small or poorly aligned can contribute to friction, swelling and reduced comfort. There is no single flange size that suits everyone. Nipple diameter can differ between breasts and may change across the postnatal period or even during a pumping session. Rather than relying only on a standard size supplied with a pump, observe nipple movement and how the breast feels afterwards. A nipple that appears compressed, blanched, swollen, misshapen or grazed afterwards may indicate that the set-up needs reviewing. A professional flange fit assessment can help ensure your breast pump is comfortable and effective for your individual anatomy. An assessment looks beyond nipple size and shape alone, taking into consideration the shape, tissue, and overall anatomy of your breast. Breasts are not universal, and with the increasing availability of a variety of flange designs, including options beyond the traditional funnel shape, finding the right fit is now more personalised than ever. A correctly fitted flange may support comfort, milk removal, and a more positive expressing experience. Flange fit assessments are available to book with me via www.tongue-tie.info. Centre the nipple in the flange before starting. Hold the shield gently against the breast to make a seal, without pressing so firmly that breast tissue is compressed. If the nipple is difficult to centre because the breast is very full, brief hand expression before pumping may make this easier and more comfortable. Suction should feel effective but tolerable. Higher suction does not automatically mean more milk. Research suggests that comfort should guide vacuum settings, as milk removal can be affected when pumping is painful or when the vacuum is poorly tolerated (Prime et al., 2012). Start at a low setting, then increase gradually only to the highest level that remains comfortable. If pain begins as suction rises, reduce it rather than trying to push through. Check the pattern, not just the pain level The timing of symptoms often offers useful clues. Discomfort at the start of a session may relate to suction that increases too quickly or sensitivity in already irritated skin. Pain that worsens as pumping continues may suggest friction, swelling or a flange that becomes less suitable as the nipple expands. Pain between sessions, or pain that continues after the pump has stopped, needs a broader assessment. It can help to make a brief note for one or two days: which breast is affected, the flange used, suction level, pumping duration, nipple appearance afterwards and any breast symptoms. This information can make a flange-fitting or lactation consultation more precise. It also helps distinguish a pattern from a difficult one-off session. If you are pumping after direct feeding difficulties, the pump is not necessarily the whole story. Nipple trauma, engorgement, oversupply, breast inflammation, skin conditions and vasospasm can all affect pumping comfort. In babies with suspected tongue-tie or other oral function concerns, anatomy provides information, but function provides context. A skilled feeding assessment considers the infant, the breast, milk transfer, pump use and the family’s goals rather than assuming one explanation. Protect sore skin without adding irritation When skin is tender, reducing mechanical irritation is the priority. Check that pump parts are smooth, intact and assembled correctly. Replace worn valves, membranes or shields in line with the manufacturer’s instructions, as damaged components can affect suction consistency. Avoid harsh soaps, scrubbing or frequent use of products that leave the skin dry or irritated. If breasts are very full, hand expression or gentle breast compression during pumping may improve comfort for some people. Be cautious about adding extra pumping sessions solely to relieve fullness, particularly if this leads to a cycle of increasing milk production. Management depends on your milk supply, your baby’s feeding pattern and whether you are expressing as a replacement for a feed. The Academy of Breastfeeding Medicine advises an individualised approach to hyperlactation and cautions against interventions that can inadvertently worsen oversupply (Johnson et al., 2020). Review duration and frequency realistically Longer sessions are not always more productive. Once milk flow has slowed and the breasts feel more comfortable, continuing solely because of a fixed time target may increase friction without meaningful benefit. Equally, reducing pumping too abruptly when you are exclusively expressing or regularly replacing feeds may cause uncomfortable fullness and affect supply. This is one of the areas where individual context matters. Someone expressing once a day for work preparation needs different guidance from a parent exclusively pumping for a newborn, or from someone temporarily expressing while feeding difficulties are assessed. A lactation professional can help create a plan that protects comfort while respecting feeding goals and the practical realities of family life. When discomfort needs clinical support Seek timely advice from your midwife, health visitor, GP or an appropriately qualified infant-feeding professional if pain persists despite adjusting fit and suction, if there is broken skin, or if pumping has become difficult to continue. Persistent pain during lactation warrants careful assessment rather than reassurance alone (Berens et al., 2016). Contact urgent medical care if you feel acutely unwell, develop fever or flu-like symptoms, notice a rapidly spreading red or hot area on the breast, or have severe pain and swelling. These symptoms may be associated with breast inflammation or infection and need prompt clinical assessment. The NHS advises seeking urgent help if symptoms are severe or you feel very unwell (NICE, 2021). A sudden change in nipple colour, such as whitening followed by blue, purple or red colour changes, especially with burning pain triggered by cold, can be consistent with vasospasm. This should be assessed because management differs from friction-related pain. Similarly, itching, flaking, a rash or recurrent nipple damage may need review for dermatological or infectious causes. What skilled support can offer A good assessment is practical and collaborative. It may include observing a pumping session, reviewing flange fit on each breast, considering your pump settings and routine, examining nipple and breast symptoms, and discussing direct feeding where relevant. For some families, small changes bring significant relief. For others, discomfort is a sign that a wider feeding or health issue needs attention. There is no prize for tolerating pain. Pumping discomfort is common, but it is not something you should be expected to manage alone. Gentle adjustments, timely assessment and a plan that fits your circumstances can make expressing feel more sustainable and help you continue in the way that works for you and your baby. References Berens, P.D., Brodribb, W., Academy of Breastfeeding Medicine, 2016. ABM Clinical Protocol #26: Persistent pain with breastfeeding. Breastfeeding Medicine, 11(2), pp.46-53. Johnson, H.M., Eglash, A., Mitchell, K.B., Bonyata, K., Chantry, C., Duchossois, S., Hawkinson, D., McGuire, E., Naylor, A.J., Noble, L. and Noble, M., 2020. ABM Clinical Protocol #32: Management of hyperlactation. Breastfeeding Medicine, 15(3), pp.129-134. National Institute for Health and Care Excellence (NICE), 2021. Postnatal care: NICE guideline NG194. London: NICE. Prime, D.K., Garbin, C.P., Hartmann, P.E. and Kent, J.C., 2012. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeeding Medicine, 7(6), pp.442-447.

A tongue tie assessment Leicestershire appointment should offer more than a quick look beneath a baby’s tongue. When feeding feels painful, prolonged, unsettled or worrying, families deserve time to talk about what is happening, a careful assessment of feeding and oral function, and clear information about the options available. A visible lingual frenulum, the band of tissue beneath the tongue, is common. Its presence alone does not tell us whether it is affecting feeding or whether any treatment is needed. Anatomy provides information. Function provides context. Why a tongue-tie assessment needs to look beyond appearance Infant feeding difficulties are rarely explained by one feature alone. Breast or chest feeding challenges may relate to positioning and attachment, milk supply, breast anatomy, infant prematurity, birth experiences, reflux-like symptoms, illness or a combination of factors. For bottle-fed babies, factors such as feeding pace, teat flow, positioning, coordination and comfort may also matter. A restrictive lingual frenulum may contribute to feeding difficulty for some babies, but it is not possible to decide this reliably from appearance alone. Professional consensus describes ankyloglossia as a condition in which a restrictive frenulum limits tongue mobility, rather than simply any visible band of tissue (Messner et al., 2020). This distinction matters: a family needs an assessment that considers the baby they have, the feeding they are experiencing and what is most important to them. Research supports this cautious approach. A Cochrane review of five small randomised trials found that frenulotomy reduced maternal nipple pain in the short term, but findings on infant breastfeeding were inconsistent and longer-term outcomes were uncertain (O’Shea et al., 2017). This does not mean parents’ experiences are unimportant. It means that individual clinical reasoning, feeding support and informed decision-making remain essential. What happens during a tongue tie assessment in Leicestershire? A skilled assessment is unhurried and family-centred. It usually begins with your story: when feeding concerns started, what a typical feed looks and feels like, your baby’s health and birth history, weight pattern where relevant, and what support you have already tried. There is no expectation that every family will follow the same feeding path. Breastfeeding, chest feeding, bottle feeding, expressing and combination feeding all deserve respectful support. Where possible, observing a feed provides valuable context. The clinician may consider comfort, milk transfer or feeding efficiency, the baby’s ability to coordinate sucking, swallowing and breathing, and signs that a feed is tiring or unsettled. A single feed is only one moment in time, so your wider experience matters just as much. The oral examination considers tongue appearance and movement alongside the wider mouth and feeding picture. Clinicians may use structured assessment principles to improve consistency, but no score or tool should replace clinical judgement. Research on assessment tools has helped describe aspects of tongue function, yet agreement on diagnosis and treatment thresholds remains limited (Ingram et al., 2015; Messner et al., 2020). For families travelling from Hinckley, Leicester, Nuneaton, Coventry, Rugby or elsewhere in the Midlands, it can help to bring any relevant feeding records or weight information. More importantly, bring your questions. You should leave understanding the clinical findings, the uncertainties where they exist, and the realistic options open to your family. A good assessment also considers differential causes Sometimes the assessment identifies a frenulum that appears unlikely to be the main cause of the feeding concern. At other times, tongue restriction may be one relevant part of a more complex picture. A careful clinician will consider whether additional lactation support, review by a GP, health visitor, midwife, paediatric clinician or another appropriate professional may be helpful. This is not a dismissal of your concerns. It is a commitment to avoid attributing every difficulty to tongue-tie when a different or additional cause may need attention. Equally, conservative support is not a lesser option. Changes to feeding support, positioning, pacing or expressing plans can be meaningful for some families, whether or not a restrictive frenulum is present. Understanding the options after assessment Following assessment, the next step may be feeding support and review, referral or onward discussion, or consideration of an infant frenulotomy. The right choice depends on the degree to which restricted tongue function appears linked with current feeding difficulties, the baby’s overall wellbeing, the family’s goals and the balance of potential benefits and limitations. Frenulotomy is a clinical procedure to divide a restrictive lingual frenulum in an infant. It should never be presented as a guaranteed solution for pain, milk transfer, bottle feeding or unsettled behaviour. The evidence suggests possible short-term improvement in maternal nipple pain for some breastfeeding dyads, while evidence for broader and longer-term feeding outcomes is less certain (O’Shea et al., 2017; Francis et al., 2015). NICE guidance recognises no major safety concerns when the procedure is undertaken with appropriate clinical governance, consent and arrangements for audit, while also noting the limitations of the evidence base (NICE, 2005). Families should have space to discuss benefits, risks, alternatives and what follow-up support will look like before deciding. If a frenulotomy is considered, continuity of care matters. Feeding does not automatically become easy immediately afterwards. Some babies feed differently straight away; others need time, practical feeding support or further review. The procedure addresses a restriction where that is clinically indicated, but it does not replace skilled support for the feeding relationship. Questions worth asking at your appointment You do not need to know the clinical terminology to advocate for yourself and your baby. Useful questions include: what features of feeding suggest tongue function is, or is not, contributing; what else could be affecting feeding; what support can be tried without a procedure; and what improvement would be reasonable to hope for if a frenulotomy is chosen. It is also reasonable to ask about the clinician’s experience, consent process, arrangements for urgent concerns, follow-up period and how feeding support is provided after the appointment. A clear answer should feel informative rather than pressurised. For healthcare professionals supporting a family, it can be helpful to avoid making a referral solely on the basis of a visual oral finding. A concise feeding history, observed functional concerns, growth information where available and the family’s priorities make referral conversations more useful. Language matters too: describing a suspected restriction and its possible relevance is more accurate and kinder than implying a procedure is inevitable. When to seek timely clinical advice Feeding concerns can be distressing, especially when a baby seems unable to feed comfortably or a parent is in significant pain. Prompt advice from an appropriately qualified healthcare professional is particularly important if a baby is unusually sleepy and difficult to rouse for feeds, has fewer wet nappies than expected, shows concerns about weight gain, has signs of dehydration, develops a fever, or if you have breast pain with flu-like symptoms or a red, hot area of breast tissue. These concerns are not specific to tongue-tie and should not wait for an oral assessment alone. Your GP, maternity team, health visitor, NHS 111 or urgent care service can advise on the most appropriate route. Choosing care that feels considered For families, the value of a specialist assessment is not simply receiving a yes-or-no answer about tongue-tie. It is being listened to, having feeding observed in context, and being supported to make a decision that fits your baby and your circumstances. D-Restricted Ltd® provides this function-focused approach through specialist infant feeding and tongue-tie care. For practitioners, the same principle supports safer, more thoughtful care: avoid reducing a complex feeding presentation to a single anatomical finding, remain open to uncertainty, and work collaboratively across services when needed. Feeding can be emotional as well as physical. Whether the next step is skilled feeding support, watchful review, referral or consideration of frenulotomy, a compassionate assessment can help your family move forward with clearer information and reassurance. 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. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2015) ‘The development of a tongue assessment tool to assist with tongue-tie identification’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 100(4), pp. F344-F348. 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 Chinnadurai, S. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. 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.

A baby may have a visible lingual frenulum and feed comfortably. Another may have feeding difficulties, yet the frenulum may be only one part of a much wider clinical picture. A tongue-tie assessment is therefore not a search for a diagnosis based on appearance alone. It is a careful consideration of anatomy, tongue function, feeding, milk transfer or bottle-feeding efficiency, parental comfort, infant wellbeing and the family’s own priorities. For families, this approach can replace uncertainty with a clearer understanding of what may be contributing to feeding challenges. For healthcare professionals, it supports clinical reasoning rather than reliance on a single sign, score or management pathway. Anatomy provides information. Function provides context. Skilled lactation support can make a significant difference to families experiencing feeding challenges, whether a baby is breastfed, bottle-fed, or combination fed. An International Board Certified Lactation Consultant (IBCLC) is the highest internationally recognised credential in lactation care, with advanced training in infant feeding, milk transfer, oral function, feeding behaviours and the many factors that can influence feeding. An IBCLC can provide individualised, evidence-informed support to help understand your baby’s unique needs, identify potential barriers to feeding, and work alongside you to develop a plan that supports your feeding goals. Whether you are seeking support with breastfeeding, bottle feeding, expressing, or transitioning between feeding methods, skilled guidance can help families feel informed, supported and confident. Why appearance alone cannot answer the question The lingual frenulum is a normal structure. It varies in where it attaches, how it looks and how it interacts with the tissues beneath the tongue. The term ankyloglossia, often called tongue-tie, is generally used when that tissue is associated with restricted tongue movement and functional difficulty. The distinction matters: not every prominent, tight-looking or unusually placed frenulum causes a feeding problem. A visual oral examination can provide useful information, but it cannot establish the impact on feeding in isolation. Consensus guidance and position statements emphasise that ankyloglossia is a functional diagnosis, requiring a skilled breastfeeding assessment where breastfeeding concerns are present (Messner et al., 2020; Academy of Breastfeeding Medicine, 2021). This does not mean that a family’s observations should be discounted if feeding looks settled during an appointment. Feeding can vary across the day, and parents often notice patterns that a clinician cannot see in one feed: repeated slipping at the breast or bottle, long feeds, distress, coughing, dribbling, nipple pain, poor sleep between feeds, or a sense that feeding remains hard work. These experiences deserve careful listening, alongside appropriate assessment of infant growth, hydration and general health. What a professional tongue tie assessment brings together An International Board Certified Lactation Consultant is trained in the assessment and management of lactation and all infant feeding methods. In the context of suspected tongue-tie, a professional assessment considers the feeding relationship as well as the infant’s mouth. The conversation usually begins with the family’s story. When did the difficulty start? Has feeding ever felt comfortable or efficient? Is the concern at breast, bottle or both? Has there been a change in feeding behaviour, weight gain, milk supply or the parent’s comfort? Relevant birth history, prematurity, jaundice, medical history and previous feeding support can all shape the picture. Feeding observation is central. In breastfeeding, this may include how the baby approaches the breast, maintains attachment, coordinates sucking and swallowing, and responds during and after the feed. The clinician considers the parent’s experience too, including nipple pain, skin damage, recurrent blocked ducts or concerns about milk removal. These signs can be associated with restricted tongue function, but they can also occur for many other reasons. For bottle-feeding families, the assessment remains equally valid and important. It may consider seal, milk loss, coordination, pacing, signs of effort or fatigue, and whether feeding is comfortable and manageable for both baby and caregiver. The oral examination then contributes further information. Rather than focusing only on the appearance of the frenulum, a function-focused assessment considers the tongue’s movement and the way the infant uses it during feeding. The wider oral environment matters too. Palate shape, jaw movement, cheeks, lips, muscle tone, nasal congestion and signs of discomfort may influence feeding. A baby’s state also matters: a tired, hungry, unsettled or unwell infant may not show their usual feeding ability at a single appointment. Assessment tools can support consistency and communication between clinicians. However, they do not replace clinical judgement, a feeding assessment or the family’s account. The Academy of Breastfeeding Medicine advises that no assessment tool should be used as the sole basis for deciding whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). Considering other explanations for feeding difficulty Feeding difficulties are often multifactorial. A thorough assessment should keep a broad differential view rather than treating tongue-tie as the automatic explanation. For example, positioning and attachment may need adjustment; a parent’s milk production may require support; a baby may be coping with reflux-like symptoms, illness, congestion, prematurity or neurological immaturity. Birth experiences, maternal pain, anxiety around feeding and the practical reality of frequent night feeds can also affect the feeding relationship. Sometimes several factors are present at once. This wider consideration is not intended to delay appropriate care or suggest that a family must simply persist with pain. It is about ensuring that recommendations are proportionate to the findings. If an infant has a frenulum but feeds effectively, gains appropriately and the family has no concerns, intervention is unlikely to be helpful. If there is clear functional restriction alongside persistent feeding difficulty despite skilled support, it may be reasonable to discuss all management options. How evidence informs management conversations Evidence about frenulotomy and infant feeding needs to be interpreted carefully. A Cochrane review of randomised trials found that frenulotomy reduced maternal nipple pain in the short term, but evidence for sustained improvement in infant breastfeeding was less certain. The trials were small and had methodological limitations, including crossover between treatment groups (O’Shea et al., 2017). More recent professional guidance similarly supports selective rather than routine intervention. The American Academy of Pediatrics advises that clinicians should first identify and address other possible causes of breastfeeding difficulty, reserve frenulotomy for infants with significant functional impairment where non-surgical measures have not resolved the problem, and provide follow-up to assess outcomes (Thomas et al., 2024). For some families, skilled feeding support and time are the preferred first steps. For others, the assessment may lead to a discussion about referral for frenulotomy. In the UK, the infant procedure is called a frenulotomy. A balanced conversation should cover the uncertainty of individual outcomes, the potential benefits and risks, the alternatives, and the practical support needed whichever path is chosen. A frenulotomy is not a guarantee that feeding concerns will resolve, particularly where several factors are contributing. Equally, choosing conservative management is an active, supported plan, not an absence of care. The best route depends on the individual baby, the feeding assessment, the impact on the family and informed shared decision-making. Continuity matters after the assessment Families often need more than a single answer to the question, ‘Is it tongue-tie?’ They need someone to help make sense of the next few days and weeks. Follow-up can review feeding progress, comfort, weight trajectory where relevant, milk supply concerns and whether the agreed plan remains right for the family. For professionals, clear documentation is part of safe, collaborative care. It is helpful to record what was observed in the feed, the functional findings, other factors considered, the support offered and the family’s goals. This gives colleagues a meaningful clinical picture and avoids reducing a complex feeding experience to a label. Where a procedure is being considered, families should have an opportunity to ask questions without pressure. They should also know who to contact if feeding remains difficult afterwards. Compassionate care includes recognising that feeding decisions can carry physical, emotional and financial weight. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. 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. Thomas, J., Bunik, M., Holmes, A.V., Krishnaswami, S., McLeod, C., McNamara, J., Nelson, C., Perrin, E.M., Scher, J.M., Taylor, S. and Valle, L. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 153(2), e2023064052. A considered next step If feeding is painful, exhausting or worrying, you do not need to prove that tongue-tie is the cause before seeking support. A skilled, unhurried assessment can help you understand the whole picture and choose a next step that feels informed, respectful and right for your family.

A tongue-tie release can feel like a significant moment, particularly when feeding has been difficult, painful or worrying. Knowing what to expect after tongue-tie release can make the first few days feel more manageable. There is no single pattern of recovery: some babies feed more comfortably straight away, while others need time, feeding support or further assessment because feeding difficulties are often multifactorial. A release changes a restriction in oral tissue, but it does not automatically change feeding skills, milk supply, positioning, a baby’s state of regulation, or other factors that may be affecting feeding. Anatomy provides information; function provides context. The most helpful aftercare therefore combines calm observation, responsive feeding and access to skilled follow-up. The first hours after tongue-tie release Immediately after the procedure, the clinician will check that bleeding has settled and that your baby is well enough to feed and go home. A small amount of blood at the time of release can occur. Your clinician should explain what was seen, what is expected locally and how to contact them if you are concerned. Many babies are offered a feed soon afterwards. Some settle at the breast, chest or bottle readily; others may be tearful, tired or temporarily unsettled after being handled. Neither response predicts the eventual feeding outcome. Skin-to-skin contact, a quiet environment and feeding when your baby shows cues can be reassuring for both of you. It is understandable to hope for an immediate improvement, especially after a difficult feeding journey. Research suggests that frenotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes is less certain (O’Shea et al., 2017). In the FROSTTIE trial, which compared frenotomy alongside breastfeeding support with breastfeeding support alone, the study was unable to establish a clear difference in breastfeeding at three months, partly because recruitment and follow-up were challenging (Knight et al., 2023). These findings reinforce the value of individualised feeding care rather than promises about outcomes. What feeding changes might you notice? Some families notice a deeper attachment, less nipple compression, less clicking, more efficient milk transfer or a more relaxed bottle feed. Others notice little change at first. A baby may need time to explore a different range of tongue movement and coordinate this with sucking, swallowing and breathing. For breastfeeding or chestfeeding families, comfort matters, but so does observing the whole feed. Is your baby attaching and staying attached? Are you hearing or seeing swallowing when milk is available? Do breasts feel reasonably softer after some feeds? Is your baby producing wet and soiled nappies appropriate for their age, and following their own growth trajectory? A skilled infant feeding practitioner can help put these observations together. Bottle-feeding families may also notice changes in seal, dribbling, clicking, pace or fatigue. However, bottle-feeding difficulties can relate to feeding position, flow rate, timing, gastrointestinal discomfort, neurological maturity or other factors. A tongue-tie release should never be treated as the only explanation or solution without considering the wider clinical picture. It is also possible for feeding to feel temporarily less organised. An infant who has developed compensatory patterns may need supportive time to adapt. If feeds remain painful, lengthy, stressful or ineffective, this is a reason for review, not a sign that you have failed or that you simply need to persist alone. Milk supply and weight gain need their own attention Where milk transfer has been reduced before release, milk supply may have been affected. A release does not immediately restore supply. Families may need a tailored plan to protect or build supply while feeding skills are assessed, and to ensure that the baby is receiving enough milk in the meantime. This plan should be developed with an appropriately qualified professional and should respect the family’s feeding goals. Some families breastfeed, chestfeed, bottle feed expressed milk, use combination feeding or choose another route. Each deserves practical, non-judgemental support. Healing: what can be normal, and what needs review? The area beneath the tongue commonly changes appearance as it heals. It may look pale, white, yellowish or like a small patch of healing tissue. This appearance alone does not reliably indicate infection or a problem. It is usually more useful to consider your baby’s overall wellbeing, feeding, comfort and the advice provided by the releasing clinician. Babies may be a little unsettled for a day or two. Some seem to feed more frequently, while others are sleepy following a stressful day. Comfort measures should be discussed with the clinician responsible for your baby’s care, who can advise whether pain relief is appropriate and, if so, how it should be used safely for your infant’s age and health. Parents should seek urgent medical advice if bleeding does not stop with the measures advised by their clinician, if their baby has breathing difficulty, appears unusually floppy or unwell, refuses feeds persistently, has markedly fewer wet nappies, develops a fever, or if there is any concern about dehydration. Trust your instincts: a baby who seems significantly different from their usual self needs prompt assessment. Why follow-up is part of good care Follow-up is not simply a check of the healing area. It is an opportunity to revisit the reason for the release and assess whether feeding function and family wellbeing are improving. Depending on the circumstances, this may include observing a breast, chest or bottle feed; considering nipple trauma or pain; reviewing weight and milk transfer concerns; and identifying other factors that may need support. The Academy of Breastfeeding Medicine advises that decisions about frenotomy should be made through shared decision-making and skilled assessment of breastfeeding function, rather than on the appearance of a frenulum alone (Academy of Breastfeeding Medicine, 2021). The same principle applies afterwards. If the original concern continues, a thoughtful reassessment is more useful than assuming that further intervention is necessarily required. Some clinicians may recommend oral activities intended to support feeding, but the evidence base for post-procedural regimens remains limited. In particular, the American Academy of Pediatrics advises against recommending post-frenotomy stretching exercises that involve parents repeatedly opening the wound, as evidence for benefit is lacking (Thomas et al., 2024). Families should not feel pressured to undertake painful or distressing wound-focused practices. Follow the specific aftercare advice given by the clinician who assessed and treated your baby, and ask for clarification if anything feels unclear. When to arrange a non-urgent review Contact your tongue-tie or infant feeding provider if pain during breastfeeding or chestfeeding is not improving, if your baby’s feeding remains difficult, or if you are worried about milk intake, weight gain or your baby’s comfort. A review is also sensible if you are unsure whether the healing appearance is within the range you were advised to expect. For healthcare professionals, persistent symptoms should prompt careful clinical reasoning. Consider feeding history, perinatal history, breast and nipple factors, bottle-feeding mechanics where relevant, milk availability, infant health, growth, positioning and attachment, and the possibility of differential diagnoses. Avoid attributing every ongoing concern to the frenulum or to the release itself. At D-Restricted Ltd®, structured aftercare is designed to recognise that a procedure is only one part of a family’s feeding journey. Continuity, clear safety-netting and skilled feeding support can make the period after release feel less uncertain. Give your baby, and yourself, time The days after a tongue-tie release can bring relief, questions and sometimes mixed emotions. Look for gradual functional changes rather than a perfect feed overnight, and seek help early if feeding still feels difficult. Every feeding journey deserves support, compassion and reassurance. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Knight, M., Kwasnicka, D., Muirhead, L., et al. (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). 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., Bunik, M., Holmes, A., et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report’, Pediatrics, 153(2), e2024067605.

A breastfeeding latch can look acceptable from across the room while the parent is gripping the chair, dreading the next feed or noticing increasingly damaged nipples. Painful breastfeeding latch support begins by taking that experience seriously. Pain that persists beyond the initial settling-in period, worsens during feeds or leaves the nipple visibly changed afterwards deserves skilled, compassionate assessment - not reassurance that feeding simply has to hurt. Some tenderness can occur in the early days after birth, particularly while feeding is being established. However, ongoing pain is not something a parent should be expected to endure. It can affect feeding frequency, milk removal, confidence and emotional wellbeing. The aim is not to find one quick explanation, but to understand what is happening for this individual parent and baby. What skilled painful breastfeeding latch support looks at An effective consultation considers the whole feeding picture. This includes the parent’s account of when pain began, where it is felt, whether it occurs on attachment, throughout the feed or afterwards, and what the nipple looks and feels like following a feed. A detailed feeding history also matters: birth and postnatal events, milk supply concerns, expressing, supplements where used, the baby’s feeding pattern, output, weight trajectory and any signs of illness can all provide useful context. Observing a feed is often valuable. It allows a practitioner to consider how the baby approaches the breast, their position and stability, the depth and comfort of attachment, audible swallowing, the rhythm of sucking and pauses, and how the parent and baby respond to one another. A feed is dynamic, not a test that a baby passes or fails in a few minutes. Breastfeeding pain is multifactorial. Positioning and attachment may contribute, but so may breast fullness, nipple shape, engorgement, skin conditions, vasospasm, infection, pumping-related trauma or a baby who is tired, unwell or finding coordination difficult. The Academy of Breastfeeding Medicine recommends a careful history and examination of both parent and infant when pain persists, rather than treating pain as a diagnosis in itself (Berens et al., 2016). Comfort and milk transfer are related, but not identical A deep, comfortable latch can support effective milk transfer, but pain alone does not tell us exactly how much milk a baby is taking. Equally, audible swallowing or a seemingly settled baby does not mean a parent’s pain should be dismissed. Looking at the feeding relationship alongside the baby’s growth, nappies and overall wellbeing gives a more reliable picture. Where changes in position or attachment are appropriate, they should be individualised and gentle. Often, helping a parent find a supported, comfortable position and allowing the baby to come close with their body well aligned can make a meaningful difference. In other situations, pain may remain despite thoughtful adjustments, indicating the need to broaden the assessment. When tongue function may be part of the picture Tongue-tie is sometimes considered when there is persistent nipple pain, nipple trauma, repeated loss of attachment, clicking, prolonged feeds, unsettled feeding or concerns about milk transfer. These signs are not specific to tongue-tie, and the presence of a visible frenulum alone does not establish that it is affecting feeding. Anatomy provides information. Function provides context. A meaningful tongue-tie assessment therefore considers oral anatomy alongside the baby’s tongue movement and feeding function, the breastfeeding assessment, the parent’s symptoms and the wider clinical history. It also considers differential explanations. This protects families from both extremes: having their concerns minimised, or being led to believe that one anatomical finding explains every feeding difficulty. The evidence for frenotomy is nuanced. A Cochrane review found that frenotomy may reduce maternal nipple pain in the short term, but evidence for longer-term breastfeeding outcomes remains limited, partly because studies are small and use different outcome measures (O’Shea et al., 2017). The Academy of Breastfeeding Medicine similarly advises that decisions should be based on a skilled breastfeeding assessment and evidence of functional restriction, within shared decision-making (LeFort et al., 2021). For some families, conservative feeding support and review are appropriate. For others, a specialist functional assessment may inform whether a referral or discussion of treatment options is warranted. No pathway should be assumed in advance, and no intervention can guarantee a particular feeding outcome. Continuity of support before and after any decision is as important as the decision itself. Practical steps while you arrange support If feeding is painful, seek help early from an appropriately qualified infant feeding professional, midwife, health visitor or GP, depending on the concerns. A prompt review may help prevent worsening nipple damage and reduce the strain of trying to manage alone. Until you are seen, it can help to notice patterns rather than repeatedly trying to perfect a latch by force. Consider whether pain is greatest at initial attachment or later in the feed; whether one side is consistently harder; whether the nipple emerges compressed, creased, blanched or damaged; and whether your baby seems satisfied after feeds. These observations can help shape a consultation. Gentle repositioning may be useful if it improves comfort, but stop and seek guidance if attempts are causing more pain or distress. If a baby is not feeding effectively at the breast, a tailored feeding plan may be needed to protect both the baby’s intake and the parent’s milk production. This plan should respect the family’s circumstances and feeding goals, whether those involve direct breastfeeding, expressing, combination feeding or bottle feeding. Pain can make feeding feel urgent and emotionally loaded. Support should make space for that. Families do not need to prove their pain, nor do they need to make major decisions during a single difficult feed. When to seek urgent medical advice Contact a midwife, GP, NHS 111 or urgent care service promptly if you or your baby are unwell. This includes a baby who is unusually sleepy, difficult to wake for feeds, feeding much less than usual, showing fewer wet nappies, appearing jaundiced or having a fever. For the breastfeeding parent, seek prompt advice for fever, flu-like symptoms, a hot or painful area of breast, rapidly worsening redness, severe nipple damage, or pain that is intense or unexplained. These symptoms do not always mean there is a serious problem, but they need timely clinical assessment. A feeding consultation complements medical care; it does not replace it. For professionals: keep assessment relational and reflective Professionals supporting painful breastfeeding latches can reduce harm by avoiding single-cause explanations. Listen to the parent’s description of pain, observe feeding where possible and assess parent and baby together. Record functional observations clearly, including what changed with support and what did not. This creates a better foundation for clinical reasoning and for conversations with other members of the care team. It is also worth acknowledging the limits of the evidence. Research on breastfeeding pain and tongue-tie is developing, but outcome measures, populations and intervention pathways vary. Families benefit from transparent discussions about what is known, what remains uncertain and the options available to them. NICE guidance recommends practical, responsive postnatal breastfeeding support, including assessment of positioning and attachment when difficulties arise (NICE, 2021). The most helpful next step is often not a perfect answer, but a careful assessment that leaves a parent feeling heard, safer and clearer about what to do next. Every feeding journey deserves that level of care. References Berens, P., Brodribb, W., Chantry, C., Davis, M.K., Eglash, A., Noble, L., O’Connor, M.E., Pinney, J. and Stuebe, A.M. (2016) ‘ABM Clinical Protocol #26: Persistent pain with breastfeeding’, Breastfeeding Medicine, 11(2), pp. 46-53. LeFort, Y., Evans, A., Livingstone, V., Douglas, P., Dahlquist, N.R., Donnelly, B., Forgione, N., Godwin, J., Leeper, K. and O’Connor, M.E. (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) (2021) Postnatal care: NICE guideline NG194. 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.

A feed can look calm from across the room while a baby is working very hard for very little milk. Equally, a noisy or fussy feed is not automatically a sign of poor transfer. The signs of poor milk transfer baby may show need to be considered alongside weight, nappy output, feeding history, the parent’s comfort and the baby’s overall health. Milk transfer means the movement of milk from the breast or chest into the baby. It is not the same as simply being attached, sucking, or spending a long time at a feed. When transfer is effective, most babies feed with periods of active, rhythmic sucking and swallowing, and show signs of satisfaction and appropriate growth over time. There is normal variation, especially in the early days, so one difficult feed rarely tells the whole story. What signs of poor milk transfer can look like A baby who is not transferring milk efficiently may feed very frequently, remain unsettled after many feeds, or spend prolonged periods feeding with little clear swallowing. They may repeatedly come on and off the breast or chest, fall asleep soon after latching and then wake quickly seeming still hungry. Some babies appear frustrated, pull back, fuss or cry during feeds. These behaviours are clues, not a diagnosis. Frequent feeding can also be normal newborn behaviour, can increase during developmental change, and may help establish milk production. Some babies feed effectively in short, frequent bursts; others take longer. Looking for a pattern across a full day is more useful than judging a single feed. Feeding behaviour and swallowing During active milk transfer, sucking usually changes from quicker, lighter sucks at the start to deeper, rhythmic sucks with pauses and audible or visible swallows. Swallowing may be quiet, particularly with abundant milk flow, so its absence by sound alone is not conclusive. Possible concerns include very few observed swallows once the initial flow has passed, persistent flutter sucking without deeper nutritive sucking, frequent slipping off, or a baby who seems unable to sustain a feed. Clicking can occur for several reasons, including changes in seal, positioning, milk flow or oral function. It should prompt curious observation rather than an assumption about cause. Nappies, weight and wellbeing Nappy output and weight trends provide important context. In the first days after birth, clinicians consider the baby’s age, changing stools and the expected course of early weight loss before interpreting output. After the milk supply increases, persistently low urine or stool output, very concentrated urine, ongoing lethargy, or inadequate weight gain can indicate that feeding needs prompt review. Weight is best interpreted as a trend using accurate measurements, rather than as one isolated number. NICE advises assessment when a newborn has lost more than 10% of birth weight, including a clinical review, detailed feeding history and direct observation of feeding (NICE, 2017). A weight concern is never simply a number to explain away, but neither does it identify the reason on its own. Seek urgent medical advice if a baby is difficult to wake for feeds, has fewer wet nappies than expected for their age, appears increasingly jaundiced or unwell, has a dry mouth, fever, breathing difficulty, or you are worried that they are not taking enough milk. Trust the concern that something has changed. The parent’s experience matters too Poor transfer can be accompanied by painful, pinched or damaged nipples, repeated blocked ducts, breast or chest discomfort after feeds, or a sense that the baby never seems to soften the breast or chest. These experiences deserve skilled support. Pain is common in early feeding but should not be treated as something a parent simply has to endure. At the same time, breast or chest fullness after a feed does not reliably measure how much milk a baby has taken. Milk production, storage capacity, the timing of a feed and individual anatomy all vary. A parent may have discomfort despite adequate transfer, or feel soft after feeding while a baby still needs a closer assessment. For bottle-fed or combination-fed babies, possible signs can include very prolonged feeds, milk leaking repeatedly from the mouth, coughing or spluttering, marked fatigue, distress, or difficulty maintaining a coordinated suck-swallow-breathe pattern. Bottle-feeding assessment should include the feeding position, teat flow, pacing, the baby’s health and their individual feeding skills. Feeding difficulties are not exclusive to breastfeeding. Why the cause is rarely just one thing Milk transfer is a relationship between a baby, a lactating parent, milk supply and the feeding environment. Positioning and attachment, breast or chest fullness, delayed onset of increased milk production, prematurity, jaundice, illness, reflux-like symptoms, neurological or developmental factors and parental pain can all influence feeding. Infant oral anatomy may be relevant for some babies, but anatomy alone cannot establish that it is causing a feeding difficulty. A visible lingual frenulum is common, and not every tongue-tie restricts function or requires treatment. A functional assessment considers what happens during feeding, the baby’s oral movement, feeding history, growth and the family’s priorities. As the D-Restricted Ltd® clinical philosophy puts it: anatomy provides information; function provides context. Evidence on frenotomy indicates that it may reduce maternal nipple pain in some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains limited and variable (O’Shea et al., 2017). This is why careful differential assessment and follow-up matter. There is no single sign, photograph or score that can replace observing feeding and listening to the family. What a skilled feeding assessment involves A thorough assessment begins with the story. When did the concern begin? How often is the baby feeding? What is happening with nappies, weight and general wellbeing? Is feeding painful? Has there been a change since birth, illness, or a shift in milk supply? A clinician may then observe a feed, considering the baby’s state and positioning, attachment, sucking pattern, swallowing, comfort and response after feeding. They may also review relevant maternal and infant health factors. If oral function is a concern, this should form part of a wider assessment rather than becoming the whole explanation. Occasionally, pre- and post-feed weights are used to estimate intake at one feed. They can be helpful when performed with appropriate equipment and interpreted by an experienced clinician, but they represent only that feed. Research has found test weighing can lack sufficient precision for routine estimation of an individual newborn feed, particularly where small volumes are involved (Savenije and Brand, 2006). A longer-term picture remains essential. While you are arranging support If your baby is well but feeding is difficult, protect the feeding relationship by seeking timely, hands-on support. A midwife, health visitor, GP, infant feeding specialist or IBCLC can help assess what is happening. It may be useful to record feeds, nappy output, any pain, and the timing of weight checks, not as a test you must pass, but to give the clinician a clearer picture. Avoid making major changes based on a single challenging day or an online checklist. If supplementation, expressing or a change in feeding plan is being considered, individualised guidance can help balance the baby’s immediate nutritional needs with the parent’s feeding goals and wellbeing. NICE recommends that decisions around feeding support and supplementation are made following assessment and discussion with parents (NICE, 2017). Families deserve clear information without blame. Whether feeding is directly at the breast or chest, by expressed milk, bottle, combination feeding or another route, the priority is a well-supported baby and parent. When milk transfer feels uncertain, a calm assessment can replace guesswork with a plan that fits your baby, your body and your family. References National Institute for Health and Care Excellence (NICE) (2017) Faltering growth: recognition and management of faltering growth in children. NICE guideline NG75. London: NICE. National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. 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. Savenije, O.E.M. and Brand, P.L.P. (2006) ‘Accuracy and precision of test weighing to assess milk intake in newborn infants’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 91(5), pp. F330-F332. World Health Organization (2017) Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018. Geneva: World Health Organization.

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.

A baby can take a bottle and still find feeding hard. Bottle feeding with a tongue-tie baby may involve dribbling, frequent breaks, clicking sounds, very long feeds or distress, but these signs do not confirm a tongue-tie on their own. They can also arise from milk flow, positioning, feeding pace, temporary nasal congestion, reflux-like symptoms, immature coordination or an underlying health concern. For families, the priority is not proving that a tongue-tie is present. It is understanding whether feeding is comfortable, safe, efficient enough for the baby’s needs and manageable for the people caring for them. Anatomy provides information. Function provides context. What tongue-tie may mean for bottle feeding Tongue-tie, also called ankyloglossia, describes variation in the tissue beneath the tongue. A visible frenulum is normal anatomy. The clinically relevant question is whether its characteristics are associated with restricted tongue movement and meaningful feeding difficulty in that individual baby. Bottle feeding requires an infant to coordinate sucking, swallowing and breathing while maintaining a stable seal around the teat. Some babies with restricted tongue movement may compensate effectively. Others may use extra jaw movement, lose their seal repeatedly or tire during feeds. Yet tongue appearance alone cannot reliably predict function or feeding outcome. Anatomical research has also challenged simplistic descriptions of the lingual frenulum as a discrete string of tissue, reinforcing the need for careful, whole-baby assessment rather than visual grading in isolation (Mills et al., 2019). The evidence base on tongue-tie is weighted towards breastfeeding. Systematic reviews and randomised trials have primarily considered maternal nipple pain and breastfeeding measures, not bottle-feeding outcomes (O’Shea et al., 2017; Francis et al., 2015). This does not mean that bottle-feeding difficulties are unimportant. It means that claims about cause and effect, or about the likely benefit of any intervention for bottle feeding, need to remain measured. Signs worth discussing in bottle feeding with a tongue-tie baby A single sign is rarely enough to explain a feeding problem. It can be useful to notice patterns over several feeds and to consider the baby’s comfort, alertness, growth and nappy output alongside what happens at the bottle. Families may describe milk leaking from the corners of the mouth, clicking, coughing or spluttering, frequent loss of suction, unusual fatigue, feeds that consistently take a long time, or a baby who appears unsettled shortly after feeding. Some babies seem to need many pauses, while others become upset at the start of a feed. Caregivers may also notice that holding the bottle feels physically demanding because the baby needs frequent readjustment. These observations deserve to be heard, but they are not diagnostic of a tongue-tie. A faster-flowing teat may overwhelm a baby who is still developing suck-swallow-breathe coordination, whereas a slower flow may be frustrating or tiring for another baby. Feeding behaviour can also change with growth, illness and time of day. The Clinical Consensus Statement on ankyloglossia similarly emphasises that diagnosis and management require clinical judgement rather than reliance on one feature alone (Messner et al., 2020). Start with feeding support and the wider picture For a well baby who is gaining weight and having appropriate wet nappies, a skilled feeding review is often a sensible first step. This should include a detailed history and observation of a feed where possible. It is helpful to consider gestation at birth, medical history, breathing, muscle tone, oral comfort, feeding environment, bottle flow and the family’s goals. Responsive bottle feeding can reduce pressure for many families. Holding the baby close and supported, allowing pauses, keeping the bottle at an angle that does not flood the teat, and responding to early cues of stress or fullness can help a baby regulate the feed. These are general feeding principles, not a treatment for tongue-tie, and the best approach will vary between babies. When feeds are difficult, changing several things at once can make it hard to see what has helped. A clinician may suggest making one considered adjustment, observing the effect and reviewing again. This approach respects both the uncertainty in the evidence and the reality that families need practical relief now. When to seek timely medical advice Seek prompt advice from a midwife, health visitor, GP, paediatric team or urgent service if a baby has markedly fewer wet nappies, appears unusually sleepy or difficult to rouse, repeatedly coughs or chokes during feeds, has breathing changes or colour change, persistently vomits, seems unwell, or there are concerns about weight gain. These signs are not specific to tongue-tie and should not be attributed to oral anatomy without appropriate medical consideration. What a specialist assessment should consider A thoughtful tongue-tie and feeding assessment is not simply a look under the tongue. It brings together the family’s experience, feeding history, infant health, observed oral function and an observation of feeding where appropriate. It should also explore other plausible contributors before concluding that a frenulum is the main issue. For bottle-feeding families, useful questions include: Is the baby transferring enough milk comfortably? Are feeds sustainable for the family? Is there evidence of respiratory, neurological, gastrointestinal or structural factors that need another professional’s input? What has already been tried, and what matters most to the parents or caregivers? This is particularly important because feeding concerns can be multifactorial. A baby may have a restrictive frenulum and also have difficulty managing milk flow. Another may have a prominent frenulum but feed comfortably and grow well. Neither situation should be reduced to a label. Considering conservative care or surgical release Conservative feeding support is a valid management option, particularly where the baby is well and functional feeding can improve with adjustments, time and skilled guidance. Ongoing review matters because a family’s experience can change, and because feeding goals deserve to be revisited without judgement. In some circumstances, following a comprehensive assessment and shared discussion, a surgical release may be considered. Research suggests frenotomy can reduce maternal nipple pain in some breastfeeding dyads in the short term, but the certainty and scope of evidence vary, and longer-term outcomes are less clear (O’Shea et al., 2017). Evidence specifically demonstrating improved bottle feeding after release remains limited. It is therefore not possible to promise that a procedure will resolve dribbling, unsettled behaviour, lengthy feeds or other bottle-feeding concerns. Families considering any intervention should receive clear information about the potential benefits, limitations, uncertainties, alternatives and follow-up arrangements. They should also feel able to choose conservative management, seek another opinion or take time to decide. The Academy of Breastfeeding Medicine advises that decisions should be grounded in skilled breastfeeding assessment and clinical context, a principle that is equally valuable when considering feeding function more broadly (Academy of Breastfeeding Medicine, 2021). Supporting the family, not just the feed Bottle feeding may be temporary, exclusive, combined with breastfeeding or part of expressing milk for a baby who cannot feed directly at the breast or chest. Each pathway is worthy of respectful support. The emotional load of difficult feeding can be considerable, especially when advice has been conflicting or when caregivers feel they must keep trying without clarity. Keeping a brief record of what happens during feeds can help a consultation feel more productive. Note the usual feed length, breaks, milk loss, signs of distress, the baby’s nappy output and weight information if available. Short video clips can sometimes be useful for a clinician, provided they are shared securely and only if requested. The most helpful next step is usually a conversation with a suitably qualified professional who can observe function, listen to the family and consider the whole clinical picture. A feeding journey does not need to fit a neat explanation to deserve support, compassion and reassurance. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., McPheeters, M. and Krishnaswami, S. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: A systematic review’, Pediatrics, 135(6), pp. e1458-e1466. 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., Simons, J.P., Tunkel, D.E., Yellon, R.F. and Mitchell, R.B. (2020) ‘Clinical Consensus Statement: Ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. Mills, N., Keough, N., Geddes, D.T., Pransky, S.M. and Mirjalili, S.A. (2019) ‘What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum’, Clinical Anatomy, 32(6), pp. 749-761. 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.

A frenotomy appointment can bring relief that a family is being listened to, alongside understandable nerves about what may happen next. If you are wondering how to prepare for frenotomy, the most useful starting point is not a long checklist. It is ensuring that the decision sits within a careful assessment of your baby’s tongue function, feeding and your family’s experience. A visible lingual frenulum is common and, on its own, does not tell us whether it is causing difficulty. Anatomy provides information. Function provides context. Some babies with a restricted lingual frenulum feed comfortably and gain weight as expected; others may have feeding challenges that deserve skilled, timely support. Those challenges can also have more than one cause. Preparation therefore includes making space for questions, feeding assessment and shared decision-making, rather than feeling that a procedure is the only possible route. Preparing for frenotomy starts with a full picture Before a frenotomy is considered, ask whether your clinician has explored how feeding is working as well as what the mouth looks like. For a breastfed or chestfed baby, this may include observing positioning and attachment, comfort, milk transfer, feeding frequency, infant weight pattern and breast health. For a bottle-fed baby, it may include observing the feed, suck-swallow-breathe coordination, teat flow, pacing, comfort and any milk loss or fatigue. If you pump, flange fit and pumping comfort may also be relevant. This wider assessment matters because research on frenotomy has limitations. Systematic reviews suggest that frenotomy may reduce maternal nipple pain in the short term for some breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains less certain (O’Shea et al., 2017; Academy of Breastfeeding Medicine, 2021). A UK randomised trial also found that feeding support remained central, whether or not frenotomy occurred (Knight et al., 2023). That does not make a family’s feeding difficulty any less real. It means the most thoughtful plan is individual. Ask what findings support the recommendation, what other factors have been considered and what support is available if you choose conservative management, proceed with frenotomy or need to reassess later. Questions to ask before you consent Consent should be a conversation, not simply a form to sign. A clinician should explain the expected purpose of frenotomy in relation to your baby’s feeding, likely benefits and limitations, possible risks, alternatives and the plan for follow-up. You should have enough time to decide and should not feel pressured by a difficult feeding day, social media messages or the experiences of others. It can help to write down your questions in advance. You may wish to ask about the clinician’s assessment of tongue function; what feeding changes would be realistic to hope for; what might not change after release; how discomfort is managed; what bleeding or unsettled behaviour can occur; and how to contact the service if you are concerned afterwards. Ask, too, what ongoing feeding support will be offered. A procedure does not replace skilled lactation or infant feeding care. For healthcare professionals supporting families, clear language is especially important. Avoid framing frenotomy as a cure for broad concerns such as sleep, speech, posture or future dental development. The available evidence does not support making these predictions for an individual infant. The focus should remain on current function, feeding goals, clinical findings and the family’s informed preferences (Messner et al., 2020). Practical preparation for the appointment Each service will provide its own instructions, which should always take priority. In general, keeping the day as ordinary and calm as possible is helpful. Dress your baby in clothing that allows easy access for cuddles and feeding afterwards, and allow extra time so you are not rushed. If possible, bring another trusted adult. They can drive, hold bags, listen to information while you focus on your baby, or simply provide reassurance. If you are attending alone, tell the clinic beforehand. Specialist services are used to supporting families in different circumstances. Bring any information that gives a clear picture of feeding so far, such as your baby’s red book, recent weight details, a list of medicines or health conditions, and notes from your midwife, health visitor, GP or feeding supporter where relevant. It is also useful to share whether your baby was born prematurely, has had jaundice, has a bleeding condition in the family, received vitamin K after birth, or has any current illness. These details can affect whether a procedure is appropriate that day. Try not to make major feeding changes immediately before the appointment unless you have been advised to do so for your baby’s wellbeing. Continue responding to feeding cues and following the plan already agreed with your maternity, neonatal or infant feeding team. If feeding is painful, exhausting or worrying, seek support promptly rather than waiting for an appointment date. Feed and comfort plans Many babies are offered a feed or comfort soon after frenotomy, where this is appropriate for them and their family. Think about what helps your baby settle: feeding at the breast or chest, bottle feeding, a familiar blanket, skin-to-skin contact, walking, rocking or a dummy if you use one. There is no requirement to feed in a particular way to demonstrate success. Some babies feed straight away; others need time, rest and gentle support to adjust. If you use expressed milk, bring what you would normally need for an outing, following safe storage guidance. Formula-feeding and combination-feeding families deserve the same individualised care and support. The aim is a comfortable, safe and sustainable feeding relationship that fits your baby and family. Plan for the first few days, not just the appointment It is sensible to keep the period after the appointment relatively quiet where you can. You do not need to isolate yourselves at home, but avoiding unnecessary commitments may give you more time to observe feeding, rest and ask for help. If you have older children, arranging practical support can make the day feel more manageable. Ask the clinician exactly what aftercare they provide. Changes may be immediate for some dyads, while others are gradual or less marked. A baby may need support with positioning, attachment, bottle-feeding pace or settling into a new feeding pattern. Occasionally, ongoing feeding difficulty points towards factors beyond the frenulum and needs further assessment. Do not begin exercises or techniques involving a healing wound unless they are specifically advised by the clinician responsible for your baby’s care. Advice in this area varies, and the evidence base is still developing. What should be consistent is access to clear safety-netting information and responsive feeding support. D-Restricted Ltd does not recommend any exercises that involves interfering with an open wound (www.tongue-tie.org.uk/position-statements). Before leaving the clinic, make sure you understand whom to contact and how. Seek urgent medical advice if your baby has bleeding that does not stop with the guidance you have been given, breathing difficulty, marked lethargy, refuses several feeds, has significantly fewer wet nappies, develops a fever, or you are otherwise seriously concerned. Trust your instincts: you know when your baby is not themselves. Supporting the person feeding the baby Preparation is also about you. Painful or difficult feeding can be physically draining and emotionally heavy, particularly when it has involved repeated advice, interrupted sleep or worries about weight gain. You do not have to prove that feeding has been hard enough to deserve compassionate care. Consider what would help you feel supported after the appointment: a partner taking over meals, someone checking in, a follow-up feeding consultation, or a protected period without visitors. If you are experiencing persistent nipple trauma, breast pain, low mood, anxiety or thoughts that feel frightening, tell a healthcare professional. Your wellbeing matters alongside your baby’s feeding. For families in the Midlands, D-Restricted Ltd® combines tongue-tie assessment and, where clinically indicated, frenotomy with structured aftercare and infant feeding support. Wherever you access care, look for a service that takes time to understand your feeding journey and offers a clear route back for review. A well-prepared frenotomy appointment is not about arriving with every answer. It is about being heard, having balanced information and leaving with a plan that supports both your baby and the person feeding them. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Knight, M., Ramakrishnan, R., Waugh, R. et al. (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. 1-112. Messner, A.H., Walsh, J., Rosenfeld, R.M. et al. (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. et al. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065.

A visible lingual frenulum can prompt understandable questions from families and clinicians alike. High-quality tongue tie training for healthcare professionals creates space for better questions: what is happening during this particular infant’s feed, what else may be contributing, and what support is most appropriate now? It moves practice away from assumptions based on appearance alone and towards thoughtful, family-centred clinical reasoning. Infant feeding can be physically and emotionally demanding. When a baby is unsettled at the breast or bottle, when feeding is painful, or when parents are worried about intake, professionals have an important role in listening carefully, assessing the wider picture and helping families make informed choices. Not every restricted frenulum causes feeding difficulty, and not every feeding difficulty is explained by a tongue-tie. Why tongue tie training for healthcare professionals matters A tongue-tie, or ankyloglossia, describes a lingual frenulum that may restrict tongue movement. The clinical significance lies not in the presence of tissue alone, but in whether movement is restricted in a way that is relevant to function. This distinction is central. Anatomy provides information. Function provides context. Feeding concerns are often multifactorial. They may relate to positioning and attachment, the infant’s gestational age and health, breast or chest anatomy, milk supply, flow preference, bottle-feeding dynamics, neurodevelopmental factors, maternal pain, previous feeding experiences or the practical realities facing a family. A skilled practitioner does not need to dismiss the possibility of tongue restriction to consider these factors. Both can be true: a frenulum may be present, and other support may still be needed. Training should therefore help professionals develop a structured way to gather a history, consider feeding observations and identify signs that require timely referral. It should also support clear communication when the picture is uncertain. Families deserve honesty about what is known, what remains unclear and what options are available. Tongue tie training in the UK Before choosing a tongue-tie release provider, it's worth taking a few simple steps to check they are appropriately qualified. The National Institute for Health and Care Excellence (NICE) Interventional Procedures Guidance IPG149 (2005) states that division of ankyloglossia (tongue-tie) for breastfeeding should only be performed by registered healthcare professionals who are appropriately trained. In the UK, providers should be registered with an appropriate professional regulator and, where applicable, the relevant national service regulator. While there are nine professional healthcare regulators in the UK, tongue-tie release currently falls within the professional scope of practice of registrants of the Nursing and Midwifery Council (NMC), General Medical Council (GMC) and General Dental Council (GDC). In England, services may be regulated by the Care Quality Commission (CQC), in Scotland by Healthcare Improvement Scotland (HIS), and in Northern Ireland by the Regulation and Quality Improvement Authority (RQIA). In Wales, providers should still be appropriately trained and professionally regulated by the NMC, GMC or GDC, although there is currently no equivalent service regulator for parents to check for tongue-tie services. Parents should feel confident asking for a practitioner's professional registration number, details of their tongue-tie training, experience, and professional indemnity insurance. A reputable provider will be happy to explain their qualifications, how they assess whether a tongue-tie release is clinically appropriate, and the standards under which they practise. The Association of Tongue-tie Practitioners (ATP) also provides a Find a Practitioner directory, which can be a useful starting point when looking for a provider. However, parents should always independently verify a practitioner's professional registration and regulatory status before proceeding with treatment. Evidence should inform, not replace, clinical reasoning The evidence base for infant frenulotomy is nuanced. A Cochrane review of five randomised controlled trials involving 302 infants found that frenulotomy was associated with reduced maternal nipple pain in the short term. However, evidence for improvement in infant breastfeeding outcomes was inconsistent, and the studies were generally small with methodological limitations (O’Shea et al., 2017). A systematic review similarly found that the available evidence suggested possible short-term improvements in breastfeeding outcomes, while concluding that the strength of evidence was low and that longer-term outcomes were insufficiently studied (Francis et al., 2015). These findings do not mean that families’ reported improvements are unimportant. They do mean clinicians should avoid promising a particular outcome, or presenting a procedure as the automatic answer to complex feeding concerns. National Institute for Health and Care Excellence guidance states that there are no major safety concerns for division of ankyloglossia for breastfeeding when appropriately trained practitioners undertake it, while recognising that evidence of efficacy is limited (NICE, 2005). Although this guidance remains relevant, professional learning should be responsive to the evolving evidence base and transparent about its limitations. For healthcare professionals, the practical implication is not indecision. It is proportionate decision-making. Where there is a clear functional concern alongside feeding difficulty, specialist assessment may be appropriate. Where function appears adequate, or where other factors are more likely to explain the difficulty, focused feeding support and review may be the most helpful first step. Sometimes the right plan includes both. Avoiding appearance-led decisions Training can be unhelpful when it encourages professionals to label, classify or refer based primarily on visual findings. A frenulum’s appearance does not reliably tell us how an infant feeds, transfers milk or manages a bottle teat. Equally, feeding symptoms alone do not establish that a tongue restriction is their cause. A stronger educational approach considers the infant and parent as a feeding dyad. It explores the onset and pattern of symptoms, the feeding relationship, growth and wellbeing where relevant, parental priorities, previous support and the baby’s oral function in context. This does not require every professional to become a specialist tongue-tie clinician. It does require practitioners to know the boundaries of their own role and when collaborative input is needed. What meaningful professional education should cover The most useful training does more than offer terminology. It develops the ability to pause, question and make defensible decisions. Core learning should include infant oral anatomy and development, the relationship between tongue movement and feeding function, principles of feeding assessment, differential diagnosis, conservative management and considerations around referral for specialist assessment. It should also address the realities of both breastfeeding and bottle feeding. Bottle-fed infants can experience feeding challenges, and they deserve the same careful, non-judgemental consideration. The aim is not to privilege one feeding pathway over another, but to support comfort, safety, responsive feeding and family wellbeing. Good education makes room for uncertainty. It teaches professionals to distinguish established evidence from emerging evidence and expert opinion. It encourages reflective practice rather than reliance on a single score, photograph or explanation. It also addresses the importance of continuity: a family may need skilled feeding support before a specialist opinion, after a frenulotomy, or when a procedure is not chosen or is not clinically indicated. Tongue-tie School is designed around this principle, supporting learners to build evidence-informed knowledge of anatomy, function, assessment principles, differential diagnosis, conservative approaches and aftercare considerations. Professional education can strengthen clinical conversations and referral decisions, but it does not replace the training, governance and clinical competence required to undertake an infant frenulotomy. Communication is part of safe care Families may arrive having heard confident claims online about tongue-tie causing a wide range of difficulties. They may also have felt dismissed when raising genuine feeding concerns. Neither extreme supports informed decision-making. Healthcare professionals can offer a calmer, more balanced message: a restricted frenulum may be relevant for some infants, but feeding difficulties have many possible contributors. A thorough assessment can help clarify the next step. That next step may be feeding support, monitoring, referral to an appropriately qualified clinician, or a combination of these options. Language matters. Rather than saying a baby “needs” a procedure, clinicians can explain why a specialist opinion is being considered and what it may involve. Rather than describing conservative management as doing nothing, they can acknowledge the skilled work involved in improving feeding comfort and effectiveness. Parents and caregivers should have time to ask questions, express their goals and make choices without pressure. Building a joined-up pathway The value of training is most visible when it improves the pathway around a family. Midwives, health visitors, nurses, lactation consultants, infant feeding specialists, GPs, paediatric teams and birth workers may each hold part of the picture. Shared language and respectful communication can reduce repeated assessments, contradictory advice and delays in appropriate support. Referral pathways should be clear about urgency, scope and follow-up. A specialist assessment should be function-focused and should not presume that an intervention will be recommended. If frenulotomy is considered, families need balanced information about potential benefits, limitations, risks and the support available afterwards. Feeding support remains relevant regardless of the management decision. Professional confidence is not about having a quick answer whenever a frenulum is seen. It is about being able to listen without judgement, recognise uncertainty, use evidence responsibly and ensure that each family feels heard, informed and supported at the next step. If you are a healthcare provider For healthcare professionals supporting infants and families affected by tongue-tie, developing a thorough understanding of oral function, assessment and treatment considerations is an important part of providing informed care. Specialist education can help practitioners understand the complexities surrounding infant tongue-tie and the factors that may influence feeding, function and decision-making. Tongue-tie School: Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations is a specialist, evidence-informed programme designed for healthcare professionals who want to deepen their understanding of infant tongue-tie. Rather than focusing on anatomy alone, the programme explores the wider clinical considerations surrounding tongue-tie, including oral function, infant feeding, assessment considerations, treatment pathways, conservative management and ongoing support. The course is designed to encourage thoughtful, function-based practice and help professionals develop the knowledge required to support families, collaborate effectively within multidisciplinary teams and recognise the importance of working within their own professional scope of practice. By combining current evidence with practical clinical considerations, Tongue-tie School supports practitioners in building confidence and understanding in this evolving area of infant care. Accredited by Advantage and IBLCE, successful completion of the programme awards 15 CPD points and 8 L-CERPs. For further information, or to enrol on the course please visit www.tongue-tie.info/school 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. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance 98. 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. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding (Interventional Procedures Guidance IPG149; now HealthTech Guidance HTG95). Available at: NICE Guidance HTG95/IPG149. Care Quality Commission (2022) Briefing for providers: Registration requirements for tongue-tie procedures. Available at: Care Quality Commission briefing. Association of Tongue-tie Practitioners (n.d.) Tongue-tie Training FAQs. Available at: Association of Tongue-tie Practitioners – Tongue-tie Training FAQs. Association of Tongue-tie Practitioners (n.d.) Find a Practitioner. Available at: https://www.tongue-tie.org.uk/find-a-practitioner

Families often search for tongue-tie aftercare and feeding support when they're hoping feeding will become easier after a tongue-tie release. Although the procedure can be an important step, it's only one part of supporting feeding. Ongoing assessment considers the whole baby, the feeding relationship, and the family's goals—not just the appearance of the mouth. Some babies feed more comfortably straight away. Others need time to adjust to a different range of tongue movement, recover from a challenging start to feeding, or work through factors that were present before the tongue-tie release (frenulotomy). A frenulotomy is not an instant fix, as infant feeding is a complex neuromuscular process involving coordination between the tongue, jaw, lips, cheeks, and the wider oral structures. When movement has been restricted, babies may have developed compensatory patterns, and they may need time and support to develop new feeding skills. The tongue, as a muscular structure, may need time to build strength, coordination, and functional movement, while surrounding oral muscles and tissues adapt and relax. A smaller number of babies may not experience the change their family had hoped for. Compassionate, skilled follow-up makes space for all of these possibilities and helps families understand and support their baby’s individual feeding journey. What post-frenotomy feeding support should include A feed is a dynamic interaction. It reflects the infant’s health, alertness, oral function and feeding skills, alongside milk supply, breast or teat shape, positioning, parental comfort and the practical realities of family life. For this reason, post-frenulotomy care should begin with listening: what was difficult before, what feels different now, and what matters most to the family? For breastfed or chestfed infants, an experienced practitioner may observe a full feed where possible. This can help identify whether there are changes in comfort, attachment, audible swallowing, milk transfer, and the baby’s ability to remain settled at the breast. It also allows a sensitive discussion about nipple trauma, engorgement, oversupply, low supply, or the need to protect milk production while feeding is being established. For bottle-fed and combination-fed infants, support should be equally thorough. The relevant questions are not whether the baby is feeding in a particular way, but whether feeding is comfortable, sustainable, and effective for both infant and caregiver. A feeding observation can explore the baby’s seal, coordination, pauses, milk loss, signs of stress, and the caregiver’s experience. https://www.tongue-tie.info/post/bottle-feeding-with-a-tongue-tie-baby-safely Parents should feel confident asking what aftercare and feeding support is included when choosing a tongue-tie practitioner. Best practice recognises that infant feeding difficulties are multifactorial and should not be attributed solely to the presence of a tongue-tie. Practitioners with advanced infant feeding expertise, such as International Board Certified Lactation Consultants (IBCLCs), are trained to assess feeding holistically and support families with all methods of infant feeding—not just breastfeeding. This enables them to identify the factors affecting feeding and provide personalised, evidence-informed support before and after a tongue-tie release. The evidence base supports this measured approach. A Cochrane review found that frenulotomy reduced maternal nipple pain in the short term, but evidence for consistent improvement in infant breastfeeding outcomes was less certain, partly because studies were small and used different outcome measures (O’Shea et al., 2017). Systematic review evidence also identifies limitations in study quality and a lack of longer-term outcomes (Francis et al., 2015). This does not mean families’ experiences of improvement are unimportant. It means clinicians should communicate honestly about what research can, and cannot, predict for an individual baby, while recognising the importance of skilled assessment and ongoing feeding support. The first hours and days after a frenulotomy If an infant is ready to feed, offering a familiar feed soon after the procedure can be reassuring. It gives the baby an opportunity to settle with a parent and allows the family to notice any early changes. There is no requirement for a baby to demonstrate a ‘perfect’ feed immediately. Babies may be sleepy, unsettled or temporarily reluctant to feed following a busy clinical appointment. In the first few days, parents may notice that feeding feels different before it feels easier. A baby who has developed compensatory feeding patterns may need time and calm repetition to find a more comfortable way of feeding. This is why general reassurance alone is sometimes insufficient. Responsive, individualised feeding support can help families make sense of what they are seeing without placing pressure on the baby or parent. It is reasonable to continue feeding responsively and to maintain the approach that has kept the baby fed and the parent comfortable before the procedure. Where milk supply has been a concern, an experienced lactation professional can help develop a plan that is proportionate to the family’s circumstances. That may include reviewing feeding frequency, expressing where clinically appropriate, and monitoring the baby’s wellbeing. Decisions about supplementation, combination feeding or expressed milk should be collaborative and free from judgement. Follow-up should also include clear safety-netting and reassurance. While concerns following a tongue-tie release are uncommon, families should know what support is available and who to contact if they have any worries during recovery. Clear guidance helps parents feel confident, ensures concerns are addressed appropriately, and provides an important safety net for families as feeding develops. Why feeding may still be difficult A frenulotomy addresses a restrictive lingual frenulum when this has been judged relevant to feeding function. It does not automatically resolve every contributor to a feeding difficulty. This distinction is central to safe, evidence-informed care. For example, pain at the breast may be influenced by attachment, skin damage, vasospasm, infection, milk supply dynamics or the baby’s feeding behaviour. A bottle-fed infant may have challenges linked to flow preference, feeding pace, coordination, reflux-like symptoms, prematurity, neurodevelopmental variation or an underlying health concern. These possibilities are not reasons to dismiss a family’s observations. They are reasons to widen the clinical lens. The Academy of Breastfeeding Medicine advises that the presence of a sublingual frenulum alone is not an indication for intervention, and that decisions should follow a skilled breastfeeding assessment (Academy of Breastfeeding Medicine, 2021). The same principle remains useful after a frenulotomy: anatomy provides information; function provides context. When feeding remains difficult, a reassessment should consider the infant’s growth, hydration, medical history, oral function and feeding behaviour, as well as parental pain, confidence and capacity. Sometimes the next best step is additional lactation support. Sometimes it is review by a GP, paediatric clinician, health visitor, midwife or another relevant professional. Sometimes families decide that a feeding plan which is not exclusive breastfeeding is the most sustainable choice. Good care supports informed choices rather than measuring families against a single outcome. Aftercare: clarity without unnecessary pressure Aftercare advice varies between services, and families can encounter conflicting information online. It is helpful to distinguish routine feeding support from practices for which evidence is uncertain. Current evidence does not establish that wound stretching or massage improves feeding outcomes or prevents reattachment, while such activities may be distressing for babies and parents. The Academy of Breastfeeding Medicine does not support the evidence base for manual manipulation or stretching at the surgical site after frenulotomy (Academy of Breastfeeding Medicine, 2021). Families should receive individual advice from their treating clinician about what to expect during healing and how follow-up will be provided. A healing area can change in appearance over time, and appearance alone cannot determine how well feeding is progressing. The more meaningful measures are the baby’s wellbeing, milk intake where this can be assessed, parental comfort and the overall feeding experience. For healthcare professionals, this is an area where language matters. Avoiding promises, timelines presented as certainties and assumptions about causation protects families from disappointment and supports informed consent. It is appropriate to acknowledge emerging questions in the literature while remaining anchored to assessment, observation and clinical reasoning. Building a realistic follow-up plan The most useful follow-up plans are specific enough to reduce uncertainty but flexible enough to meet changing needs. Families benefit from knowing when review will occur, what concerns warrant earlier contact, and which professional can support feeding beyond the immediate post-procedure period. A structured review might consider whether parental pain has changed, whether feeds are becoming calmer or more manageable, whether the baby appears satisfied between feeds, and whether growth and nappy output are reassuring. These indicators need interpreting in context. A single unsettled evening, for instance, is not a reliable test of whether a frenulotomy has ‘worked’; neither is one comfortable feed. NICE describes division of ankyloglossia for breastfeeding as a procedure that should be undertaken by appropriately trained practitioners with suitable arrangements for audit and clinical governance (NICE, 2005). Continuity of feeding support is part of that wider responsibility. Families should not be left to interpret complex feeding changes alone after a procedure. At D-Restricted Ltd®, post-frenulotomy support is approached as continuing infant feeding care, rather than a separate final step. The aim is to help families feel heard, informed and safely supported, whether feeding improves quickly, gradually, or needs further assessment www.tongue-tie.info. A frenulotomy may be one part of an infant’s feeding story. The care that follows should give equal attention to the baby in front of us, the parent doing the feeding, and the practical, emotional work of finding a plan that feels possible for their family. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Francis, D.O., Krishnaswami, S., McPheeters, M. and the Committee on Health Care for Underserved (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. 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.

A baby may have a visible lingual frenulum and feed comfortably. Another may have significant feeding difficulty with no visible anatomical explanation. That is why a Recognising the signs of disordered oral function in your baby needs to begin with the whole feeding picture, rather than with appearance alone. Families deserve to be heard without assumptions, and professionals need a framework that supports careful clinical reasoning. Oral assessment can provide valuable information, but it is only one part of understanding feeding. The central question is not simply, “Is there a tie?” It is whether oral movement and feeding function may be contributing to the concerns described, alongside the many other factors that can affect a baby’s ability to feed. What is an infant oral function evaluation? An infant oral function evaluation is a skilled, structured consideration of how a baby uses their mouth, tongue, jaw and lips during feeding and at rest. It brings together a feeding history, observation of a feed where possible, an assessment of oral anatomy and movement, and an understanding of the family’s priorities. This is not a diagnosis based on a single sign. A lingual frenulum is normal anatomy, with considerable variation in its appearance and attachment. The presence of a frenulum alone does not establish that it is restrictive or that it is causing feeding problems. Current guidance and professional statements emphasise that ankyloglossia is a functional diagnosis, requiring assessment in the context of breastfeeding or other feeding concerns (Academy of Breastfeeding Medicine, 2021; American Academy of Pediatrics, 2024). For families who bottle feed, combination feed, express milk, or use feeding methods that change over time, the same principle applies. The clinician considers the individual baby’s feeding efficiency, comfort, coordination and growth alongside the family’s experience. Breastfeeding, chestfeeding and bottle feeding are all valid feeding journeys, and each may present different practical challenges. Why function must sit beside anatomy “Anatomy provides information. Function provides context.” This distinction matters because visual appearance does not reliably predict feeding impact. Some babies with a prominent or tightly appearing frenulum feed effectively and comfortably. Conversely, feeding difficulty can arise from positioning, milk flow, prematurity, birth-related factors, neurological or developmental differences, nasal congestion, reflux-like symptoms, maternal nipple pain, breast fullness, bottle teat flow, or a combination of issues. A functional assessment does not seek to attribute every concern to the mouth. It asks whether observations are consistent, whether they change with skilled feeding support, and whether there are other plausible explanations that need attention. This protects families from both dismissal and oversimplification. Research into assessment tools reflects this complexity. Tools may support consistency in describing appearance and movement, but no tool should replace clinical judgement, observation of feeding and shared decision-making. The Academy of Breastfeeding Medicine advises that no published tool should be used as the sole basis for deciding whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). What a thoughtful evaluation considers The family’s feeding story An assessment usually starts with listening. Families may describe pain, frequent feeds, clicking, dribbling, unsettled feeds, prolonged bottle feeds, difficulty maintaining attachment, concerns about milk transfer or slow weight gain. These experiences are real and deserve a careful response, even when the cause is not immediately clear. Useful context includes the baby’s age and birth history, health and growth, feeding frequency and duration, any changes since birth, previous support, and what feels most difficult for the family. It can also be helpful to understand what is going well. A baby who is gaining appropriately, feeding comfortably and whose parent feels well supported may need a very different conversation from a baby with persistent feeding difficulty and a parent in pain. Observation of feeding When appropriate and possible, observing a feed offers information that an oral examination cannot provide on its own. For breastfeeding, this may include the baby’s positioning, attachment, audible swallowing, milk transfer cues and the parent’s comfort. For bottle feeding, observation may consider the baby’s readiness, seal, pacing, coordination, milk loss and signs of fatigue or stress. One feed is still a snapshot. Babies vary across the day, and milk flow, tiredness, hunger and the setting can all influence what is seen. A sensitive clinician will balance direct observation with the family’s account, rather than disregarding either. Oral anatomy, movement and wider wellbeing The oral examination considers structures and movement in an age-appropriate, gentle way. The aim is to understand whether the tongue appears able to move in ways that may support feeding, while recognising that a settled baby may show different movement from a hungry, crying or fatigued baby. The wider examination and history matter too. Professionals remain alert to concerns that may warrant review by an appropriate medical practitioner, such as poor weight gain, dehydration risk, respiratory symptoms during feeds, marked feeding aversion, illness or other developmental concerns. Oral function assessment is not a substitute for comprehensive infant care. Making sense of the findings A good evaluation ends in interpretation, not a score or label. The clinician should explain what was observed, what remains uncertain and which factors may be interacting. Families should have space to ask questions and to say what outcome matters most to them, whether that is reducing pain, making feeds calmer, supporting milk transfer, protecting supply, or feeling more confident with bottle feeding. Conservative feeding support may be appropriate when feeding mechanics, positioning, pacing or comfort can be improved without a procedure. This support can be valuable whether or not a restrictive frenulum is suspected. Sometimes reassessment after a period of skilled support clarifies the picture. Where restriction of tongue function appears to be contributing to ongoing infant feeding difficulties, frenulotomy may be discussed as one possible option. Evidence from randomised trials and systematic reviews suggests that frenulotomy can reduce maternal nipple pain for selected breastfeeding dyads, but evidence for longer-term breastfeeding outcomes remains limited and heterogeneous (O’Shea et al., 2017; Francis et al., 2015). The decision should therefore be individualised, with realistic discussion of potential benefits, limitations, alternatives and aftercare. It is equally valid for a family to choose continued conservative management, to seek another opinion, or to decide that no intervention is right for them. Informed consent is a conversation, not a signature. Questions families and professionals can use Whether you are attending an appointment or referring a family, it can help to ask: What feeding concerns are we trying to understand? What did the feeding observation show? Are there factors beyond oral anatomy that may be relevant? What support could be tried first or alongside further assessment? What are the expected benefits and uncertainties of each option? For professionals, reflective practice is particularly valuable where findings are mixed. Avoiding both over-diagnosis and under-recognition requires humility, ongoing education and appropriate referral pathways. A function-focused approach does not promise a simple answer, but it creates a safer and more compassionate route towards one. If you are a healthcare professional interested in developing your understanding of infant tongue-tie, oral function and feeding, you may be interested in my Tongue-tie School professional education programme, Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations. The programme takes a function-based, evidence-informed approach, exploring the relationship between anatomy, oral function and infant feeding, alongside treatment considerations, supportive strategies, preparation, rehabilitation and ongoing care. It is designed for healthcare professionals supporting infants and families who would like to deepen their knowledge and understanding of this complex area. For more information, please visit https://www.tongue-tie.info/school Every feeding journey deserves support that is practical, respectful and grounded in the baby and family in front of us. The most helpful next step is often not to search for a single cause, but to seek a skilled assessment that makes room for the full story. 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, 153(2), e2023064052. Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., Krishnaswami, S., McPheeters, M. and Walsh, J. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: A systematic review’, Pediatrics, 135(6), e1458-e1466. 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.

Bottle feeding can be a calm, connected part of family life, whether it is occasional, exclusive or alongside breastfeeding. Learning how to pace bottle feeds can help carers slow the flow, notice their baby’s communication and allow time for pauses. It is not a test to perform perfectly, nor is it a treatment for every feeding concern. It is one responsive approach that may be adapted to the individual baby and family. Paced bottle feeding is often discussed in relation to breastfeeding because it aims to avoid a consistently fast, passive flow of milk from the bottle. However, responsive pacing can be helpful for any bottle-fed baby when it supports comfort, feeding regulation and an enjoyable experience for both baby and carer. What does paced bottle feeding mean? Paced bottle feeding means offering milk in a way that gives the baby regular opportunities to pause, breathe and show whether they would like to continue. Rather than holding the bottle vertically so milk flows continuously, the carer keeps it more horizontal and responds to the baby’s cues throughout the feed. The underlying principle is responsive feeding: the adult offers nourishment and attentive support, while the baby communicates hunger, readiness, comfort and fullness. This does not mean that every feed will look the same. Some babies feed slowly, others have periods of eager sucking, and needs can change with age, health, time of day and milk supply. Direct research specifically evaluating paced bottle feeding remains limited. Much of the practice is based on physiological reasoning, clinical experience and wider responsive-feeding principles. Observational research has found that infants fed from a bottle may be more likely to consume a set amount regardless of appetite than infants feeding directly at the breast, although this does not show that bottles themselves cause later feeding difficulties (Li et al., 2010). This is a reason to remain curious about feeding interaction, not a reason to judge a family’s feeding method. How to pace bottle feeds step by step Paced bottle feeding is a way of offering a bottle that allows your baby to control the pace of the feed. Rather than encouraging a continuous flow of milk, you respond to your baby's sucking, swallowing, breathing and signals that they need a pause or have had enough. Position your baby Hold your baby close to you in a semi-upright position, with their head and neck well supported. Their head should be free to move and their face should remain visible to you. This position allows you to watch your baby's face, breathing and feeding cues while helping them coordinate sucking, swallowing and breathing comfortably. Avoid feeding your baby lying flat. Invite your baby to take the teat Touch or gently brush the teat against your baby's upper lip and wait for them to open their mouth. Allow your baby to draw the teat into their mouth rather than pushing it in. As the teat is first accepted, you can keep the bottle angled down so that the teat is not immediately full of milk. This gives your baby an opportunity to latch onto and suck the teat before milk begins to flow. Sucking on an unfilled teat may result in your baby drawing some air into their mouth. This is not the same as swallowing air. Air can be sucked into the mouth without necessarily being swallowed. Swallowing air occurs when air passes back into the throat and is swallowed into the digestive tract. Once your baby has accepted the teat and is ready to feed, gradually bring the bottle up to a near-horizontal position, allowing milk to fill the teat. Bring the bottle to horizontal Hold the bottle almost horizontal, tilted only enough for milk to remain in the teat. The aim is not to have milk pouring continuously into your baby's mouth. Instead, your baby should need to suck to obtain the milk, allowing them greater control over the flow. Watch for the rhythm of your baby's sucking, swallowing and breathing. Babies naturally feed in bursts, with pauses between them. Watch your baby's cues Rather than counting a particular number of sucks or timing the feed, watch your baby. Your baby may need to slow down or pause if they stop or slow their sucking, take a breath or pause between sucks, spill milk from their mouth, splay their fingers or toes, turn their head away, wriggle or move away from the teat, push the teat away, or appear tense, unsettled or overwhelmed. There is no single number of sucks or number of seconds that every baby should feed before taking a break. The aim is to follow your baby's individual rhythm. Give your baby a break without removing the teat When your baby shows that they need a pause, tilt the bottle downwards while keeping the teat in their mouth. This moves the milk away from the teat and stops or greatly reduces the flow, while allowing your baby to continue holding the teat in their mouth if they want to. Your baby can then pause, breathe and organise themselves before deciding whether to start sucking again. When your baby resumes active sucking, gradually bring the bottle back towards the horizontal position so that milk fills the teat again. You do not need to remove the teat for every pause. If your baby wants to keep the teat in their mouth, lowering the bottle can provide a gentler interruption to the flow. If your baby turns away, pushes the teat out or otherwise indicates that they do not want to continue, respect that cue and remove the bottle. Continue to follow your baby's rhythm Continue alternating between periods of sucking and periods of rest according to your baby's cues. Your baby may naturally pause several times during a feed. They may also need to burp. There is no need to deliberately prolong a feed simply to make it more paced. The purpose of pacing is to give your baby opportunities to breathe, pause and recognise their own fullness, not to make every feed last a particular amount of time. Let your baby decide when the feed is finished Do not encourage your baby to finish the bottle simply because milk remains. Signs that your baby may have had enough include slowing or stopping sucking, turning their head away, pushing the teat away, spilling or letting the teat fall from their mouth, relaxing their hands and body, becoming distracted, or appearing settled and content. Falling asleep can occur during a feed, but on its own it does not always tell you whether your baby has had enough. Consider it alongside their sucking pattern, body language and other feeding cues. Choosing the flow rate The flow rate of the teat matters just as much as bottle position. A flow that is too fast for a baby may be associated with milk spilling from the mouth, gulping, coughing, spluttering, wide eyes, finger splaying, pulling away or distress. These signs are not diagnostic on their own, but they are useful information. A very slow flow is not automatically better. If a baby has to work excessively hard, feeds may become long and frustrating, and milk intake may be affected. The most suitable flow depends on the individual baby’s feeding skills, age, medical history and the type of milk being offered. Teat labels are not standardised between manufacturers, so a numbered size does not reliably predict how a particular baby will manage. If there are concerns about flow, positioning or feeding comfort, a health visitor, midwife, infant feeding specialist, IBCLC (International Board Certified Lactation Consultant) or other appropriately qualified clinician can observe a full feed and consider the wider context. IBCLCs are the most highly trained infant-feeding specialists and support breastfeeding, bottle feeding, combination feeding and other feeding methods. Choosing an appropriate teat shape There is no single teat shape that is right for every baby. Babies differ in their oral anatomy, feeding skills and preferences, and the position and organisation of the suck reflex changes as the mouth grows and feeding skills develop. The most appropriate teat is one that allows your baby to achieve a comfortable latch and seal, with coordinated sucking, swallowing and breathing. A baby moving or “chewing” on a short, wide teat does not necessarily mean that this shape is better or more developmentally appropriate. What matters is how the baby is using the teat. Look at their jaw and tongue movements, seal, comfort and the rhythm of their suck–swallow–breathe pattern rather than focusing on whether they are sucking, biting or chewing. The suck-to-swallow relationship can also provide useful information. Babies may take several sucks before a swallow, depending on their age, oral skills and the flow of milk. There is no single ideal ratio, but the pattern should remain organised and comfortable. A flow that is too fast may result in frequent swallowing, gulping, coughing, spluttering or difficulty coordinating breathing. A flow that is too slow may result in prolonged sucking, fatigue or frustration. The aim is to find a teat and flow that allow the baby to maintain an effective, coordinated feeding pattern. Wider, gradually sloping teats provide a broader surface for the lips and may encourage a wider jaw gape. Their shape can also more closely resemble the way breast tissue is taken into the mouth than a short, flat teat. Narrow-neck teats create a different oral shape and may suit some babies. Neither should automatically be considered better; the baby's individual oral posture and feeding response are more important than the appearance of the teat. The triangle test can be useful when considering how a teat sits in the mouth. Look at the space created between the teat, tongue and palate and whether the baby can maintain a comfortable seal without repeatedly losing suction or taking in excessive air. A well-fitting teat should allow the baby to organise their tongue and jaw movements comfortably and coordinate sucking, swallowing and breathing without needing to compensate for the teat's shape. Ultimately, teat selection should be based on the whole feeding pattern, rather than choosing a shape because it is marketed as more “natural”, more developmental or better for oral development. If a baby is consistently struggling with their latch, seal, flow, coordination, comfort or feeding efficiency, observing a full feed can help identify whether the teat, flow or another aspect of feeding may be contributing. Reading cues matters more than finishing the bottle Many carers have been taught, directly or indirectly, that a baby should finish the milk prepared. This can create understandable worry about waste, intake or growth. Yet encouraging a baby to continue after they have clearly disengaged can make it harder to respond to their internal appetite cues. Responsive feeding guidance recommends watching the baby rather than focusing only on volume (UNICEF UK Baby Friendly Initiative, 2016). This is particularly relevant when another person is feeding the baby, when expressed breast milk feels precious, or when a baby’s intake is being monitored. In those circumstances, families may need a clear plan from the clinicians involved, balancing cue-led feeding with any medical or growth-related advice. Pacing is not intended to restrict milk. Babies may take different amounts at different feeds, and appetite often varies over a 24-hour period. Regular wet nappies, growth, alertness and overall wellbeing need to be considered together rather than relying on a single bottle volume. When feeding is not straightforward A baby who coughs, splutters or leaks milk occasionally may simply be coping with a fast moment in a feed. Recurrent difficulty deserves a fuller assessment. Feeding challenges can reflect positioning, teat flow, prematurity, nasal congestion, reflux-like symptoms, neurological or developmental factors, milk supply, previous feeding experiences or oral function. Often, more than one factor is present. Tongue anatomy may provide useful clinical information, but function provides context. Not all babies with a visible lingual frenulum have feeding difficulties, and not all bottle-feeding difficulties are caused by tongue-tie. A skilled assessment should include a detailed feeding history, observation of feeding, growth and health information, and the family’s experience and goals. Seek prompt medical advice if your baby is unusually sleepy, showing signs of dehydration, repeatedly vomiting, has poor weight gain or a significant reduction in feeding. These concerns need medical assessment rather than bottle-feeding adjustments alone. Call 999 if your baby is struggling to breathe, has persistent choking, or develops blue or grey colour changes. Supporting the person giving the feed Pacing works best when the person feeding feels settled too. It can help to explain the approach to partners, grandparents, childcare providers and anyone else who offers bottles: hold baby close, keep the bottle relatively level, pause when baby pauses and trust clear fullness cues. This protects consistency without asking everyone to copy an exact technique. For breastfeeding families using expressed milk, paced feeding may be one part of protecting a feeding relationship, alongside effective milk removal and timely, individualised lactation support. For formula-feeding and combination-feeding families, the same responsive principles apply. Feeding with care is not defined by what is in the bottle. If feeds feel tense or confusing, you do not need to work it out alone. A calm observation of a complete feed can often identify practical changes while ensuring that wider health, growth and feeding factors are not overlooked. Every feeding journey deserves support that is compassionate, realistic and centred on the baby in front of you. References Alder Hey Children’s NHS Foundation Trust (2025) Paced responsive feeding (bottle feeding). Liverpool: Alder Hey Children’s NHS Foundation Trust. Cresi, F. et al. (2024) ‘Effects of a valved infant-bottle with ergonomic teat on the coordination of sucking, swallowing, and respiration in late-preterm infants: The Safe Oral Feeding randomized trial’, Frontiers in Pediatrics, 12, 1309923. doi: 10.3389/fped.2024.1309923. Goldfield, E.C., Smith, P.B., Buonomo, C., Perez, J., Larson, K. and Lee, K.G. (2006) ‘Coordination of sucking, swallowing, and breathing and oxygen saturation during early infant breast-feeding and bottle-feeding’, Pediatric Research, 60(4), pp. 450–455. doi: 10.1203/01.pdr.0000238378.24238.9d. Li, R., Fein, S.B. and Grummer-Strawn, L.M. (2010) ‘Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants?’, Pediatrics, 125(6), pp. e1386–e1393. doi: 10.1542/peds.2009-2549. Mizuno, K., Ueda, A. and Takeuchi, T. (2002) ‘Effects of different fluids on the relationship between swallowing and breathing during nutritive sucking in neonates’, Biology of the Neonate, 81(1), pp. 45–50. doi: 10.1159/000047183. NHS (2026) Feeding on demand – bottle feeding. Available at: NHS website. Rogers, B. and Arvedson, J. (2005) ‘Assessment of infant oral sensorimotor and swallowing function’, Mental Retardation and Developmental Disabilities Research Reviews, 11(1), pp. 74–82. doi: 10.1002/mrdd.20055. Salisbury, D.M. (1975) ‘Bottle-feeding: influence of teat-hole on suck volume’, The Lancet, 1(7908), pp. 655–656. doi: 10.1016/S0140-6736(75)91759-6. Steer, K.E. et al. (2024) ‘The impact of varying nipple properties on infant feeding physiology and performance throughout ontogeny in a validated animal model’, Dysphagia, 39, pp. 1008–1020. doi: 10.1007/s00455-023-10630-w. UNICEF UK Baby Friendly Initiative (2019) Infant formula and responsive bottle feeding. London: UNICEF UK. UNICEF UK Baby Friendly Initiative (2021) Bottle Feeding Assessment Tool. London: UNICEF UK.

A breast pump flange fitting assessment is not simply a matter of matching a number to a nipple measurement. It is a skilled, individualised review of how the breast, nipple, pump and feeding plan work together. For some families, a small adjustment may make expressing more comfortable or effective. For others, flange fit is only one part of a wider picture that may include pump settings, frequency of expression, milk supply, infant feeding, nipple trauma or the practical realities of family life. Pumping can support many different feeding journeys: expressing for a premature or unwell baby, returning to work, combination feeding, managing temporary separation, donating milk, or feeding directly at the breast alongside occasional expression. There is no single ‘right’ pumping pattern, and there is no one flange size that is correct for every person. What is a breast pump flange fitting assessment? A flange, sometimes called a breast shield, is the funnel-shaped part of a pump that sits against the breast. Its tunnel is designed to allow the nipple to move during expression while the flange maintains a seal against the breast. A breast pump flange fitting assessment considers more than the diameter of the tunnel. It brings together the person’s account of comfort and symptoms, observation of nipple movement during pumping, the amount of areolar tissue drawn into the tunnel, skin colour changes, the seal against the breast and the person’s response to the pump settings. It should also consider whether milk is being expressed in a way that is workable and sustainable for that family. This matters because breasts and nipples are dynamic tissues. Nipple dimensions can alter during pumping and across the day. The anatomy of the lactating breast also varies considerably between individuals, so a measurement taken before pumping cannot, by itself, confirm an effective or comfortable fit (Ramsay et al., 2005). Why Flange Shape and Size Matter The findings from the Flange FITS™ study, published in 2025, highlight just how important individual flange sizing can be. While 24 mm remains a common “standard” size supplied with many breast pumps, participants in the study frequently needed considerably smaller flanges when sized according to their nipple measurement. The most commonly selected smaller-fit sizes were 15 mm and 17 mm. Participants also reported greater comfort and, on average, higher milk output when using the smaller-fit flanges. This is a useful reminder that there really is no “one size fits all” when it comes to breast pump flanges — and that the 24 mm flange supplied with your pump is simply a starting point, not necessarily the right size for you. As a flange fitter, I look beyond the diameter of the tunnel. Flange shape matters too. Two flanges can have exactly the same tunnel diameter but feel and perform very differently because their overall shape, depth, angle and breast contact are different. Maymom is one of the most commonly used flange brands among UK flange fitters, and it is the brand I suggest most often because it has one of the largest ranges of flange shapes available. Maymom has five different shapes, giving me much more flexibility when fitting a parent than simply being able to change the tunnel diameter. I use all five shapes, because different breast shapes and different levels of breast fullness can require very different flange designs. Breast shape can make a real difference to how a flange sits. A softer, less full breast may sit very differently within a flange from a breast that is naturally fuller or more rounded. Then there is engorgement, when the breast can become considerably firmer and fuller and the tissue around the nipple can change shape. A flange that looks and feels right when your breast is soft may therefore not be the most comfortable or effective choice when you are very full or engorged. This is why, when I fit a flange, I am looking at much more than a nipple measurement. I consider the size and shape of the nipple, the shape of the breast, how much breast tissue sits within the flange, how full the breast is, and what happens once the pump is switched on. The aim is for the nipple to move freely within the tunnel without unnecessary rubbing or compression, while the flange itself sits comfortably against the breast. Material is another part of the fitting process. In my experience, most women respond better to a rigid, hard-plastic flange, as it provides a stable and consistent shape against the breast during pumping. Silicone flanges are softer and more flexible, which can be helpful for some parents, but softer does not automatically mean a better fit. Ultimately, flange fitting isn't simply about finding the right number. Size, shape and material all matter, and so does the state of your breast at the time you are pumping. Your breasts can change considerably during your breastfeeding journey — and sometimes even during the same day. The flange that works beautifully for you at one point may not be the flange that works best when you are engorged, when your breast has softened, or as your body changes over time. Why discomfort is not always a flange-size problem Pain while expressing deserves attention, but it does not automatically mean that a flange is too large or too small. Excessive vacuum, a pumping session that is too long, friction from dry skin, swelling, engorgement, pump position, damaged components, infection, dermatitis or vasospasm may all contribute. A person may also find pumping uncomfortable despite a reasonable visual fit, particularly where there is existing nipple trauma or sensitivity. Likewise, milk volume during a single session is not a reliable test of flange fit. Output can be influenced by the interval since the previous milk removal, stage of lactation, stress, hydration, pump effectiveness, breast storage capacity, settings and the individual’s milk ejection reflex. A low volume may warrant skilled support, but it should not be assumed to prove a poor fit or inadequate supply. The available evidence on methods of milk expression shows that research is heterogeneous and that outcomes can be shaped by the context in which pumping takes place (Becker, Smith and Cooney, 2016). There is not currently a universally accepted, independently validated clinical standard that can determine an ideal flange size for every pumping parent. This makes careful assessment, review and shared decision-making particularly valuable. What a careful flange fitting assessment may include A clinician will usually begin by listening. Understanding why someone is pumping, how often they express, which pump they use and what they are experiencing is essential. A parent who pumps once a week for occasional separation may have different priorities from someone who is exclusively expressing for a newborn. The assessment may include a respectful observation of a pumping session, with consent. This allows the practitioner to consider the flange’s position, whether the nipple appears to move freely in the tunnel and whether there is rubbing, marked pulling of surrounding tissue, persistent blanching, swelling or pain. The person’s own sensory experience matters as much as what can be seen. Measurements can be useful as one starting point, especially when selecting flanges to try. However, they should not be treated as a prescription. The aim is not to achieve a particular appearance based on a photograph or a rigid rule about how much areola should enter the tunnel. Instead, it is to identify an option that supports comfort, effective expression where possible and skin wellbeing. A meaningful assessment also looks at pump settings. More suction is not necessarily better. The highest comfortable setting is not always the most useful setting, and a lower setting may be more tolerable and productive for some people. Changes should be made gradually, with attention to comfort during and after the session. Signs that a review may be helpful Some early sensitivity when beginning to pump can occur, but ongoing pain, damaged skin or symptoms that continue after pumping are not something a parent should feel they simply have to endure. A review may be helpful where there is persistent rubbing, a pinching sensation, nipple blanching or purple discolouration, pronounced swelling, repeated milk leakage around the flange, or uncertainty about whether the pump is removing milk comfortably. It is also sensible to seek timely clinical advice for breast redness, a hot or painful area, fever, flu-like symptoms, a breast lump that does not settle, broken skin with increasing pain, or concerns about milk supply and infant feeding. These symptoms have a range of possible causes and should not be managed solely by changing flange size. For a baby who is feeding at the breast, an assessment should remain wider than the pump. Observing feeding, considering milk transfer and growth, reviewing maternal comfort and listening to the family’s concerns can help avoid reducing a complex feeding relationship to one piece of equipment. Anatomy provides information; function provides context. Additional Tips for Getting More From Your Pump Getting the right flange fit is an important part of pumping, but it isn't the only factor that can influence how much milk you express. If you're trying to improve your pumping output, there are several other things worth considering. Heat and cold therapy Warmth can be useful before or during pumping. A warm compress or warm shower may help you relax and can encourage milk ejection, and research into methods of expressing milk has found that warming the breast before expression can be associated with greater volumes of milk expressed. Gentle warmth can therefore be particularly useful if you find that your milk takes a while to start flowing. Cold has a different purpose. A cool or cold compress can help reduce swelling, inflammation and discomfort, particularly when breasts are very full or engorged. Cold is generally more appropriate for reducing inflammation than trying to use heat continuously. If you have significant breast pain, redness, swelling or flu-like symptoms, seek appropriate medical advice rather than relying on heat or cold therapy alone. Current mastitis guidance also cautions against deep breast massage and excessive attempts to 'empty' the breast. 'Hands-on' pumping Your pump does not have to do all the work. Hands-on pumping combines mechanical pumping with gentle breast massage, compression and hand expression. Research by Morton and colleagues found that combining hand techniques with electric pumping increased milk production in mothers of preterm infants. This can be particularly useful towards the end of a pumping session, when the flow has slowed. Rather than increasing the suction, try gently compressing different areas of the breast while pumping, following the natural shape of the breast and avoiding painful or forceful pressure. You can also finish with some hand expression to remove milk that the pump may not have reached as effectively. Breast stimulation matters Milk production is fundamentally a supply-and-demand process. The more effectively and regularly milk is removed, the stronger the signal to the breast to continue producing milk. This is why the frequency and effectiveness of milk removal are so important when trying to build or maintain your milk supply. There is an important difference, however, between feeding directly at the breast and expressing with a pump. Direct breastfeeding is a highly sensory and hormonal process. Your baby's suckling, touch, smell, sight and even the anticipation of a feed can contribute to the hormonal responses involved in milk production and milk ejection. Pumping is a more mechanical form of milk removal. It still provides nipple stimulation and milk removal and therefore still stimulates hormonal pathways, but it doesn't necessarily provide all of the same sensory stimulation as feeding your baby directly. This is one reason some parents find it helpful to incorporate additional stimulation when pumping. Looking at your baby, smelling a piece of their clothing, having skin-to-skin contact, gently stimulating or massaging the breast before pumping, or simply taking a few moments to relax can all help create a more favourable environment for milk ejection. Oxytocin is particularly important for the milk-ejection reflex, and positive touch, relaxation and skin-to-skin contact can support the release of oxytocin. So, if pumping feels very different from feeding your baby at the breast, you're not imagining it. The pump is removing milk mechanically, but you can add some of the sensory cues that naturally accompany breastfeeding. Combined with effective and regular milk removal, these can help support the process of expressing milk. Galactagogues: natural and prescribed You may also hear about galactagogues — substances used with the aim of increasing milk production. These include herbal products and prescription medicines. It is important to understand that a galactagogue isn't a substitute for effective milk removal. If milk is not being removed frequently or effectively, increasing prolactin alone will not necessarily solve the underlying problem. Herbal galactagogues such as fenugreek, blessed thistle and others are widely discussed, but the evidence for many of these products is limited, and 'natural' does not automatically mean safe. Products can have side effects, interact with medicines and vary considerably in dose and quality. The Academy of Breastfeeding Medicine recommends addressing potentially correctable causes of low milk production and optimising milk removal before considering a galactagogue. In the UK, domperidone is sometimes prescribed off-label for low milk supply following an appropriate assessment and after non-medical measures have been tried. The NHS Specialist Pharmacy Service identifies domperidone as the preferred medicine when drug treatment is considered, but also stresses that the evidence is limited and that treatment should be reviewed. It should only be taken under the direction of an appropriately qualified prescriber. For me, the key message is that galactagogues should be considered as one possible part of a wider plan — not as a quick fix. Before reaching for a supplement or medication, it is worth looking at the fundamentals: is milk being removed often enough, is it being removed effectively, is the flange correctly fitted, and is the pumping process allowing you to achieve good milk ejection? Don't forget the small pump parts If your flange fit is good but your pump suddenly doesn't seem to be performing as well, don't forget to check the small parts of your pump. Valves, membranes and other silicone components are working parts of the pumping system and can wear over time. A valve that is stretched, damaged or no longer sealing properly can affect suction and milk removal, while a worn membrane can also affect the performance of some pumps. These parts don't always need replacing at exactly the same interval for every pump. Check your pump manufacturer's guidance for how often valves and membranes should be replaced, but also look at the parts themselves. If a valve or membrane looks stretched, split, warped, cloudy, damaged or no longer sits correctly, it is worth replacing it. Parents who pump frequently may find that these parts need replacing more often than someone who pumps occasionally. It is an easy thing to overlook: before assuming your body, your flange or your milk supply has changed, make sure your pump is still working as it should. A good flange fit cannot compensate for a worn or damaged pump part. Sometimes the answer isn't that you need to pump harder. You may simply need to make pumping work better for your body. Practical preparation for an assessment It can help to bring the pump, the flanges currently in use and any parts that affect fit, such as inserts or collection bottles. If possible, note how long each session lasts, typical settings, frequency of pumping, pain or skin changes, and any patterns in milk expression. These details allow the discussion to focus on what is happening in real life rather than an isolated measurement. Avoid making several major changes at once. If a new flange or setting is tried, allow enough time to notice comfort, nipple condition and how manageable the routine feels, unless pain or skin damage means it should be stopped sooner. Keeping changes measured makes it easier to understand what has helped. A flange fitting assessment should leave a family with clear, realistic next steps. This may include trying an alternative size or shape, adjusting positioning or settings, checking pump parts, arranging feeding support, or seeking medical review. Sometimes the most helpful outcome is reassurance that fit appears reasonable and that another factor deserves attention. A supportive next step Pumping is often treated as a purely technical task, yet it takes place within a demanding period of recovery, caring and feeding. A thoughtful assessment makes space for both the practical and emotional aspects: what feels comfortable, what is achievable, and what will best support your family’s own feeding goals. If expressing is painful, stressful or simply not working as expected, you deserve to be heard and supported without judgement. If you would like personalised support, you can visit tongue-tie.info to book a flange fitting. Together, we can look at your individual flange size, shape and fit, how your breast responds during pumping, and any other factors that may be affecting your comfort or milk removal. The aim isn't simply to find a smaller or larger flange — it is to find what works best for you. References Anders, L.A., Frem, J.M. and McCoy, T.P. (2025) ‘Flange Size Matters: A Comparative Pilot Study of the Flange FITS™ Guide Versus Traditional Sizing Methods’, Journal of Human Lactation, 41(1), pp. 54–64. doi: 10.1177/08903344241296036 Academy of Breastfeeding Medicine (2018) ‘ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018’, Breastfeeding Medicine, 13(5), pp. 307–314. doi: 10.1089/bfm.2018.29092.wjb. Becker, G.E., Smith, H.A. and Cooney, F. (2016) ‘Methods of milk expression for lactating women’, Cochrane Database of Systematic Reviews, 9, CD006170. Morton, J., Hall, J.Y., Wong, R.J., Thairu, L., Benitz, W.E. and Rhine, W.D. (2009) ‘Combining hand techniques with electric pumping increases milk production in mothers of preterm infants’, Journal of Perinatology, 29(11), pp. 757–764. doi: 10.1038/jp.2009.87. Mitchell, K.B. et al. (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022’, Breastfeeding Medicine, 17(5), pp. 360–376. doi: 10.1089/bfm.2022.29207.kbm. NICE (2021) Postnatal care, NG194. Recommendation 1.5.12 Ramsay, D.T., Kent, J.C., Owens, R.A. and Hartmann, P.E. (2005) ‘Ultrasound imaging of milk ejection in the breast of lactating women’, Pediatrics, 115(2), pp. 361-367. World Health Organization (2016) ‘Methods of milk expression for lactating women’. WHO e-Library of Evidence for Nutrition Actions (eLENA). Specialist Pharmacy Service (2024) ‘Using domperidone for low milk supply’. 21 June. World Health Organization (2017) Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: World Health Organization.

A nipple shield can feel like a very small piece of equipment carrying a great deal of hope. For some families, learning how to use nipple shields can provide a short-term bridge through painful feeding, latch difficulty or an unsettled start. For others, it may not improve feeding at all. The aim is not simply to get a shield to stay on, but to support comfortable, effective milk transfer while understanding what is happening for both baby and parent. Nipple shields are thin, flexible silicone covers worn over the nipple during breastfeeding or chestfeeding. They are not a treatment for every feeding difficulty, and they do not replace a skilled assessment of positioning, attachment, milk production, infant wellbeing and oral function. Used thoughtfully, with follow-up, they can be one useful option within a wider feeding plan. When might a nipple shield be considered? A clinician may suggest a nipple shield when a baby is struggling to latch directly to the breast, particularly where the nipple is very sore, the nipple shape makes attachment more difficult, or a baby is finding the transition from bottle to breast challenging. Sometimes a shield is considered for babies born early or for babies who need help maintaining a latch while feeding skills develop. The research base is limited and mixed. Older shield designs were associated with reduced milk transfer, while modern thin silicone shields may be helpful for some dyads when appropriately selected and monitored. However, studies are generally small and do not show that shields are the right answer for every situation (McKechnie and Eglash, 2010; Chertok, Schneider and Blackburn, 2006). This is why individual feeding assessment matters. Painful feeding, frequent slipping off, clicking, very long feeds, concerns about milk transfer or a baby who is not gaining weight as expected deserve careful attention. These experiences can have several contributing factors. Anatomy provides information; function provides context. How to use nipple shields: fitting and application A shield should fit the nipple, not merely cover it. The tunnel should allow the nipple to draw in comfortably during a feed without rubbing tightly against the sides or leaving a pronounced compressed ring afterwards. A shield that is too small may cause friction and restrict nipple movement. One that is too large may be difficult for a baby to hold deeply in their mouth. Sizes vary between manufacturers, so the number on a packet is not a substitute for observing a feed. Before feeding, wash your hands. Follow the manufacturer’s instructions for cleaning and sterilising the shield, particularly for young babies. Check that it is intact, clean and free from tears. To apply it, turn the outer edges partly inside out, centre the nipple in the tunnel, then roll the edges back on to the breast. This gentle turning action often helps create a seal. A few drops of expressed breast milk inside the tip may encourage a baby to begin sucking, though it is not essential. Bring baby to the breast in a stable, close position. Their nose should be level with the nipple and their body held facing yours, rather than turning their head towards the breast. Wait for a wide mouth, then bring them on deeply. The baby needs to take a generous mouthful of breast as well as the shield, not just the shield’s tip. If the shield repeatedly slips, pauses can help. Repositioning yourself and baby, drying excess milk from the breast or checking the fit may make more difference than pressing the shield more firmly into place. How to clean and sterilise nipple shields Nipple shields come into direct contact with your baby's mouth and breast milk, so good hygiene is important. They should be cleaned after every use and sterilised regularly. After every feed Wash your hands before handling the nipple shield. After the feed, rinse the shield and then wash it thoroughly in hot, soapy water. Pay particular attention to the inside of the shield and the small openings through which milk passes. Rinse it thoroughly in clean, running water and allow it to dry completely before storing it in a clean, dry container. For a healthy, term baby, nipple shields should be washed after every use and sterilised at least once every 24 hours. This approach is consistent with NHS guidance used for infant feeding equipment and specific NHS guidance relating to nipple shields. Sterilisation can be carried out using an appropriate steam steriliser, cold-water sterilising solution or boiling, provided the nipple shield manufacturer confirms that the particular product is suitable for that method. NHS guidance recommends following the steriliser manufacturer's instructions for steam sterilisation, keeping equipment submerged for at least 30 minutes when using cold-water sterilising solution, and boiling suitable equipment for at least 10 minutes. If using cold-water sterilisation, the solution should be changed every 24 hours in accordance with the manufacturer's instructions. What about premature or neonatal babies? The requirements can be different for babies who are premature, receiving neonatal care or otherwise particularly vulnerable to infection. In neonatal settings, more stringent infection-control procedures may be used. If your baby is receiving neonatal care, follow the specific instructions provided by your neonatal or infant-feeding team. What about after tongue-tie division? Extra care with hygiene is appropriate when a nipple shield is being used following tongue-tie division (frenulotomy). The procedure leaves a healing wound beneath the tongue, so anything placed into the baby's mouth should be kept particularly clean. If a nipple shield is being used following division, it should continue to be cleaned thoroughly after every use. In this situation, I would recommend following the specific post-procedure advice given by the clinician who performed the division regarding sterilisation. Depending on the baby's age, health and clinical circumstances, this may be more stringent than routine advice for a healthy term baby. It is therefore helpful to distinguish between routine nipple-shield hygiene and the additional precautions that may be appropriate following an oral procedure. There is not a single UK-wide rule stating that every nipple shield must automatically be sterilised after every feed following tongue-tie division; the individual clinical circumstances and the clinician's aftercare instructions should be taken into account. It is also important to remember that cleaning and sterilising are not the same thing. Cleaning removes milk residue and contamination, while sterilisation is an additional process to reduce microorganisms. The nipple shield should always be thoroughly cleaned before it is sterilised. Nipple shield sizes and shapes Nipple shields are available in different sizes and shapes, and choosing an appropriate shield can make a difference to comfort and feeding effectiveness. There is no universal nipple-shield size that will suit everyone. How do you measure for a nipple shield? Nipple-shield sizing is generally based on the diameter of the nipple (the distance across the nipple), rather than the size of the breast or areola. The Association of Breastfeeding Mothers (ABM) describes nipple shields as being sized according to the diameter of the base of the nipple, with commonly available UK sizes including 16 mm, 20 mm and 24 mm (Association of Breastfeeding Mothers, 2019). A nipple-measuring tool or ruler can be used to measure the nipple in millimetres. Measurement should be considered a starting point rather than an exact prescription, as different manufacturers use different sizing systems and the internal dimensions of shields can vary between brands. Research into nipple-shield sizing suggests that the relationship between nipple diameter and shield diameter may be clinically relevant. In a mechanistic study examining milk removal, Geddes et al. (2020) compared a fitted shield, where the shield diameter was at least 4 mm larger than the nipple diameter, with a smaller shield. The authors found differences in milk removal between the conditions, suggesting that shield size may influence milk removal efficiency. It is important to note, however, that this study investigated milk removal using breast pumping rather than direct breastfeeding, so its findings should not be interpreted as establishing a universal sizing formula for breastfeeding. Does the shape of the nipple shield matter? Nipple shields differ in their overall shape and design. Traditional shields have a more uniform, conical shape, while some modern designs have a cut-out or asymmetric section around the base. This design allows more of the baby's nose or chin to remain in contact with the breast rather than against the silicone shield. The Association of Breastfeeding Mothers describes a 'contact' nipple shield as having a cut-away section that allows the baby's nose or chin to remain close to the breast (Association of Breastfeeding Mothers, 2019). Shields can also differ in tunnel length, flexibility, teat shape and the number and position of milk-transfer openings. These differences mean that two shields with the same stated diameter may not behave or feel identically during feeding. The design of a nipple shield may also influence milk transfer. Earlier research comparing different shield designs found differences in milk transfer between shield types, although the evidence base is limited and much of the research relates to older shield designs that are different from the thin silicone shields commonly used today (Chow et al., 2015). Consequently, size should not be considered in isolation from the design of the shield. The manufacturer's sizing guidance should always be considered, alongside an assessment of comfort, milk transfer and the individual breastfeeding circumstances. What effective feeding can look and feel like Comfort is one important sign, but it is not the only one. Once the initial tugging settles, feeding should usually feel manageable rather than pinching, burning or persistently painful. You may notice slow, rhythmic jaw movement and hear or see periods of swallowing. The shield may contain milk after a feed, but this alone does not tell us how much milk baby has transferred. Look at the whole picture: baby’s alertness, feeding pattern, nappy output appropriate to their age, weight trajectory and your breast comfort. A baby who comes off content at times can still need review if feeds are consistently exhausting, milk transfer is uncertain or weight gain is a concern. Protecting milk supply while using a shield A nipple shield does not inevitably reduce supply, but any situation in which milk removal is less effective can affect supply over time. This is a practical reason for arranging early follow-up rather than assuming that a shield has solved the issue. Offer feeds responsively and observe whether your breasts soften after feeds. If baby is not transferring milk effectively, a feeding professional may recommend expressing after some feeds to protect supply and provide milk for baby. The right approach depends on baby’s age, weight, feeding frequency, your milk production and the overall plan. There is no single expressing schedule that suits every family. Where supplementation is clinically indicated, decisions about what, how and for how long should be made with appropriate professional support and in line with your feeding goals. The Academy of Breastfeeding Medicine emphasises that discharge and follow-up planning should include assessment of breastfeeding effectiveness, infant intake and timely support when concerns are identified (Hoyt-Austin et al., 2022). Common problems and gentle adjustments Some babies become frustrated because milk is not flowing quickly enough at the beginning of a feed. Gentle breast compression while baby is actively sucking may help maintain milk flow. Others may find the shield changes the feel of feeding and need calm, repeated opportunities to practise. If feeds are painful, do not assume that pain is an unavoidable part of using a shield. Check the fit and depth of latch first. Persistent nipple pain may be linked to skin damage, positioning and attachment, milk blebs, infection, vasospasm or other causes, each of which needs a different response. A shield can sometimes reduce friction temporarily, but it should not delay assessment of ongoing pain (Berens et al., 2016). Some parents find that baby will feed with a shield but not without it. This is not a failure. If direct feeding is your goal, try when baby is calm rather than very hungry. Skin-to-skin contact, offering the breast without the shield at the start of a feed, or removing it partway through when milk is flowing may be worth exploring. If baby becomes upset, return to what enables feeding and seek specialist support from a lactation consultant (IBCLC). There is rarely a benefit in turning feeding into a battle. When to seek prompt support Contact your midwife, health visitor, GP, infant feeding team or another suitably qualified clinician promptly if your baby is unusually sleepy for feeds, has fewer wet nappies than expected for their age, appears jaundiced or unwell, or is not gaining weight as expected. Seek support too if you have worsening breast pain, fever, a red or hot area of breast, damaged nipples that are not healing, or significant worries about milk supply. If you are unsure whether a nipple shield is the right size, shape or solution for you and your baby, or if you are experiencing ongoing pain or feeding difficulties, seeking individual breastfeeding support can be helpful. International Board Certified Lactation Consultants (IBCLCs) are internationally recognised specialists in lactation and breastfeeding care and are considered the gold standard in lactation care. An IBCLC can assess the breastfeeding dyad, including feeding, attachment, milk transfer and nipple-shield use, and provide individualised support. A skilled feeding assessment involves watching a feed and considering the parent, baby and feeding relationship together. It may include discussion of birth history, bottle feeding where relevant, breast and nipple comfort, infant growth, positioning, attachment and oral function. Tongue-tie can be one consideration in some babies, but it is not the sole explanation for complex feeding difficulties, and not every visible frenulum requires treatment. Using a shield as a bridge, not a test to pass For many families, nipple shields are temporary. For others, they remain useful for longer. Neither outcome defines the success of your feeding journey. The priority is that baby is fed, the feeding parent is supported, and decisions are made with clear information rather than pressure. If a shield is helping, continue to monitor feeding and keep review in place. If it is not helping, you do not need to persist alone. Thoughtful support can identify what is working, what needs adjusting and what matters most to your family. References Alder Hey Children's NHS Foundation Trust (2023) Nipple Shields – Breastfeeding Leaflet. Available at: https://www.alderhey.nhs.uk/wp-content/uploads/2023/06/Nipple-Shields-Breastfeeding-Leaflet-PIAG-343.pdf (Accessed: 14 August 2026). Association of Breastfeeding Mothers (2019) Weaning from a shield. Available at: https://abm.me.uk/wp-content/uploads/ABM-nipple-shields-breastfeeding.pdf (Accessed: 14 August 2026). Berens, P., Brodribb, W., Academy of Breastfeeding Medicine and Protocol Committee (2016) ‘ABM Clinical Protocol #26: Persistent pain with breastfeeding’, Breastfeeding Medicine, 11(2), pp. 46-53. Chertok, I.R.A., Schneider, J. and Blackburn, S. (2006) ‘A pilot study of maternal and term infant outcomes associated with ultrathin nipple shield use’, Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(2), pp. 265-272. Chow, S., Chow, R., Popovic, M., Lam, H., Merrick, J., Milne, S., Laks, R., and Theam, M. (2015) 'The use of nipple shields: a review', Frontiers in Public Health, 3, p. 236. East of England Neonatal Network (2025) Clinical Guideline: Using a Nipple Shield. Available at: https://eoeneonatalpccsicnetwork.nhs.uk/wp-content/uploads/2023/07/EoE-Nipple-Shield-Guideline.pdf (Accessed: 14 August 2026). Geddes, D.T., Prime, D.K., Hartmann, P.E. and others (2020) 'Effect of nipple shield use on milk removal: a mechanistic study', BMC Pregnancy and Childbirth, 20. Hoyt-Austin, A.E., Kair, L.R., Larson, I.A., Stehel, E.K., Marinelli, K.A. and Academy of Breastfeeding Medicine (2022) ‘Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for birth hospitalization discharge of breastfeeding dyads, revised 2022’, Breastfeeding Medicine, 17(3), pp. 197-206. McKechnie, A.C. and Eglash, A. (2010) ‘Nipple shields: A review of the literature’, Breastfeeding Medicine, 5(6), pp. 309-314. NHS (2026) How to sterilise feeding equipment. Available at: https://www.nhs.uk/best-start-in-life/baby/feeding-your-baby/bottle-feeding/how-to-make-up-a-feed/how-to-sterilise-equipment/ (Accessed: 14 August 2026). NHS (2026) Sterilising baby bottles. Available at: https://www.nhs.uk/baby/breastfeeding-and-bottle-feeding/bottle-feeding/sterilising-baby-bottles/ (Accessed: 14 August 2026).

A newborn who usually wakes and feeds but suddenly cannot sustain a feed needs a different response from a baby who has had a difficult latch since birth. Knowing the top newborn feeding red flags can help families and professionals distinguish a feeding challenge that needs skilled support from signs that need urgent medical assessment. Feeding can look very different between babies. Breastfeeding, chestfeeding, bottle feeding, expressing and combination feeding are all valid ways to nourish an infant. One unsettled feed, a cluster-feeding evening or a short feed does not automatically mean something is wrong. The concern is a change in the baby’s usual pattern, especially when it occurs alongside changes in alertness, colour, breathing, output or weight. Top newborn feeding red flags: looking at the whole baby A feeding assessment should never rely on one sign in isolation. The pattern matters: the baby’s age, gestation at birth, health history, feeding method, feeding frequency, observable swallowing, milk or feed intake, nappy output, weight trend and the parent’s experience all add context. For families, this means you do not need to work out the cause before asking for help. For professionals, it means avoiding assumptions. Oral anatomy may provide useful information, but function and the wider clinical picture provide context. A restricted lingual frenulum can coexist with feeding difficulty, but it is not the only possible explanation for poor feeding, pain or low intake. 1. A baby who is too sleepy, weak or unable to feed Newborns are often sleepy, particularly in the first days after birth. However, a baby who is difficult to wake for feeds, does not remain awake long enough to feed, has a noticeably weak suck, repeatedly stops feeding because they appear exhausted, or takes much less than usual needs prompt assessment. This is particularly urgent if a baby has missed several feeds, is refusing feeds, or their feeding has suddenly changed. Reduced feeding can be an early, non-specific sign of illness. It should not be attributed to a presumed tongue-tie, reflux or normal newborn behaviour without considering the infant’s overall condition. Contact your midwife, health visitor, GP, maternity assessment unit or NHS 111 promptly for advice if a newborn is feeding poorly and seems unusually sleepy or unwell. If the baby is floppy, unresponsive, has significant breathing difficulty or looks blue, grey, very pale or mottled, call 999. 2. Signs of dehydration or insufficient intake Nappy output is a practical part of assessing intake, although it needs to be interpreted according to the baby’s age. In the early days, output normally changes as feeding becomes established. From around day five, many babies who are feeding effectively will have at least six pale, wet nappies in 24 hours. Persistently fewer wet nappies, very concentrated urine, a dry mouth, a sunken fontanelle, or increasing sleepiness may indicate that a baby needs clinical review (NHS, n.d.). Stools can also offer useful context. A delay in the normal transition from dark meconium stools to lighter stools, or very infrequent stooling alongside poor feeding and low urine output, warrants discussion with a healthcare professional. Output alone cannot confirm whether a baby is receiving enough milk or feed, but it can identify a pattern that should not be ignored. For a breastfed or chestfed baby, skilled observation of a complete feed can be more useful than focusing only on feed length. For a bottle-fed baby, it is helpful to consider how the baby manages the feed, rather than assuming that a particular volume proves wellbeing. A baby who coughs, splutters, becomes distressed, falls asleep from fatigue or cannot coordinate sucking, swallowing and breathing may need assessment even if some milk is taken. 3. Excessive weight loss or poor weight gain It is normal for newborns to lose some weight after birth. The key question is whether the weight pattern is expected for that individual baby and whether feeding is effective. The Academy of Breastfeeding Medicine advises that weight loss of more than 10% of birth weight, or very low output, should prompt a careful feeding assessment rather than an automatic conclusion that supplementation or a procedure is required (Academy of Breastfeeding Medicine, 2022). A weight check is one piece of information, not a verdict on a parent’s effort or feeding choice. Scales, timing, birth interventions, fluids given during labour and individual variation can all affect interpretation. Nevertheless, a baby whose weight loss is concerning, who has not begun to regain weight as expected, or whose weight gain is poor needs timely review by the appropriate maternity, neonatal, primary care or infant-feeding team. The assessment should consider feeding frequency, transfer or intake, maternal health and milk production where relevant, the baby’s health, and any possible anatomical or functional factors. Families deserve a plan that is clear, practical and reviewed, rather than being left to manage concern alone. 4. Jaundice with poor feeding or increasing sleepiness Jaundice is common in newborns, but a yellow colour that is becoming more noticeable or occurs with poor feeding and lethargy needs assessment. Babies with jaundice can become sleepy and feed less effectively; reduced intake can then contribute to worsening jaundice. This is a cycle that benefits from early, skilled support. Seek urgent advice if your baby is yellow and difficult to wake, feeding significantly less, has dark urine or pale stools, or appears unwell. NICE recommends prompt assessment of jaundice in newborns because the timing, level of bilirubin and the baby’s clinical condition guide care (NICE, 2023). Do not rely on skin colour alone, particularly in different skin tones or under artificial light. 5. Vomiting, breathing changes or unsafe feeding behaviour Small amounts of milk coming back after a feed can be common. Repeated forceful vomiting, green vomit, blood in vomit, a swollen abdomen, or vomiting with reduced wet nappies and lethargy requires urgent medical assessment. Green vomit is not a feeding issue to monitor at home. During feeds, pauses to breathe can be normal. However, persistent coughing, choking, colour change, noisy or laboured breathing, sweating, or visible distress are not signs to work through by changing a latch or encouraging the baby to finish. Stop the feed if needed, keep the baby safe and seek urgent clinical advice. Call 999 if there is blue or grey colour, severe breathing difficulty, a prolonged episode of unresponsiveness or you believe your baby is in immediate danger. When feeding pain or difficulty needs timely support Not every concern is an emergency, but persistent difficulties deserve care before they become overwhelming. Nipple pain, damaged skin, repeated clicking, very long or very short feeds, frequent loss of milk from the mouth, difficulty maintaining a latch, bottle refusal, distress at feeds or concern about milk transfer can all justify a skilled feeding assessment. These signs may relate to positioning and attachment, feeding pace, flow, infant health, prematurity, muscle tone, sensory factors, parental milk supply, breast anatomy, bottle-feeding technique or a combination of factors. An assessment that observes feeding and considers the baby’s oral function, rather than appearance alone, supports better clinical reasoning and shared decision-making. A calm next step when you are concerned If your newborn has a red flag, seek help on the same day unless emergency signs mean you need 999. Before speaking with a clinician, it can help to note when the baby last fed, how the feed differed from usual, wet and dirty nappies, vomiting, temperature if taken, and any change in behaviour. This information supports triage, but it should never delay asking for help. For ongoing feeding concerns without signs of acute illness, ask for a full feeding review from an appropriately trained professional. The goal is not to force a single explanation or pathway. It is to understand what is happening for this baby and this family, protect feeding where possible, and make a plan that feels safe, realistic and supported. If you are experiencing ongoing feeding difficulties, seeking individual breastfeeding support can be helpful. International Board Certified Lactation Consultants (IBCLCs) are internationally recognised specialists in lactation and breastfeeding care and are considered the gold standard in lactation care. An IBCLC can provide specialist support across a range of infant feeding methods, including breastfeeding, bottle feeding and other feeding approaches, with individualised assessment and guidance to support feeding function and help prevent or reduce recurrence of feeding difficulties. Where a 'red flag' or urgent medical concern is present, appropriate medical advice should be sought in the first instance. Trust the sense that something has changed. Parents know their baby’s usual rhythms, and a compassionate clinical assessment can turn uncertainty into a clear next step. References Academy of Breastfeeding Medicine (2022) ‘ABM Clinical Protocol #2: Guidelines for birth hospitalisation discharge of breastfeeding dyads, revised 2022’, Breastfeeding Medicine, 17(3), pp. 197-206. National Institute for Health and Care Excellence (NICE) (2023) Jaundice in newborn babies under 28 days. Clinical guideline CG98. London: NICE. National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. London: NICE. NHS (n.d.) How to tell if your baby is getting enough milk. London: NHS.

Fundamentals in Infant Tongue-tie Anatomy, Function & Treatment Considerations A visible lingual frenulum can prompt urgent questions from families and confident opinions from professionals. Yet anatomy alone rarely explains an infant’s feeding experience. D-Restricted Ltd’s Tongue-tie School is built around a more careful starting point: anatomy provides information, while function provides context. For professionals supporting infants and families, this distinction matters. Feeding concerns may involve positioning, attachment, milk supply, infant maturity, neurological or medical factors, bottle-feeding mechanics, maternal comfort, family goals and many other influences. A skilled response is not simply to identify a frenulum, but to understand the wider feeding picture and help families make informed choices. Why tongue-tie education needs clinical reasoning The term tongue-tie, or ankyloglossia, is used to describe a restrictive lingual frenulum that may affect tongue movement and function. However, terminology, diagnostic approaches and assessment methods are not universally consistent. A 2020 clinical consensus statement highlighted both areas of agreement and continuing uncertainty around the diagnosis and management of ankyloglossia, including disagreement around some commonly used terminology and the limitations of available evidence. This is one reason that a visual finding should not be treated as a diagnosis in isolation. For some infant–caregiver dyads, restricted tongue movement may be relevant to persistent feeding difficulty. For others, a frenulum may be visible without causing an apparent functional problem, or feeding concerns may be better explained by other factors. Families deserve neither dismissal nor the assumption that one anatomical finding accounts for every challenge. A thoughtful assessment therefore brings together a detailed feeding history, observation of feeding where appropriate, infant oral function, maternal or parental experience, growth and milk-transfer concerns, and the wider clinical context. It also recognises the limitations of individual assessment tools. Tools can support structured observation and communication, but they do not replace professional judgement, clinical reasoning or shared decision-making. This function-based approach is central to Tongue-tie School. The programme considers the relationship between anatomy, tongue movement, oral skills, infant feeding and the wider infant–caregiver feeding dyad, rather than focusing solely on the presence or appearance of a frenulum. What Tongue-tie School covers D-Restricted Ltd’s Tongue-tie School is a structured, accredited online education programme for healthcare professionals supporting infants and families. Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations takes a function-based, evidence-informed approach to infant tongue-tie, exploring oral anatomy and function alongside infant feeding, assessment principles, treatment considerations, conservative management and ongoing support. The programme is delivered through six self-paced modules and takes approximately 10 hours of study, with additional reading and self-directed learning. It provides 15 CPD points and 8 L-CERPs for IBCLCs, and participants retain ongoing access to the course materials and the Tongue-tie School community support hub. Oral anatomy and physiology The first module explores the relevant anatomy and physiology of the oral structures, including the tongue, oral cavity and surrounding structures, and their relationship with infant feeding function. Understanding anatomy provides an important foundation, but the course encourages practitioners to consider what that anatomy means functionally. What can the infant actually do? How is tongue movement affecting oral skills? What is happening during feeding? And how does this relate to the experience of the infant and caregiver? Functional considerations over time The course then considers the potential relationship between oral ties, function and feeding experiences over time. Importantly, this is approached within the context of individual variation and the wider clinical picture. Feeding is a dynamic process. An infant’s maturity, regulation, oral skills, feeding method and changing developmental needs can all influence how feeding presents. Understanding these factors can help practitioners avoid viewing tongue-tie as a static anatomical problem with a single predictable outcome. Feeding assessment and differential diagnosis Feeding difficulties are multifactorial. A baby who slips off the breast, feeds for long periods, coughs during bottle feeding, causes nipple pain or gains weight slowly may need timely support, but these signs are not specific to tongue-tie. D-Restricted Ltd's 'Tongue-tie School' explores assessment principles, the role of assessment tools and differential diagnosis. This encourages practitioners to consider the whole feeding picture rather than allowing a particular sign or assessment score to become the diagnosis. This approach is consistent with wider professional thinking around tongue-tie assessment. The University of Bristol, for example, notes that structured assessment tools can assist clinicians, but that assessment should be combined with clinical judgement and discussion with the mother about comfort and perceived feeding effectiveness. Depending on the individual situation, appropriate support may include skilled breastfeeding or chest/body feeding support, responsive bottle-feeding guidance, review of milk supply, pump or flange support, oral-function support, bodywork where appropriate, or referral to another suitably qualified professional. The right next step depends on the infant, the feeding relationship, the clinical findings and the family’s priorities. Body therapies, tongue exercises and sensorimotor oral activities The programme also considers supportive approaches including body therapies, oral play, tongue exercises and sensorimotor oral activities. These are considered within the broader concepts of preparation, rehabilitation and ongoing feeding support rather than as isolated interventions. The emphasis remains on understanding why an approach may be appropriate for an individual infant and how it fits within the wider feeding journey. Frenulotomy: evidence, uncertainty and clinical considerations Where frenulotomy is being considered, professionals need to understand both the potential benefits and the limitations of the available evidence. NICE guidance states that there are no major safety concerns identified with division of ankyloglossia and that limited evidence suggests the procedure may improve breastfeeding. NICE also recommends that the procedure should be performed by appropriately trained registered healthcare professionals, with appropriate arrangements for consent, audit and clinical governance. Research on frenulotomy in young infants suggests that it may reduce maternal nipple pain in the short term for some breastfeeding dyads. However, the evidence for consistent improvement in infant breastfeeding outcomes and longer-term breastfeeding success remains limited. The Cochrane review found a short-term reduction in maternal nipple pain but no consistent positive effect on infant breastfeeding, while also noting the small number of studies and methodological limitations. A UK randomised controlled trial involving infants with mild-to-moderate tongue-tie found no difference in its primary breastfeeding outcome at five days between early frenotomy and standard breastfeeding support. Maternal breastfeeding self-efficacy improved, however, illustrating the importance of considering both clinical outcomes and family experience. D-Restricted Ltd's 'Tongue-tie School' encourages professionals to engage with this uncertainty rather than presenting frenulotomy as an automatic solution. A procedure may be one consideration where there is a clear functional concern and persistent feeding difficulty despite appropriate support, but the appearance of a frenulum alone does not establish that an intervention is required, nor can a procedure guarantee a particular feeding outcome. The programme addresses surgical release methods, risks and clinical considerations, but it is not a surgical skills course. Its focus is on developing the knowledge and reasoning required to understand treatment pathways, informed decision-making, preparation and aftercare within the practitioner’s own professional role and scope of practice. Assessment and completion Assessment is designed to support both knowledge acquisition and reflective clinical thinking. Participants complete six module quizzes, with a minimum pass mark of 80% for each assessment. They also submit a reflective case study based around an infant feeding journey. The case study encourages participants to consider the journey holistically, including initial contact, assessment considerations, potential treatment options, referral pathways, follow-up care and ongoing support for the infant, mother and wider family network. Successful completion of the required elements leads to a Certificate of Online Attendance and Certificate of Accreditation. The programme is self-paced and on-demand, with an estimated study time of approximately 10 hours, alongside additional reading and self-directed study. Participants also have ongoing access to the Tongue-tie School community support hub while the programme remains available. The programme is accredited by Advantage and has been awarded 8 L-CERPs by the International Board of Lactation Consultant Examiners (IBLCE), alongside 15 CPD points. Regulation, professional scope and clinical governance Education and training are only one part of safe tongue-tie practice. In the UK, all tongue-tie release providers must be registered and regulated by both a professional regulatory body and the appropriate service regulatory body. Importantly, undertaking a tongue-tie training course does not, in itself, give a practitioner the authority to perform a surgical procedure. Any surgical procedure must fall within the scope of practice of the professional regulator under which the practitioner is registered. (Association of Tongue-tie Practitioners, Tongue-tie Training FAQs) Professional regulatory bodies There are nine professional regulatory bodies in the UK. However, where surgical tongue-tie release is concerned, the professional regulatory bodies currently applicable are: Nursing and Midwifery Council (NMC) General Medical Council (GMC) General Dental Council (GDC) The procedure must fall within the scope of the practitioner’s professional regulator in order for them to undertake it. Practitioners must also ensure that they have the appropriate education, training, competence, experience, professional indemnity and clinical governance arrangements required for their role. This distinction is important. A practitioner may complete additional education in infant tongue-tie, but a course or certificate does not independently extend their statutory professional scope of practice. Practitioners remain responsible for working within the requirements of their professional regulator and their own competence. The ATP specifically highlights this distinction within its guidance on tongue-tie training and regulation. (Association of Tongue-tie Practitioners, Tongue-tie Training FAQs) Service regulatory bodies Professional regulation is separate from regulation of the healthcare service in which tongue-tie release is provided. Private practitioners are also required to consider the service regulatory requirements applicable to the location in which they practise. The relevant service regulatory bodies are: Care Quality Commission (CQC) – England Healthcare Improvement Scotland (HIS) – Scotland Jersey Care Commission (JCC) – Jersey Regulation and Quality Improvement Authority (RQIA) – Northern Ireland At the time of writing, practitioners providing tongue-tie services in Wales are not required to register with Healthcare Inspectorate Wales (HIW). (Association of Tongue-tie Practitioners, Tongue-tie Training FAQs) The regulatory position therefore involves more than simply completing a course. Practitioners undertaking tongue-tie release need to consider their professional registration, scope of practice, service registration requirements, professional indemnity, training and competence, consent, clinical governance and ongoing professional responsibilities. The Association of Tongue-tie Practitioners also requires practitioners listed within its directory to be registered healthcare professionals, appropriately insured and regulated for surgical procedures where required by law. The ATP is not itself a regulatory body and does not regulate individual practitioners or services; responsibility for meeting the relevant professional and service regulatory requirements remains with the individual practitioner and service. (Association of Tongue-tie Practitioners) Practitioners should ensure that they understand and comply with the regulatory requirements applicable to their individual professional registration and service before undertaking tongue-tie division. Who is D-Restricted Ltd's 'Tongue-tie School' for? Tongue-tie School has been developed for healthcare professionals supporting infants and families, particularly those working across infant feeding, maternity, neonatal and early-years settings. The programme is suitable for a range of professional backgrounds, including: Registered nurses Midwives Health visitors International Board Certified Lactation Consultants (IBCLCs) Lactation consultants and infant feeding specialists Healthcare professionals supporting infants and families Existing tongue-tie providers seeking to refresh and consolidate their knowledge The programme is designed to complement existing professional knowledge rather than replace it. Participants bring their own clinical experience and professional perspective, while the course provides an opportunity to develop a deeper understanding of infant tongue-tie, oral function, feeding and treatment considerations within a multidisciplinary context. Why aftercare begins before a decision Families often arrive at an appointment having already read conflicting advice. Some may have been told that a procedure will solve every feeding concern; others may feel that their concerns have been minimised. Both experiences can add pressure at a time when feeding may already feel exhausting. Good aftercare begins with preparation before any intervention is considered. Professionals can help families understand what is known, what remains uncertain, what support will continue regardless of the decision, and when further review may be appropriate. If a frenulotomy is undertaken, feeding support remains central. A procedure does not remove the need for responsive feeding care or eliminate the possibility that more than one factor may be affecting feeding. Clear communication also means respecting different feeding goals. Breastfeeding, chest/body feeding, expressing, bottle feeding, combination feeding and changing feeding plans are all decisions that deserve non-judgemental support. The clinical task is not to direct every family towards a preferred outcome, but to provide accurate information, recognise individual circumstances and support informed decision-making. Learning that strengthens collaborative care Tongue-tie work is most effective when it is collaborative. Midwives, health visitors, neonatal and paediatric teams, GPs, nurses, IBCLCs, infant feeding specialists, speech and language therapists and other professionals may each see different aspects of the same feeding journey. Shared language, appropriate referral pathways and an understanding of professional scope can help reduce duplication, mixed messages and delays in support. For practitioners, education also creates space for reflection. It is reasonable to hold uncertainty, seek a second opinion and recognise when a concern sits outside one’s scope of practice. Clinical confidence is not about having a quick answer for every infant. It is about knowing how to gather relevant information, weigh evidence, recognise uncertainty, explain options and remain attentive to the family in front of you. D-Restricted Ltd's 'Tongue-tie School' community support hub extends this learning beyond the formal modules, providing participants with opportunities for professional discussion, shared experiences, resource exchange and continued connection with colleagues working in infant feeding and tongue-tie support. A deeper approach to infant tongue-tie education D-Restricted Ltd developed 'Tongue-tie School' for professionals who want to develop a deeper understanding of infant tongue-tie through anatomy, function, feeding and evidence-informed clinical reasoning. The Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations programme does not promote a single pathway for every infant. Instead, it encourages practitioners to look beyond anatomy alone, consider the whole infant–caregiver feeding dyad, recognise the multifactorial nature of feeding difficulties and support families through informed, individualised decision-making. With six self-paced modules, approximately 10 hours of learning, 15 CPD points, 8 L-CERPs for IBCLCs, module assessments and a reflective case study, the programme provides a structured opportunity for healthcare professionals to develop and consolidate their knowledge. Further information: Tongue-tie School – Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations Every feeding journey deserves to be heard in full. When professionals look beyond anatomy alone, they are better placed to ask meaningful questions, recognise uncertainty, work collaboratively and provide care that is calm, respectful and responsive to the individual infant and family. References Association of Tongue-tie Practitioners (ATP) (2025) Tongue-tie Training FAQs. Available at: https://www.tongue-tie.org.uk/tongue-tie-training?locale=en (Accessed: 15 August 2026). Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., Sutcliffe, A. and Barlow, S. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 99(3), pp. F189-F195. 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., Walsh, S.A. and Yellon, R.F. (2020) ‘Clinical consensus statement: Ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. 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.

A pump that feels manageable at 2 am, protects comfort and helps meet a family’s particular feeding goals is more useful than one carrying the label of the best breast pump for expressing. The right choice is rarely about buying the most powerful, newest or most expensive option. It is about fit, frequency of use, milk-removal needs, practical circumstances and skilled support when feeding is not going as hoped. For some families, a pump is used occasionally to leave milk for a feed. For others, expressing is a central part of feeding because a baby is premature, temporarily unable to feed at the breast, combination fed, or because this is the feeding relationship that works best for their family. All of these reasons are valid. Is there a best breast pump for expressing? There is no single pump that is best for every lactating parent. A Cochrane review of methods of expressing milk found that the available research was generally limited and variable, making it difficult to draw firm conclusions about one method or type of pump being consistently superior for all women (Becker, Smith and Cooney, 2016). This matters because product comparisons can make a complex decision sound simple. Pump effectiveness is not only a feature of the device. It can be affected by breast shield fit, suction settings, timing, the parent’s comfort, their milk supply, whether they are pumping alongside direct feeding, and the support available when challenges arise. Hand expression also remains a useful skill. In the early postnatal period, particularly when only small volumes of colostrum are expected, it may be practical and reassuring. NICE recommends that parents who wish to breastfeed receive information and support, including help with expressing where this is needed (NICE, 2021). A pump need not replace hand expression; many families use both at different times. Choosing the best breast pump for expressing milk: start with your needs Before comparing pump types, it helps to name the job the pump needs to do. A parent expressing once or twice a week for occasional separation may prioritise portability, quiet use and straightforward cleaning. Someone expressing several times a day, or relying largely on expressed milk, may need a durable pump that is comfortable over repeated sessions and has readily available replacement parts. Occasional expressing A simple manual pump may suit occasional use, especially when portability and cost are important. It can offer direct control over rhythm and suction, but it requires active hand use and may be tiring if used frequently. Some parents prefer a compact electric pump for convenience, particularly if they expect expressing to become more regular. Regular or exclusive expressing When expressing is frequent, an electric pump is often more practical than a manual option. Some people find a double pump helpful because it can reduce the time spent pumping. However, time saved is not the only consideration. A pump that is painful, poorly fitted or difficult to clean is unlikely to be sustainable, whatever its specification. Parents who are expressing to support or establish milk production may benefit from individualised input from an appropriately qualified infant feeding professional. The frequency and pattern of milk removal should be considered alongside the whole clinical picture, including the baby’s age, feeding behaviour, growth, parental recovery and family capacity. A rigid pumping schedule is not appropriate for everyone and may be unhelpful where it creates discomfort, exhaustion or an unintended oversupply. Wearable pumps Wearable pumps can be appealing where discretion and mobility are priorities. Yet they are not automatically the best choice for every body or every feeding situation. Their fit can be more sensitive to positioning, capacity may be limited, and some parents find that a wearable pump does not remove milk as effectively for them as another option. Others find it entirely adequate for part of their routine. It is reasonable to view a wearable pump as one possible tool rather than a guaranteed substitute for other forms of expression. If expressed volumes change significantly, breasts remain persistently full after pumping, or discomfort develops, it is worth reviewing fit, settings, pump function and the wider feeding plan. Comfort and flange fit deserve more attention A breast shield, often called a flange, is the part of the pump that sits against the breast. It is not a one-size-fits-all component. The flange needs to allow the nipple to move comfortably in the tunnel while creating a seal against the breast. Nipple size can change during the postnatal period and may differ between breasts. Pain, rubbing, blanching, swelling, persistent nipple trauma or marked pulling of breast tissue can all indicate that something needs reviewing. They do not diagnose the problem on their own. A setting may be too strong, the flange may not be suitable, the pump position may need adjusting, or there may be an underlying breast or nipple concern requiring assessment. More suction is not necessarily more effective. The most appropriate setting is generally the highest level that remains comfortable, rather than a level endured because it appears more powerful. Milk ejection can be affected by pain, stress, fatigue and the practical reality of caring for a baby. A warm, private space, a drink within reach and support with the baby may matter as much as a technical feature. A skilled flange-fitting assessment can be particularly helpful for parents who are pumping frequently, have ongoing discomfort, notice reduced output with a previously effective pump, or are unsure whether the equipment is working for their body. The purpose is not to chase a perfect measurement or promise a particular volume. It is to improve comfort, observe function and make proportionate adjustments. Use a pump safely, without making feeding harder Pumps and milk-contact parts should be kept clean and used according to the manufacturer’s instructions and local infection-prevention guidance. Families should also know how to store expressed milk safely for their circumstances, especially if their baby was born prematurely or has additional health needs. In these situations, neonatal or paediatric guidance should take priority. It is sensible to check that valves, membranes, tubing and other parts are intact and working as intended. Worn components can affect performance. If a pump suddenly seems less effective, replacing a component may help, but it is also worth considering changes in fit, feeding frequency, breast comfort, infant feeding or parental wellbeing. Expressed volume is not a reliable measure of total milk production or of a parent’s capacity to feed their baby. A baby may transfer milk at the breast differently from a pump, and output can vary over the day. Looking only at millilitres can create understandable anxiety. Where there are concerns about milk transfer, growth, wet nappies, breast pain or a baby’s feeding behaviour, a timely feeding assessment is more informative than changing pumps repeatedly. When feeding difficulties are more complex A pump can be valuable while feeding is being assessed or supported, but it cannot resolve every cause of difficulty. Latch, positioning, breast and nipple health, infant development, prematurity, bottle-feeding technique, milk supply and parental wellbeing can all be relevant. Tongue anatomy may provide information, but function provides context. Not every visible frenulum causes a feeding difficulty, and not every feeding difficulty is explained by tongue function. Where concerns persist, families deserve an assessment that considers the whole feeding relationship rather than a single finding or a single piece of equipment. For healthcare professionals, discussions about pumps are most helpful when they are exploratory rather than prescriptive. Ask what the parent hopes the pump will make possible, how often they expect to use it, whether expression is comfortable, and what is happening at the breast or bottle. This keeps equipment advice connected to clinical reasoning and family-centred care. A considered choice is often the kindest one The best breast pump for expressing is the one that supports a family’s feeding plan without adding avoidable pain, cost, pressure or complexity. It may be a manual pump used occasionally, an electric pump used regularly, a wearable option for selected sessions, hand expression, or a combination that changes over time. If pumping is uncomfortable, stressful or no longer meeting the need it was bought for, that is not a personal failure. It is useful information - and a reason to pause, seek skilled support and choose the next step with compassion. References Becker, G.E., Smith, H.A. and Cooney, F. (2016) ‘Methods of milk expression for lactating women’, Cochrane Database of Systematic Reviews, 9, CD006170. National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. London: NICE. World Health Organization (2003) Global strategy for infant and young child feeding. Geneva: World Health Organization.

A search for a frenulotomy procedure often begins after a difficult feed: a baby slipping from the breast or bottle, feeding for long periods, clicking, dribbling milk, or a parent experiencing pain and worry. Those experiences deserve careful attention. They do not, however, automatically mean that a tongue-tie is the cause or that a procedure is the right next step. In UK infant care, the procedure commonly referred to online as a frenotomy is more accurately called a frenulotomy. This article uses the widely searched term where helpful, while explaining what frenulotomy involves within a thoughtful, function-focused care pathway. Anatomy provides information. Function provides context. What is a frenulotomy procedure? A frenulotomy is a minor surgical division of a restrictive lingual frenulum, the tissue connecting the underside of the tongue to the floor of the mouth. The aim is to improve tongue mobility where a restriction is clinically relevant to feeding. A visible frenulum is normal anatomy. Frenula vary considerably in appearance, thickness and attachment, and appearance alone cannot show whether feeding will be affected. Some babies with a restrictive frenulum feed comfortably and transfer milk effectively. Other babies have feeding difficulties with no tongue restriction at all. For this reason, a good decision about a frenulotomy starts with a skilled assessment of the whole feeding picture. This includes the baby’s health and growth, feeding history, observations of feeding where appropriate, maternal or parent comfort, milk transfer concerns, bottle-feeding efficiency and the family’s own goals. Other possible contributors may need consideration, such as positioning, milk supply, breast or teat shape, infant prematurity, reflux-like symptoms, neurological differences or feeding aversion. When might frenulotomy be considered? Frenulotomy may be considered when there is evidence of a restrictive frenulum alongside persistent functional feeding difficulties, and when skilled feeding support has not sufficiently addressed those difficulties or is not the family’s preferred course after informed discussion. For breastfeeding dyads, the best available trial evidence suggests that frenulotomy may reduce maternal nipple pain in the short term. Evidence for consistent improvement in infant breastfeeding outcomes is less certain. The Cochrane review of randomised trials found short-term improvements in nipple pain, but studies were small and had methodological limitations, including differences in how feeding outcomes were measured (O'Shea et al., 2017). This does not make a family’s experience any less real. It means clinicians should be honest about what research can and cannot predict for an individual baby. A procedure may be one reasonable option, but it is not a guarantee of pain-free feeding, improved supply, weight gain or an easier feeding relationship. Evidence concerning bottle feeding is more limited. A baby may find feeding difficult for many reasons, and a tongue-tie assessment should not overlook teat flow, pacing, feeding position, respiratory comfort, oral coordination and the individual feeding history. Families who bottle feed, combination feed, express milk or use donor milk deserve the same careful, respectful support as those who breastfeed. Conservative support is also active care Choosing not to proceed with frenulotomy, either now or at all, is not the same as doing nothing. A plan may include feeding support, review of positioning and attachment, paced bottle feeding where relevant, monitoring weight and hydration, and a follow-up assessment if concerns continue. In some circumstances, particularly where a baby is feeding effectively and comfortable growth is established, observation may be appropriate. In others, the burden of ongoing feeding difficulty may lead a family to consider a procedure sooner. There is no single pathway that suits every baby. What should happen before a frenulotomy? A clinician should provide clear information in language that makes sense to the family. Consent is a conversation, not simply a form. Parents and carers should have time to ask what the assessment has found, what uncertainties remain, what alternatives exist and what support will be available afterwards. Useful areas for discussion include the expected purpose of the procedure, potential benefits and limitations, possible complications, whether feeding support is needed alongside it, and how to seek help after the appointment. The National Institute for Health and Care Excellence states that evidence on safety is adequate, while evidence of efficacy is limited and should be explained during consent (NICE, 2005). Frenulotomy is usually undertaken in a clinical setting by an appropriately trained and regulated practitioner, following local policies and individual assessment. The exact clinical arrangements can vary according to the baby’s age, health, service setting and practitioner. Families should feel able to ask who will carry out the procedure, what experience and governance supports the service, and what emergency arrangements are in place. What are the possible risks and limitations? Most reported complications are uncommon, but they should not be minimised. They can include bleeding, pain or distress, infection, damage to nearby structures, and the need for further assessment if feeding concerns persist. Rare but more significant complications have been reported in the literature, reinforcing why appropriate training, clinical judgement and follow-up matter (NICE, 2005; O'Shea et al., 2017). A further limitation is that feeding can remain difficult even when tongue movement appears improved. Feeding is a learned, relational and physical process. A baby may need time to adapt, while a parent may need support with comfort, milk supply, pumping or confidence after a demanding period of feeding. Neither the presence of a tongue-tie nor the choice to have a frenulotomy should be used to explain every present or future concern. Claims that release will prevent speech, dental, sleep, posture or developmental difficulties are not supported by evidence in an individual infant feeding assessment. These concerns require their own appropriate assessment if and when they arise. Aftercare: supporting feeding, not chasing perfection Aftercare should be planned before the appointment, not treated as an afterthought. Families need practical guidance about normal recovery, feeding in the hours and days afterwards, signs that merit clinical advice, and how to access follow-up support. Some babies feed straight away; others may be unsettled or feed differently for a short time. A review of feeding can help identify whether there has been a meaningful change in comfort, milk transfer, efficiency or the baby’s ability to manage feeds. It can also identify issues that were present alongside the tongue restriction. There is insufficient high-quality evidence to support routine post-procedural stretching or massage of an infant’s healing wound. Families should not feel pressured to undertake painful oral exercises, particularly without a clear individual rationale and appropriate professional guidance. The Academy of Breastfeeding Medicine advises against evidence-free post-procedural stretching of the wound (Academy of Breastfeeding Medicine, 2021). For healthcare professionals, this is where clinical reasoning is especially valuable. A post-procedure review should not focus solely on the wound or on whether the tongue looks different. It should return to the original functional concerns, observe feeding where possible, and remain open to differential explanations if the hoped-for change has not occurred. Questions families can bring to an appointment It can be helpful to write questions down before a consultation. You may wish to ask how the clinician links the findings to your baby’s actual feeding, what non-surgical support has been considered, what outcomes are realistic in your circumstances, and how follow-up will work. You can also ask what to do if feeding does not improve, or if you remain concerned about pain, milk intake, wet nappies, weight gain or your baby’s general wellbeing. A service that welcomes these questions makes space for shared decision-making rather than presenting surgery as an automatic answer. References Academy of Breastfeeding Medicine (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 (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. A feeding journey does not need to follow a perfect script to deserve skilled care, clear information and compassion. Whether your family chooses support alone, frenulotomy, or time to review the options, the right plan is one that keeps your baby’s function, wellbeing and your informed preferences at its centre.

When parents search for the best bottles for tongue tied infants, they are often hoping for something that will make feeds calmer, shorter and more comfortable. That hope is understandable. Yet there is no single bottle, teat shape or flow rate that is best for every baby with a tongue-tie. A bottle may support feeding for one infant and be unhelpful for another, even where their oral anatomy appears similar. The most useful question is not, “Which bottle is best?” but, “What is happening during this baby’s feed?” Anatomy provides information. Function provides context. A thoughtful choice considers the infant’s age, feeding history, milk flow, sucking and swallowing coordination, respiratory comfort, growth, parent experience and the feeding goals that matter to the family. Why bottle choice is only one part of the picture A tongue-tie describes a restrictive lingual frenulum, but the presence of a frenulum alone does not establish that it is causing feeding difficulty. Some infants feed effectively with a tongue-tie, while others experience challenges that may relate to tongue function alongside positioning, prematurity, birth experiences, neurological development, nasal congestion, reflux-like symptoms, milk flow, feeding frequency or learned feeding patterns. Research into ankyloglossia has largely focused on breastfeeding, and the evidence base for bottle-feeding interventions is much more limited. A systematic review by Francis and colleagues found that the available research on treatment for ankyloglossia was generally small and heterogeneous, with limited longer-term outcome data (Francis et al., 2015). This means it is sensible to be cautious about claims that a particular bottle can diagnose, resolve or compensate for a tongue-tie. For bottle-fed or combination-fed babies, an effective feed usually looks more important than a fashionable bottle design. The baby should be able to maintain a comfortable rhythm of sucking, swallowing and breathing, with milk transfer that supports wellbeing and growth. Parents should not feel that every feed is a battle. Features to consider when choosing bottles for tongue-tied infants Rather than ranking products, it is more helpful to consider a small number of functional features. These can guide a careful trial while avoiding unnecessary spending on multiple systems. Teat flow rate Milk flow can make a substantial difference. If flow is faster than an infant can comfortably manage, they may splutter, cough, leak milk, pull away, gulp, show wide-eyed distress or finish a feed very quickly without appearing settled. These signs do not prove that the flow is the only issue, but they are worth discussing with a suitably skilled feeding professional. A slower-flow teat is often a reasonable starting point for a young infant, particularly where feeding coordination appears immature or milk loss is evident. However, slower is not automatically better. If the baby works very hard, becomes tired, takes unusually long to feed or repeatedly falls asleep before taking enough milk, the flow may be too slow or another factor may need attention. Flow-rate labels are not standardised between manufacturers. Research measuring commercially available teats found considerable variation in milk flow, including between teats described in similar terms (Pados et al., 2015). For this reason, changing brands can alter feeding considerably even when the labelled stage seems equivalent. Teat shape and firmness Some infants appear more comfortable with a longer, shorter, narrower, wider, softer or firmer teat. This is individual rather than a reliable marker of whether a tongue-tie is affecting feeding. A baby may find one shape easier to maintain in their mouth, while another may compress it, lose their seal or become unsettled. It can be tempting to keep changing teats after a difficult feed. In practice, changing one variable at a time and observing several feeds may provide clearer information. If a bottle seems to improve feeding, consider what has actually changed: flow, the baby’s state, the feeding position, the caregiver’s pacing, the time since the last feed, or the teat itself. Teat texture and material When choosing a bottle for a tongue-tied baby, the texture and material of the teat can make a difference to how comfortable and effective feeding feels. Silicone teats are generally soft, flexible and durable, and their smooth texture can be comfortable for babies who may already find feeding challenging. Some parents may also come across latex or rubber teats, which can feel softer and more natural but are less commonly used and may wear out more quickly Bottle venting and air intake Many bottles are marketed around reducing air intake. Air swallowing can occur during feeding, particularly when a baby repeatedly loses their seal, but burping, wind and unsettled behaviour are common infant experiences with many possible explanations. There is not strong evidence that a particular venting system is the answer for tongue-tied infants. A practical consideration is whether the bottle is easy to assemble, clean and use consistently. A complex system that is difficult to prepare when parents are tired may create more stress than benefit. Whatever bottle is used, follow the manufacturer’s instructions for cleaning, sterilising and replacing components. The baby’s feeding cues The bottle matters, but so does the way milk is offered. Responsive bottle feeding means watching the baby rather than encouraging them to finish a set volume. Holding the baby close and supported, allowing pauses, and responding when they turn away, slow down or show signs of stress can help make feeds more manageable. UNICEF UK Baby Friendly guidance recommends paced, responsive bottle feeding to support cue-based care and reduce pressure to feed beyond an infant’s appetite (UNICEF UK Baby Friendly Initiative, 2019). Avoid propping bottles or leaving an infant to feed without a responsive caregiver. Feeding is not simply milk intake. It is also a time when babies regulate their breathing, comfort and connection with the adult caring for them. Bottle-propping itself can be dangerous and may cause a baby to aspirate, as milk can flow into the airway rather than the oesophagus. It can also increase the risk of choking, ear infections and overfeeding because the baby may continue sucking even when they are full. Most importantly, without a caregiver present and attentive, early signs of distress, coughing or difficulty breathing may be missed. Holding and feeding a baby responsively allows the caregiver to notice these cues, pause the feed when needed and provide the comfort and reassurance that are an important part of feeding. Signs that a feeding assessment would be more useful than another bottle Occasional coughing, dribbling or fussiness can happen in babies who are otherwise feeding and growing well. Persistent concerns deserve a broader view, particularly if parents are distressed or exhausted. A skilled infant feeding assessment may be helpful where there is repeated coughing or choking, frequent milk loss, very prolonged or very short feeds, clicking alongside poor transfer, marked fatigue during feeds, bottle refusal, recurrent distress, concerns about weight gain, or significant caregiver anxiety. The clinician should consider the baby’s medical history, growth pattern, feeding observations and oral function, rather than relying on the appearance of the frenulum alone. For families combining breast and bottle feeding, assessment should include both feeding methods where possible. A bottle that seems manageable does not necessarily mean breastfeeding concerns are resolved, and breastfeeding difficulty does not automatically mean the bottle is unsuitable. Each method places different demands on the infant and feeding dyad. A calm, practical way to trial a bottle If your baby is generally well and growing, choose one bottle and teat arrangement that is manageable for your household and observe it over a few days rather than judging it from one difficult feed. Notice whether your baby can stay settled, pause comfortably and feed without persistent signs of overwhelm or fatigue. Try to keep other factors as consistent as possible. Offer feeds when your baby is showing early hunger cues, allow breaks, and avoid pressure to complete a volume. If you change the flow rate or teat, make that the only major change at first. A short note of feed duration, milk loss, coughing, pauses, comfort and overall intake can be useful if you later seek support. If there are concerns about feeding safety, hydration, weight gain or persistent respiratory symptoms during feeds, seek timely advice from an appropriate healthcare professional. Urgent medical assessment is needed if an infant has breathing difficulty, appears blue or unusually pale, is very sleepy or difficult to rouse, has significantly fewer wet nappies, or you are worried they are becoming unwell. Where tongue-tie fits into the decision A tongue-tie assessment may be appropriate when there is a concern about restricted tongue function and feeding difficulties, but it should be part of a wider clinical conversation. Conservative feeding support may be enough for some families. Others may, following skilled assessment and shared decision-making, consider whether frenulotomy is clinically appropriate. No bottle choice can determine that decision, and no intervention can promise a particular feeding outcome. At D-Restricted Ltd®, families are supported with function-focused assessment and feeding guidance that recognises both bottle feeding and breastfeeding as valid ways to nourish a baby. The aim is not to find a perfect product. It is to understand what your individual baby needs and help feeding feel safer, more sustainable and more supported. A bottle that supports your baby is one that allows feeding to be responsive, comfortable and workable for your family. If that still feels out of reach, you deserve careful listening and skilled support, not blame or another expensive bottle to try. References Academy of Breastfeeding Medicine Protocol Committee (2017) ‘ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017’, Breastfeeding Medicine, 12(3), pp. 188-198. Francis, D.O., Krishnaswami, S., McPheeters, M. and Feurer, I.D. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. Pados, B.F., Park, J., Thoyre, S.M., Estrem, H. and McComish, C. (2015) ‘Milk flow rates from bottle nipples used after hospital discharge’, Advances in Neonatal Care, 15(5), pp. 378-384. UNICEF UK Baby Friendly Initiative (2019) Responsive bottle feeding. London: UNICEF UK Baby Friendly Initiative.

A referral for tongue-tie release can leave families with a surprising number of questions: Is one method safer? Will it help feeding? What happens afterwards? Conversations about frenulotomy methods in infants should begin with the feeding relationship, the infant’s oral function and the family’s experience - not with an instrument. Anatomy provides information. Function provides context. In UK practice, the procedure to divide a restrictive lingual frenulum in an infant is called a frenulotomy. It may be considered when a skilled assessment identifies a restrictive frenulum alongside feeding difficulties that have not improved with appropriate, individualised support. Not every visible frenulum causes feeding difficulty, and not every feeding difficulty is caused by tongue-tie. A method is only one part of clinical decision-making A frenulotomy is a small procedure, but it is not a stand-alone answer to a complex feeding concern. Breastfeeding, chestfeeding, bottle feeding and combination feeding can be affected by positioning, attachment, milk supply, flow preference, prematurity, birth experiences, infant health, oral-motor coordination and parental comfort, among other factors. A careful assessment therefore considers more than appearance. It brings together the history, the infant’s feeding behaviour, observed milk transfer or bottle feeding, parental symptoms, growth where relevant, oral anatomy and tongue function. It should also allow space for what matters to the family, including whether they wish to continue with feeding support, consider a frenulotomy, or take time before making a decision. The Academy of Breastfeeding Medicine (ABM) advises that the presence of a sublingual frenulum alone is not an indication for surgery. A decision to offer frenulotomy should be based on a functional diagnosis and shared decision-making (Academy of Breastfeeding Medicine, 2021). What does the evidence say about frenulotomy methods in infants? The strongest research question is often not whether one instrument is preferable, but whether frenulotomy is appropriate for a particular infant and feeding dyad. Randomised trials included in a Cochrane review found that frenulotomy may reduce maternal nipple pain in the short term. However, the trials were small, outcomes were inconsistent, and evidence for sustained improvement in infant breastfeeding was less certain (O’Shea et al., 2017). This matters when discussing expectations. Some families notice a meaningful change after a release; others need time, skilled feeding support or further assessment of contributory factors. Some may not experience the improvement they had hoped for. A thoughtful consent conversation should make room for all of these possibilities. Evidence comparing instruments and techniques is limited. The American Academy of Pediatrics states that there is no evidence that laser is superior to other approaches for infant frenotomy procedures (American Academy of Pediatrics, 2024). Similarly, the ABM notes that comparative evidence is insufficient to establish that one method is consistently better than another for breastfeeding outcomes, pain, healing or complications (Academy of Breastfeeding Medicine, 2021). For this reason, it is not clinically helpful to frame a choice of method as a simple ranking of “best” versus “worst”. The practitioner’s training, clinical governance, ability to assess feeding function, consent process, infection-control arrangements, emergency preparedness and follow-up provision all deserve close attention. The methods that may be discussed In infant practice, clinicians may use sterile scissors or a thermal device, such as laser or electrosurgery, depending on their setting, training, professional scope and local governance. These approaches differ in how tissue is divided and in the equipment required. They may also involve different practical arrangements around consent, comfort measures, aftercare and review. Families may hear claims that one approach causes less bleeding, less discomfort or quicker healing. Such claims should be approached carefully. The available evidence does not allow reliable promises about an individual infant’s experience or feeding outcome. A clinician should explain the method they use in clear, non-technical language, including known risks, uncertainties and what support is available afterwards. The setting is also relevant. A safe service has clear eligibility criteria, appropriate clinical records, informed consent, infection prevention processes, a plan for managing complications and arrangements for post-procedure contact. These measures are not extras around a procedure - they are part of safe, family-centred care. Comfort and analgesia Comfort during a frenulotomy is an understandable concern. Approaches vary between services and may depend on the infant’s age, medical history, the clinical setting and the method used. Families should be told in advance what their clinician recommends and why, as well as how feeding and soothing will be supported immediately afterwards. It is reasonable to ask how your baby will be comforted, whether you can remain present, when a feed may be offered, and whom to contact if you are worried once home. Clear answers can reduce uncertainty without minimising the emotions that may accompany the decision. Choosing care: questions that support informed consent A family does not need to become an expert in surgical devices to make an informed decision. More useful questions focus on the assessment and the care around the procedure. For example: what functional feeding concerns have been identified; what non-surgical support has been tried or remains available; what benefit is realistically anticipated; what are the risks; and how will feeding be reviewed afterwards? It is also appropriate to ask about the clinician’s infant feeding expertise, their experience within their professional role, governance arrangements and how complications are managed. For healthcare professionals referring families, a detailed feeding history and observation can help ensure that a referral is based on function rather than appearance alone. Conservative management is a valid pathway. It may include skilled support with positioning and attachment, paced and responsive bottle feeding, support with expressing where needed, and review of maternal or infant factors affecting feeding. Choosing to wait, or deciding against a frenulotomy, should be respected and accompanied by a plan for review if concerns continue. Risks, aftercare and realistic expectations Frenulotomy is generally described as a minor procedure, but minor does not mean risk-free. Potential complications include bleeding, pain, infection, oral aversion, scarring and the need for further assessment or treatment. Serious complications appear uncommon in the published trials, but those studies were small and may not detect rare events reliably (O’Shea et al., 2017). Good consent explains both the low frequency of serious harm and the limits of the evidence. Aftercare should focus on the infant and feeding, rather than the wound alone. Families benefit from knowing what is expected in their particular service, when feeding support is available, and which changes require prompt clinical advice. Ongoing bleeding, breathing difficulty, marked lethargy, fever, poor feeding or a parent’s sense that their baby is unwell warrant timely assessment. Routine exercises intended to repeatedly open or disrupt a healing wound are not supported by evidence and may cause distress. The AAP advises against recommending post-frenotomy stretching exercises for this purpose (American Academy of Pediatrics, 2024). Any oral activities discussed by a suitably qualified practitioner should have a clear functional rationale, be responsive to the infant’s cues and never replace appropriate medical review. Feeding support after a frenulotomy remains important. An infant may be learning a different pattern of movement, while a parent may be recovering from pain, protecting milk supply or building confidence. Follow-up can identify whether feeding is improving, whether other factors need attention, and whether the family needs additional support without assuming that every concern is related to the frenulum. For professionals: hold uncertainty with care For clinicians, this area calls for clinical reasoning rather than protocol-led assumptions. Assessment tools can support documentation and communication, but no tool should replace a skilled feeding assessment or be used as the sole basis for surgery. The ABM stresses that tools vary in purpose and reliability, and should not independently determine whether a frenulotomy is indicated (Academy of Breastfeeding Medicine, 2021). Language matters, too. Families deserve accurate explanations that neither dismiss their feeding difficulties nor imply that release will resolve every concern. A balanced conversation can acknowledge uncertainty while still offering a clear plan: optimise feeding support, assess function, consider the potential role of frenulotomy where indicated, and provide continuity whichever route the family chooses. 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, 153(2), e2024067605. National Institute for Health and Care Excellence (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. A final thought The most reassuring next step is rarely a particular instrument. It is being heard, having feeding assessed with care, and making a decision that feels informed, supported and right for your baby and family.

A feed that feels painful, takes an hour, ends in tears, or leaves a baby unsettled can make every day feel smaller. An infant feeding specialist offers skilled, compassionate support to understand what is happening within the whole feeding picture - not simply to find one explanation or recommend one pathway. For some families, a few targeted adjustments and reassurance are enough. Others need a fuller review of milk transfer, bottle-feeding mechanics, pumping, infant oral function, health history or the effect feeding difficulties are having on family wellbeing. The aim is not a perfect feed. It is an informed, workable plan that supports the baby and the people caring for them. What is an infant feeding specialist? An infant feeding specialist is a practitioner with additional knowledge and clinical experience in supporting infants and families with feeding. In the UK, the title itself is not a single regulated professional role, so it is reasonable to ask about a practitioner’s background, scope of practice, training and arrangements for referral when concerns fall outside that scope. Specialists may be midwives, nurses, health visitors, doctors, speech and language therapists, dietitians or lactation consultants. An International Board Certified Lactation Consultant, or IBCLC, is a practitioner who has met an international standard in lactation-specific education, clinical practice and examination. However, a credential is only one part of good care. Listening carefully, observing function, recognising uncertainty and working collaboratively matter just as much. Infant feeding support should be inclusive. Breastfeeding, chestfeeding, expressing, bottle feeding, combination feeding and feeding donated human milk can all involve practical questions and emotional weight. Families deserve respectful care regardless of how their baby is fed or what their feeding goals may be. When might an infant feeding specialist help? Families often seek support when feeding is difficult rather than when a single diagnosis is already clear. Common reasons include ongoing nipple or breast pain, difficulty achieving a comfortable latch, worries about milk transfer, very long or frequent feeds, an unsettled baby around feeds, reluctance to feed, bottle refusal, coughing or leaking during bottle feeds, or challenges maintaining milk supply while pumping. Support can also be valuable after a difficult birth, premature birth, separation following delivery, maternal illness, a change in feeding method or a period of slow weight gain. These concerns should never be reduced to a matter of technique. They may relate to positioning, timing, infant maturity, feeding cues, milk supply, breast or nipple anatomy, bottle and teat flow, reflux-like symptoms, allergy or illness, neurodevelopment, medication, family exhaustion or several factors at once. Where there are concerns about hydration, illness, lethargy, persistent vomiting, breathing difficulty, jaundice, fever, poor weight gain or fewer wet nappies than expected, families should seek timely assessment from an appropriate NHS professional. Feeding support complements medical care; it does not replace it. Understanding infant feeding specialists and their qualifications Families seeking help with infant feeding may encounter a number of different professionals and support roles, and the terminology used can be confusing. These roles are not interchangeable, and the amount and type of training undertaken can vary considerably. This does not mean that one form of support has no value; each has an important place. The key is understanding what a person has been trained to do, what they are qualified to assess and when they should refer to someone with a higher level of specialist training. Peer supporters provide valuable peer-to-peer support, encouragement, reassurance, a listening ear and practical help. They can be an important source of emotional and social support for families and can recognise when additional help may be needed. Their role is primarily supportive rather than clinical, and they are not trained to diagnose or manage complex feeding difficulties. Breastfeeding counsellors have undertaken more extensive breastfeeding-specific training and are trained to provide skilled breastfeeding support and counselling. Their training includes breastfeeding management, communication and supporting families with common breastfeeding challenges. They have an important role within the wider feeding-support pathway and will refer families on when a situation falls outside their scope of practice. A breastfeeding counsellor is, however, not the same qualification as an IBCLC, and the two should not be used interchangeably. UNICEF UK Baby Friendly-trained healthcare professionals receive training to support breastfeeding and responsive infant feeding within their healthcare or early-years setting. This may include midwives, health visitors, maternity support workers and other members of the infant feeding team. The training is an important part of ensuring that families receive consistent, evidence-based support within maternity and community services. However, completing Baby Friendly training is not the same as holding a specialist infant feeding qualification, and it does not confer the IBCLC credential. UNICEF UK describes its training as preparing healthcare professionals to support breastfeeding and relationship building within their role rather than as a standalone professional qualification. Lactation Consultant (LC) is another term families may encounter. A lactation consultant may have undertaken dedicated training in lactation and infant feeding and can provide valuable specialist support. However, “Lactation Consultant” is not a protected title in the UK, and there is no single nationally standardised qualification attached to the letters LC. Consequently, the education, clinical experience, assessment and scope of practice of someone using this title can vary. An LC should therefore not automatically be assumed to be an IBCLC. International Board Certified Lactation Consultant (IBCLC) is a distinct, internationally recognised professional credential. IBCLCs have to meet defined eligibility requirements covering health-science education, lactation-specific education, clinical experience and professional conduct, before successfully passing an internationally administered examination. Current requirements include 95 hours of lactation-specific and communication education and substantial clinical experience. There are three routes to eligibility: Pathway 1 requires 1,000 hours of lactation-specific clinical practice; Pathway 2 requires completion of an accredited lactation academic programme incorporating at least 300 hours of directly supervised clinical practice; and Pathway 3 requires 500 hours of directly supervised clinical practice under an IBCLC. The IBCLC credential also requires ongoing maintenance. IBCLCs must recertify every five years, demonstrating continued clinical practice, continuing education and ongoing competence. For example, the current recertification process includes 250 hours of lactation consulting practice and, where recertifying through continuing education, completion of a Continuing Education Self-Assessment followed by 75 CERPs targeted to areas of professional development. It is also important not to be misled by the word “lactation” in the IBCLC title. IBCLC practice is not limited to breastfeeding alone. IBCLCs support families with a wide range of infant-feeding situations, which may include direct breastfeeding, expressing and providing human milk, combination feeding, formula feeding, bottle feeding and the introduction of complementary foods. The focus is on the infant, the caregiver and the feeding relationship as a whole. The Lactation Consultants of Great Britain (LCGB) has produced a useful Who’s Who in Breastfeeding Support and Lactation in the UK resource comparing different types of breastfeeding and lactation support, including IBCLCs, breastfeeding counsellors, peer supporters and Baby Friendly-trained staff. It is a useful reference for families who want to understand the differences between these roles and the level of training involved. Ultimately, the title someone uses is not enough to establish their level of expertise. Families have every right to ask what qualification a practitioner holds, who awarded it, what clinical training they have undertaken, how their competence is maintained and what they are qualified to assess and manage. For straightforward support, a peer supporter or breastfeeding counsellor may provide exactly what a family needs. Where feeding difficulties are persistent, complex or require clinical assessment, it is important that families know when they are accessing a practitioner with the appropriate level of specialist training. Feeding assessment is more than looking in a baby’s mouth A thoughtful consultation usually begins with the family’s story. What has feeding been like since birth? What feels hardest? What is already helping? How is the baby growing and behaving between feeds? What are the family’s hopes, capacities and limits right now? Observation then provides context. A specialist may consider the feeding environment, infant state and cues, positioning, attachment or bottle-feeding coordination, swallowing, comfort and the practical pattern of feeds across 24 hours. If pumping is part of the picture, assessment may include pump use and flange fit, as poor fit can contribute to discomfort or ineffective expression. When oral anatomy or tongue function is relevant, it should be considered alongside these wider findings. A visible lingual frenulum is common and anatomy alone cannot establish that it is the cause of feeding difficulty. As the D-Restricted Ltd® approach puts it: anatomy provides information; function provides context. Tongue-tie: keeping the discussion proportionate Tongue-tie, also called ankyloglossia, describes a variation in which the lingual frenulum may restrict tongue movement. Some babies with tongue-tie feed comfortably and grow well. Others have feeding difficulties, but these may have more than one contributing factor. A careful assessment therefore matters before any decision about management. For UK families, the infant procedure is termed a frenulotomy. It may be considered where there is a functional restriction and persistent feeding difficulty despite appropriate skilled support, but it is not the only response to a tongue-tie finding and it cannot promise a particular outcome. Conservative management, further feeding support, a period of observation or referral to another professional may be the most appropriate next step, depending on the individual baby and family. Many infant feeding specialists, doctors, GPs and midwives have not received specific training in the assessment and diagnosis of tongue-tie. Their clinical experience and observations are valuable, and their suspicion that an infant may have a tongue-tie can be an important reason for seeking further assessment. However, recognising a possible tongue-tie is different from diagnosing a tongue-tie and determining whether it is functionally restrictive. A diagnosis should be made by a practitioner who has specific training, knowledge and competence in tongue-tie assessment and who is working within their professional scope of practice. In England, tongue-tie division is a surgical procedure and may only be undertaken by an appropriately qualified and regulated healthcare professional. The practitioner must be registered with the Care Quality Commission (CQC) for the relevant regulated activity and must also hold professional registration with the Nursing and Midwifery Council (NMC), General Dental Council (GDC) or General Medical Council (GMC), depending on their profession. Families can therefore be given misleading reassurance when a tongue-tie is described as “slight”, “mild” or “not significant” based primarily on its appearance, particularly when the person making that assessment has not received specific training in tongue-tie assessment. The appearance of the frenulum alone cannot determine the extent to which tongue movement is restricted or whether that restriction is affecting feeding. Anatomy provides information; function provides context. A properly trained assessment considers both. What good infant feeding support feels like Good support is practical without being prescriptive. It recognises that feeding advice must fit real life: recovery from birth, other children, work, finances, sleep deprivation, mental health and the presence or absence of support at home. A plan that is technically sound but impossible to sustain is unlikely to be helpful. It should also be strengths-based. Rather than focusing only on what is going wrong, a specialist can identify what the baby and parent are already doing well, then prioritise the changes most likely to make a meaningful difference. This may mean working on comfort at the breast, responsive paced bottle feeding, protecting milk supply during temporary feeding difficulties, or simply reducing pressure while further assessment takes place. Continuity matters. Feeding changes often need reviewing because babies develop quickly and a plan that suits one week may not suit the next. Follow-up provides an opportunity to assess whether feeding is becoming more comfortable, whether growth and wellbeing remain on track, and whether the family needs a different level of support. Questions families and professionals can ask Before arranging specialist support, it can help to ask whether the practitioner works with both breastfeeding and bottle-feeding concerns, how they assess feeding function, and when they recommend referral to other services. If tongue-tie is raised, ask how the practitioner distinguishes anatomical appearance from functional impact, what conservative options have been considered, and how decisions about frenulotomy are made. Healthcare professionals referring a family can strengthen continuity by sharing relevant information with consent, such as birth history, growth data, previous feeding support and any medical concerns. Equally, specialists should communicate their findings clearly, avoid overstepping professional boundaries and encourage families to remain connected to their usual maternity, neonatal, primary care or health visiting team. The World Health Organization emphasises skilled breastfeeding counselling that is responsive to each woman’s needs and circumstances, rather than relying on generic instruction alone (WHO, 2018). That principle is equally valuable when supporting any infant feeding relationship: expertise should help families feel more informed, not more judged. The right next step is often not a rushed answer, but a careful conversation in which the family feels heard, the baby is seen as a whole person, and feeding support is allowed to be both evidence-informed and kind. References Francis, D.O., Krishnaswami, S., McPheeters, M. and McPheeters, M.L. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. Lactation Consultants of Great Britain (LCGB) (2025) Who’s Who in Breastfeeding Support and Lactation in the UK. Revised June 2025. Available at: https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/. National Institute for Health and Care Excellence (NICE) (2021) Postnatal care. NICE guideline NG194. 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. UNICEF UK Baby Friendly Initiative (2026) Breastfeeding and Relationship Building Course – Health Professionals. Available at: https://www.unicef.org.uk/babyfriendly/training/courses/breastfeeding-and-relationship-building/health-professionals/. World Health Organization (WHO) (2018) Guideline: counselling of women to improve breastfeeding practices. Geneva: WHO.

A tongue-tie release can feel like a moment when families hope feeding will suddenly become easier. When a tongue-tie release has not worked in the way you expected, it can be upsetting, exhausting and confusing - particularly if feeding was already painful or worrying. It does not mean you have failed, nor does it automatically mean the procedure itself was inappropriate. It means the feeding relationship deserves a further careful, whole-picture review. Tongue-tie is one possible factor in infant feeding difficulty, but it is rarely the only factor worth considering. Anatomy provides information. Function provides context. A thoughtful next step is to look at what is happening for the baby and the person feeding them now, rather than assuming there is one simple explanation. What does ‘not worked’ mean after a tongue-tie release? Families use this phrase to describe several different experiences. Pain during breastfeeding may be unchanged. A baby may still struggle to remain latched, feed very frequently, take a long time to feed, cough or dribble with bottles, or seem unsettled around feeds. Some parents notice an initial improvement that does not continue. Others feel that feeding is better in one respect, but not enough to make it manageable. These experiences are real and deserve to be heard. However, a persistent feeding difficulty does not, by itself, confirm that tongue movement remains restricted or that a further procedure is needed. It may indicate that the original difficulty had more than one cause, that feeding skills need time and support to change, or that a separate issue needs assessment. The research evidence reflects this complexity. A Cochrane review found that frenulotomy in newborn infants with tongue-tie may reduce maternal nipple pain in the short term, but evidence for consistent improvement in infant breastfeeding outcomes was limited by the small size and methodological differences of the studies (O'Shea et al., 2017). This does not mean that families cannot experience meaningful benefit. It does mean that clinicians should be honest about uncertainty and avoid promising a particular outcome. Why a tongue-tie release may not resolve feeding difficulties Feeding is a learned, shared skill Feeding involves the infant’s state, positioning, attachment, suck-swallow-breathe coordination, milk flow, comfort and endurance. It also involves the feeding parent’s comfort, milk supply where relevant, confidence and ability to access help. A restriction under the tongue may have contributed to difficulty, yet changing that tissue does not instantly alter every part of a feeding pattern. Some babies need time to develop different movement patterns. Equally, a feeding parent may need practical, individualised support to find positions or approaches that are more comfortable and effective. This is not about asking families to persevere through pain. It is about ensuring that support is responsive to what is actually happening at a feed. The initial assessment may not explain the full picture A visible lingual frenulum is a normal anatomical structure. Its appearance alone cannot determine whether it is affecting feeding. Assessment should consider tongue function alongside a detailed feeding history, observed feeding where possible, infant growth and wellbeing, and the wider clinical context. Persistent symptoms can have many contributors. Depending on the baby and family, these may include early feeding experiences, prematurity, birth-related factors, nasal congestion or illness, reflux-like symptoms, muscle tone, developmental variation, milk flow, breast or chest fullness, bottle teat flow, positioning, or challenges with expressing and maintaining milk supply. This is not an exhaustive list, and it is not a diagnosis. It illustrates why a function-focused reassessment matters. The Academy of Breastfeeding Medicine advises that tongue-tie should be assessed within a skilled breastfeeding assessment, rather than by using any single tool or anatomical finding in isolation (Academy of Breastfeeding Medicine, 2021). The same principle is valuable after a frenulotomy. Improvement may be partial rather than immediate For some families, the change after frenulotomy is clear and quick. For others, improvement is gradual, partial or difficult to measure. The available trials have often assessed outcomes over short periods, so they cannot answer every question about longer-term feeding experiences (O'Shea et al., 2017). A randomised trial involving infants with mild to moderate tongue-tie found no objective improvement in breastfeeding at five days, despite improved maternal breastfeeding self-efficacy; many families in the comparison group later chose frenulotomy (Emond et al., 2014). This highlights both the limits of simple outcome measures and the importance of shared decision-making. What matters to one family - less pain, calmer feeds, improved milk transfer, or a more sustainable combination-feeding plan - may differ from what matters to another. When a tongue-tie release has not worked: practical next steps Start by arranging a review with an appropriately qualified infant feeding professional or the clinician who provided the procedure. A useful review makes space for your concerns and does not begin with an assumption that the answer is another intervention. It should explore what has changed, what remains difficult and what is most urgent for your family. Where breastfeeding or chestfeeding is part of your plan, an observed feed can help identify whether pain, attachment, swallowing, milk transfer or feeding duration needs further attention. Where bottle feeding is used, observing a typical feed can be equally informative. Combination feeding families deserve the same careful support, without pressure to follow a particular feeding route. It can help to bring a brief record of feeds, wet and dirty nappies, any expressed milk or supplementary feeds, and recent weight information if you have it. This is not a test for parents to pass. It gives the clinician a clearer picture of intake, output and feeding patterns over time. A review may lead to feeding support, monitoring, discussion with your GP, health visitor, midwife or paediatric team, or a referral to another relevant professional. In some circumstances, the clinician may discuss whether there are ongoing functional concerns that warrant specialist reassessment. Further intervention should never be presented as automatic, and potential benefits, limitations and risks should be considered together. The role of paediatric body therapies When feeding difficulties persist following tongue-tie division, it is important to consider the whole infant rather than focusing solely on the frenulum. A restrictive tongue-tie can be associated with orofacial tension because restricted tongue and jaw movement may result in compensatory patterns involving the tongue, jaw and surrounding muscles. Where jaw gape and oral movement have been restricted during development, these patterns may become established and continue to influence feeding even after the frenulum has been divided. Tension can also arise from other factors, including intrauterine positioning and the physical demands or interventions associated with birth. For some infants, these combined factors may contribute to ongoing tension, asymmetry, altered movement patterns or difficulty coordinating effective feeding. Paediatric body therapies may therefore have a role for some infants, particularly where assessment identifies areas of tension, asymmetry, restricted movement or altered postural patterns. This does not mean that every infant who has undergone tongue-tie division requires bodywork, nor that body therapy replaces appropriate feeding assessment or treatment. Rather, it may form part of an individualised, multidisciplinary approach where clinically indicated. It is equally important to distinguish between supporting tongue function and oral-motor development and manipulating the healing wound. Functional exercises may be used to encourage tongue movement, strength, coordination, sucking and oral-motor skills. These are fundamentally different from physically manipulating or disrupting the healing wound. Routine disruptive wound manipulation is NOT recommended. There is an important distinction between exercises that support function and strengthening and using a finger to repeatedly rub, sweep, stretch or reopen the healing wound. Further information can be found in the ATP Position Statements (www.tongue-tie.org.uk/position-statements). When tongue-tie treatment has not produced the expected improvement, this does not necessarily mean that the division has "failed" or that the wound needs to be manipulated. It may indicate that other contributing factors, including orofacial tension, body tension, oral-motor patterns or feeding difficulties, also require assessment and appropriate support. When to seek urgent help Please seek prompt medical advice from your GP, midwife, health visitor, NHS 111 or urgent care service if your baby is feeding much less than usual, has fewer wet nappies, seems unusually sleepy or difficult to wake for feeds, has signs of dehydration, develops jaundice, or you are worried about weight gain or general wellbeing. Trust your instincts. A baby who appears unwell needs timely medical assessment, whatever the suspected cause of feeding difficulty. What supportive aftercare should feel like Aftercare is more than checking whether a procedure site is healing. Families need an opportunity to discuss feeding, comfort, infant wellbeing and the practical realities of the days that follow. They also need clear information about what is known, what remains uncertain and when to ask for further help. Current evidence does not support presenting post-procedure wound stretching or massage as a universal requirement. The Academy of Breastfeeding Medicine states that evidence is lacking to support manual manipulation or stretching of the incision site after frenulotomy (Academy of Breastfeeding Medicine, 2021). Families should follow the individual advice provided by their treating clinician and seek review if they are concerned, rather than feeling they must manage uncertainty alone. For professionals, this is a useful point for reflection. If a family reports that a tongue-tie release has not worked, the question is not simply whether enough tissue was released. It is: what is happening functionally at this feed, for this baby and this family? Listening carefully, reviewing differentials and being willing to revisit an initial hypothesis are central to safe, compassionate care. At D-Restricted Ltd®, follow-up is approached as part of continuity of care: an opportunity to understand the feeding journey, not to judge it. Whether the next best step is skilled feeding support, medical review, watchful monitoring or discussion of further options, families deserve calm information and care that keeps both infant wellbeing and parental experience in view. A difficult feed after a frenulotomy is not a verdict on your choices. It is a reason to pause, be heard and seek the right support for the feeding journey in front of you. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Association of Tongue-tie Practitioners (ATP) (2022) Routine aftercare and wound management following infant frenulotomy: ATP position statement. Available at: https://www.tongue-tie.org.uk/position-statements (Accessed: 22 August 2026). Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A. and Copeland, M. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 99(3), pp. F189-F195. 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.

Many families notice that feeds involve clicking, gulping, coughing, frequent winding, milk coming back up and an unsettled baby. It is understandable to ask, can tongue-tie cause reflux? The careful answer is that a tongue-tie may contribute to feeding mechanics that are associated with reflux-like symptoms in some babies, but it is not established as a direct cause of gastro-oesophageal reflux disease (GORD). Reflux symptoms are common in infancy, and feeding challenges are often multifactorial. A helpful assessment considers the whole picture: the baby’s growth and health, their oral function, how feeding is going, milk flow, positioning, the family’s concerns and any symptoms that need medical review. Anatomy provides information. Function provides context. What do we mean by reflux? Gastro-oesophageal reflux is the movement of stomach contents back into the oesophagus. In young babies, small amounts of milk coming back up are very common. Their digestive system is still maturing, they mostly have a liquid diet and they spend much of their time lying down. A baby can posset frequently and still be well, comfortable and growing appropriately. GORD is different. It describes reflux associated with troublesome symptoms or complications, such as feeding refusal, poor weight gain, marked distress or inflammation of the oesophagus. Symptoms often attributed to reflux - crying, waking frequently, hiccups, arching or bringing up milk - are not specific to reflux and can have several possible explanations (NICE, 2015; Rosen et al., 2018). This distinction matters. Treating ordinary developmental reflux as disease can create understandable anxiety and may lead families away from practical feeding support that could make a real difference. Can tongue-tie cause reflux symptoms? A restrictive lingual frenulum, commonly called tongue-tie, is a variation in which the tissue beneath the tongue may limit tongue movement. Its appearance alone cannot tell us whether it is affecting feeding. Some babies with a visible frenulum feed comfortably and effectively; others have feeding difficulties where restricted tongue function may be one relevant factor. The proposed connection with reflux is indirect. If a baby cannot maintain an effective seal or coordinate sucking, swallowing and breathing comfortably, they may take in more air during feeds. They may also come off and re-latch repeatedly, cough with faster flow, or become tired and unsettled. Swallowed air can increase burping and abdominal discomfort, and milk may be brought up alongside it. These experiences can look like reflux. However, this is a plausible clinical mechanism, not proof that tongue-tie causes GORD. Current evidence does not demonstrate that tongue-tie is a sole or universal cause of reflux, nor that frenulotomy reliably resolves reflux symptoms. The Academy of Breastfeeding Medicine advises that decisions about ankyloglossia should follow a skilled breastfeeding assessment rather than be based on anatomy appearance alone (Academy of Breastfeeding Medicine, 2021). For bottle-fed babies, similar principles apply. A baby may have difficulty maintaining a seal, cope poorly with teat flow, take frequent pauses or seem to swallow air. Yet bottle-feeding challenges can also relate to teat flow, pacing, feeding position, volume, the baby’s maturity, nasal congestion or an underlying health issue. It would be too simple to attribute these difficulties to a frenulum without considering alternatives. Tongue-tie, Reflux or Feeding Mechanics? Not every baby who brings milk back up has gastro-oesophageal reflux disease (GORD). In some infants, particularly those with tongue-tie and associated feeding dysfunction, what appears to be “reflux” may actually be the consequence of how the infant is feeding. A restricted tongue can affect the infant’s ability to achieve and maintain an effective seal, coordinate suck–swallow–breathe patterns and regulate the flow of milk. This can create a cascade of feeding behaviours that may produce symptoms which look very similar to reflux. Rapid feeding and overfeeding This can be particularly noticeable in bottle-fed infants. When milk is flowing quickly and the infant has limited ability to regulate that flow, a feed may be completed very rapidly. The infant may continue to suck and accept milk even though their stomach is approaching or has reached its comfortable capacity. There is an important distinction here between wanting to suck and actually needing more milk. Feeding is not simply controlled by hunger in the moment. Satiety is a physiological process involving signals from the stomach and intestine, together with neural and hormonal signalling. When milk is delivered very quickly, there can be a mismatch between the amount of milk consumed and the time required for these fullness signals to influence the infant's behaviour. The result can be overfeeding relative to the infant's immediate gastric capacity. Once the stomach is too full, milk may be brought back up. To the caregiver, this can look like reflux, but the mechanism is different from pathological GORD. This is one reason why looking at the whole feeding pattern, rather than simply the volume taken or the fact that an infant is vomiting, is so important. Swallowing air (aerophagia) A second potential mechanism is aerophagia — swallowing excessive air during feeding. Efficient feeding requires highly coordinated movements of the tongue, jaw, lips, pharynx and respiratory system. If an infant is struggling to maintain an effective seal or coordinate milk transfer with breathing, they may compensate by repeatedly breaking and re-establishing the seal, gulping, spluttering, clicking or swallowing air alongside the milk. This can occur with both breast and bottle feeding, although the mechanics and flow characteristics are different. Air entering the stomach can contribute to gastric distension. A distended stomach is less comfortable and can increase the likelihood that milk and gastric contents are brought back up, particularly when the infant is moved, compressed or laid down soon after a feed. Again, this does not necessarily mean that the infant has GORD. Milk coming back up can be the end result of feeding mechanics, excessive gastric volume and swallowed air rather than evidence of an underlying gastrointestinal disease. Why this distinction matters Gastro-oesophageal reflux (GER) is the movement of stomach contents back into the oesophagus and is common in infancy. GORD is different: it refers to reflux that causes troublesome symptoms or complications and requires clinical assessment. Tongue-tie should therefore not be presented as a proven cause of GORD. Current evidence investigating the relationship between ankyloglossia and reflux is limited, and studies reporting improvement in reflux symptoms following frenotomy have not been able to establish that the tongue-tie was the cause of those symptoms. However, a tongue-tied infant can experience feeding difficulties that may contribute to reflux-like symptoms. Looking at milk flow, feeding duration, swallowing frequency, airway protection, oral seal, air intake, feeding volume and the infant's regulation during the feed can help identify whether the problem may be occurring primarily at the feeding interface rather than within the gastrointestinal tract. This is why an assessment of an infant presenting with “reflux” should not automatically stop at the digestive system. Sometimes the more useful question is not simply “Why is this baby refluxing?” but “What is happening during the feed that is causing this baby to bring milk back up?” Why feeding assessment is more useful than symptom lists Lists of possible tongue-tie symptoms can be helpful prompts, but they are not diagnostic. Clicking, reflux-like behaviour and fussiness occur in babies with and without tongue-tie. Equally, a baby may have restricted tongue movement but no functional feeding difficulty. A skilled clinician will usually explore whether there is a pattern across the feeding relationship. This might include comfort for the feeding parent, latch or seal stability, audible swallowing, milk transfer where relevant, the baby’s ability to stay settled at the feed, weight trajectory, output and the timing of symptoms. Observing a feed, where possible, adds information that cannot be gathered from a photograph of the mouth or a symptom checklist. For breastfeeding families, discomfort, nipple compression after feeds, frequent feeding or concerns about milk transfer may warrant support, but each has a range of potential causes. Positioning, attachment, breast fullness, milk ejection reflex, previous breast surgery, infant prematurity and health conditions can all be relevant. For families expressing milk, a flange fitting assessment may also be useful where pumping is painful or inefficient. This doesn’t mean your concerns about your baby should be dismissed. If your baby is unsettled, bringing milk back up, swallowing lots of air or struggling during feeds, those symptoms are real and deserve to be understood. Sometimes the answer may not be “reflux” alone — looking at how your baby is feeding can help build a clearer picture of what is happening. What does the evidence say about frenulotomy and reflux? Research on frenulotomy has mainly examined short-term breastfeeding outcomes, particularly maternal nipple pain and breastfeeding effectiveness. The Cochrane review found that frenotomy was associated with reduced maternal nipple pain in the short term, while evidence for longer-term breastfeeding outcomes remained limited (O’Shea et al., 2017). Reflux has not been studied with the same quality or consistency. Some observational reports describe improvement in parent-reported reflux symptoms after a tongue-tie release, but these findings cannot establish cause and effect. Infant reflux commonly changes over time, feeding support may be provided alongside the procedure, and parent-reported symptoms are influenced by many factors. Controlled research using clear definitions of reflux and meaningful follow-up is still needed. Where a restrictive lingual frenulum is judged to be affecting feeding function, frenulotomy may be one option discussed as part of shared decision-making. It is not a treatment for reflux in isolation. Conservative feeding support may be appropriate, either before considering a procedure or as the preferred pathway for a family. The best plan depends on the individual baby, the feeding goals of the family and the clinical findings. Practical things you can try If your baby is showing reflux-like symptoms, there are some simple changes you can try during and after feeds. These won't address every cause of reflux, but they may help you work out whether feeding mechanics are contributing to your baby's symptoms. Avoid excessive overfeeding. A baby who feeds very quickly may take more milk than their stomach can comfortably manage before their fullness signals have had time to catch up. Try responding to your baby's cues rather than encouraging them to finish a feed simply because milk remains. Smaller, appropriately paced feeds may be more comfortable for some babies. Slow the feed down. If your baby is taking a bottle very quickly, consider whether the teat flow is too fast. A slower flow and a more paced approach can give your baby more time to coordinate sucking, swallowing and breathing and recognise when they have had enough. Give your baby regular pauses. Short pauses during a feed can give your baby an opportunity to breathe, swallow, release air and respond to their own fullness cues. Try winding before as well as during or after a feed. Some babies, particularly those who swallow a lot of air, may already have air in their stomach before they begin feeding. This can be particularly relevant where a baby has a high palate and is struggling to maintain an effective seal, as they may swallow air while trying to organise their mouth around the breast or teat. A gentle opportunity to release air before starting a feed may sometimes help. Don't wait until the end of the feed to wind. If your baby is gulping, clicking, pulling away or becoming unsettled, pause and give them an opportunity to release swallowed air before continuing. Watch your baby's cues rather than encouraging them to finish. Turning away, slowing their sucking, relaxing their hands or becoming sleepy can all be signs that they need a break or have had enough. A baby doesn't necessarily need to finish the bottle simply because milk remains. Keep your baby upright after feeding. If this seems to help your baby, you can hold them comfortably upright for around 20–30 minutes after a feed. Some babies may need longer, while others are comfortable sooner. Avoid pressure on their tummy during this time. Keeping a baby upright after feeding is not a treatment for GORD, but may help reduce milk coming back up for some babies. When your baby is ready to sleep, always place them flat on their back on a firm, flat sleep surface. Do not use inclined sleep products or leave your baby sleeping propped upright. Look at how your baby is feeding, not just how much they are taking. Are they gulping, clicking, frequently losing their seal, swallowing noisily, pulling away or becoming unsettled? These observations can provide useful clues about what is happening during the feed. If breastfeeding, consider the milk flow as well as your baby's tongue function. A very fast let-down can sometimes make it difficult for a baby to coordinate sucking, swallowing and breathing. Positioning and feeding strategies may help some babies manage the flow more comfortably. Keep a short feeding and symptom diary. Note the duration of feeds, approximate volume if bottle feeding, how quickly the feed was taken, signs of air swallowing and what happened afterwards. Patterns can be much easier to see when they are written down. The aim isn't to try every suggestion at once. Make one change at a time where possible and see whether it makes a difference. If your baby's symptoms improve when feeding is slowed down, excessive feeding is reduced or swallowed air is better managed, that can be useful information when considering whether feeding mechanics are contributing to what looks like reflux. When reflux-like symptoms needs urgent medical assessment Most posseting is harmless, but some symptoms need prompt review by a GP, paediatric clinician or urgent care service. Seek medical advice if a baby has green or yellow vomit, blood in vomit or stools, forceful or projectile vomiting, fever, persistent diarrhoea, a swollen abdomen, breathing difficulty, dehydration, unusual sleepiness, feeding refusal, faltering growth/weight loss or fewer wet nappies than expected. A baby who appears very distressed, has recurrent choking episodes or whose feeding changes suddenly also deserves timely assessment. These signs are not evidence of tongue-tie and should not be managed by assuming a feeding restriction is the explanation. Next steps for families and professionals If reflux-like symptoms occur alongside feeding difficulty, start with a thorough history and an observed feed where possible. For families, it can help to note what happens during feeds, how often milk comes back up, whether the baby appears comfortable, nappy output and any changes in weight or alertness. This is not about monitoring every feed perfectly; it gives the clinician a clearer starting point. For professionals, assessment should remain function-focused and include differential diagnosis. Consider the infant’s age, medical history, growth, feeding method, flow management and the wellbeing of the parent as well as oral anatomy. Avoid presenting frenulotomy as a test of whether symptoms are ‘really’ caused by tongue-tie. Families deserve clear information about uncertainty, potential benefits, limitations and available support whatever they decide. A feeding journey can be exhausting when every feed feels unpredictable. Whether the issue is developmental reflux, feeding mechanics, tongue function or a combination of factors, being heard and receiving careful, individualised support is a meaningful place to begin. References Academy of Breastfeeding Medicine (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) (2015) Gastro-oesophageal reflux disease in children and young people: diagnosis and management. NICE guideline NG1. 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. Rosen, R., Vandenplas, Y., Singendonk, M., Cabana, M., DiLorenzo, C., Gottrand, F., Gupta, S., Langendam, M., Staiano, A., Thapar, N., Tipnis, N., Tabbers, M. and Benninga, M. (2018) ‘Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition’, Journal of Pediatric Gastroenterology and Nutrition, 66(3), pp. 516-554.

When you are looking for help with your baby's feeding, you are not simply choosing somewhere to have a tongue-tie assessed or a procedure carried out. You are choosing someone to care for your baby at a time when you may already be tired, worried, in pain or unsure what to do next. You may be wondering: Is my baby safe? Does this person really understand infant feeding? Will someone listen to our whole story, rather than simply look inside my baby's mouth? What happens if we need help afterwards? What qualifications, experience and regulation sit behind the service? If we decide against a procedure, will we still be supported? These questions matter. For me, they are at the heart of how I have developed D-Restricted Ltd®. My vision for D-Restricted Ltd ® At D-Restricted Ltd, my vision is to provide highly skilled, compassionate, and evidence-informed support in infant feeding, ensuring every feeding dyad can feed comfortably and confidently within a nurturing family or wider network. I am committed to maintaining up-to-date clinical expertise and delivering care grounded in best practice, with tongue-tie and infant feeding care close to my heart. Central to my approach is personalised aftercare and ongoing guidance, recognising that feeding challenges do not end at the consultation. Through attentive intervention, education, and compassionate support, I aim to strengthen the feeding relationship, empower families, and foster reassurance and confidence throughout the feeding journey, always prioritising the infant’s wellbeing and the needs of their supportive network. This is not simply a statement on a website. During its inspection of D-Restricted Ltd®, the Care Quality Commission (CQC) assessed whether the service's leadership, culture, clinical care, systems and approach to families reflected this vision. In June 2026, D-Restricted Ltd® received an Overall Outstanding rating from the Care Quality Commission at its first inspection. Read the CQC press release: CQC rates specialty tongue-tie service Outstanding at first inspection Read the full CQC inspection report Experience behind the service D-Restricted Ltd® was founded in 2014, but my experience of caring for people and supporting families began much earlier. I began working with families as a healthcare worker in 1998 before starting my nurse training in 2002. I qualified as a Registered Nurse in 2005 and initially worked in neurosurgery, developing my clinical assessment, observation and care-planning skills. My own experience of having children with tongue-tie then led me to develop a particular interest in infant feeding and tongue-tie. I moved into neonatal nursing, where I worked with newborn babies and their families and developed specialist knowledge and experience in neonatal care. I qualified in neonatal nursing and continued to develop my understanding of infant feeding, including becoming a tongue-tie specialist in 2014 and founding D-Restricted Ltd®. My specialist infant-feeding journey continued to develop through further education and experience. I became an LEAARC Infant Feeding Specialist in 2017 and an International Board Certified Lactation Consultant (IBCLC) in 2018. Before this, I had also undertaken training as an ABM breastfeeding peer supporter and counsellor. Each stage of my career has added something different to the way I work today. My nursing background provides a strong foundation in clinical assessment, safety and recognising when a baby or caregiver may need additional medical support. My neonatal experience has given me many years of caring for newborn babies and their families. My infant-feeding education and IBCLC qualification have developed my understanding of breastfeeding and infant feeding, while my specialist tongue-tie experience has allowed me to develop a deeper understanding of how oral function can interact with feeding. Most importantly, supporting families over many years has taught me that there is rarely a single answer to a feeding problem. A baby is not simply a tongue, a frenulum, a feeding position or a weight. There is a baby, a caregiver, a feeding relationship and a wider family or support network around them. That understanding is central to the way D-Restricted Ltd® operates today. The service has therefore developed from years of clinical experience, specialist education and listening to families, rather than being built around a single procedure. It is this experience that has shaped my emphasis on whole-dyad assessment, family-centred care, informed choice and, importantly, personalised aftercare and ongoing support. The CQC Outstanding rating is recognition of the service as it operates today, but the experience behind that service has been built over many years. What does an Overall Outstanding CQC rating mean? The CQC regulates health and social care services in England and assesses services using five key questions: Is it safe? Is it effective? Is it caring? Is it responsive to people's needs? Is it well-led? These five areas are important because good healthcare is about much more than what happens during a single appointment. An Overall Outstanding rating is the highest overall rating that CQC awards. The significance of this is that the rating is not based simply on one procedure, one appointment or one family's experience. It reflects the CQC's assessment of the service as a whole. What does this mean for your baby's care? For a family, regulation can sometimes feel like a world of paperwork and terminology. So what does it actually mean when you are choosing a tongue-tie service? It means there should be systems behind the care you receive. There should be appropriate clinical governance, risk management, infection prevention and control, safeguarding arrangements, record keeping, consent processes, professional development and processes for responding when something does not go as expected. It also means that the person providing regulated care needs to have the appropriate professional knowledge, skills and experience for the care they provide. Tongue-tie care is a regulated healthcare service In England, certain healthcare activities are regulated by the CQC under the Health and Social Care Act 2008 and associated regulations. Where a provider is carrying out a regulated activity that requires CQC registration, the provider must be registered with the CQC. D-Restricted Ltd® is registered with the CQC for the regulated activity of Surgical procedures. This is an important distinction for families. A person offering information about tongue-tie, feeding support or a non-regulated service is not necessarily providing the same type of regulated healthcare service as a CQC-registered provider undertaking a surgical procedure. CQC registration does not mean that a procedure is right for every baby. It means that the service providing the regulated activity is subject to a specific regulatory framework and inspection process. The people providing care must be appropriately registered Where a provider employs people to carry out regulated activities, the provider must have appropriate systems to ensure that staff have the necessary qualifications, competence, skills and experience for their roles. For a CQC-registered provider, the provider's 'Statement of Purpose' identifies the regulated activities and the people responsible for delivering them. For families, this provides another important layer of transparency about who is providing their care and under what regulatory framework. The person providing your baby's care matters too D-Restricted Ltd® is a specialist independent service led and delivered by me. My professional background includes nursing, neonatal nursing experience, International Board Certified Lactation Consultant (IBCLC) qualification and specialist experience in infant feeding and tongue-tie care. I have continued to develop my clinical knowledge and skills throughout my career because caring for babies and feeding families requires more than completing one course and stopping there. My approach is evidence-informed and function-focused. Anatomy provides information. Function provides context. A visible or restricted lingual frenulum is one part of an assessment. It should not automatically become the explanation for every feeding difficulty. Feeding can be affected by many factors, and sometimes there is more than one contributing factor. This is why I take time to understand the individual baby's feeding, the caregiver's experience, the feeding history, the infant's function and the family's goals. Family-centred care means listening to you CQC rated D-Restricted Ltd® Outstanding for Caring. This is particularly meaningful to me because family-centred care is central to the way I work. You are not simply bringing your baby to have something "fixed". You are bringing your own experience. You may have been struggling with painful breastfeeding. You may be worried about your baby's weight gain. You may be experiencing difficulties with bottle feeding. You may have been given conflicting advice. You may have already tried different approaches. Or you may simply have a feeling that feeding isn't going as you expected. Your experience matters. Family-centred care means listening to what you are experiencing, understanding what matters to you, explaining what I am seeing and giving you the information you need to make an informed decision. It means discussing options rather than assuming there is only one. And it means respecting your decision. Whether you choose breastfeeding, bottle feeding, combination feeding, expressed milk, conservative management, further assessment or a procedure, you should be treated with the same respect and support. An assessment is not simply looking at a frenulum A tongue-tie assessment should consider more than what a baby's tongue looks like. The assessment needs to consider function and the impact that any restriction may be having on feeding. This may include discussing feeding history, observing feeding where appropriate, considering the baby's oral function and looking at the wider circumstances surrounding feeding. There may be other reasons for a feeding difficulty. There may be several factors contributing at the same time. This is why an assessment should not begin with the assumption that a frenulum is automatically the cause of the problem. The aim is to understand your baby and your feeding journey. Outstanding care does not mean every baby needs a procedure An Overall Outstanding CQC rating does not mean that every baby seen by D-Restricted Ltd® has a tongue-tie that needs dividing. Nor does it mean that a frenulotomy will resolve every feeding difficulty. Evidence surrounding tongue-tie and frenotomy has limitations, and good care requires honest conversations about what is known, what is uncertain and what other factors may be involved. The Cochrane review of frenotomy in newborn infants found that frenotomy reduced maternal nipple pain in the short term, but evidence for improvements in infant breastfeeding was inconsistent and based on small studies with methodological limitations (O'Shea et al., 2017). The Academy of Breastfeeding Medicine similarly emphasises the importance of a skilled breastfeeding assessment and functional assessment when considering ankyloglossia (Academy of Breastfeeding Medicine, 2021). This means families deserve an individualised discussion rather than a promise of a particular outcome. Sometimes feeding support is the appropriate next step. Sometimes further assessment is needed. Sometimes a procedure may be considered. Sometimes another healthcare professional needs to be involved. Outstanding care leaves room for all of those possibilities. Informed consent is more than signing a form If a procedure is being considered, informed consent should be a conversation. You should have the opportunity to understand what has been identified, why a procedure may or may not be considered, what alternatives exist, what the potential benefits and risks are, and what support is available afterwards. You should have time to ask questions. You should not feel pressured into making a decision. And choosing not to proceed with a procedure should not mean that you are no longer supported. Why aftercare matters so much This is one of the most important differences in the way I have developed D-Restricted Ltd®. Feeding challenges do not necessarily end when the appointment ends. A procedure may change tongue movement, but a baby's feeding experience does not automatically change overnight. A baby may need time to adapt. A caregiver may need support with positioning or attachment. Breastfeeding families may need help protecting milk supply or adjusting feeding techniques. Bottle-feeding families may need help understanding changes in feeding behaviour, pace, comfort or coordination. Some babies may need further assessment or support from another professional. And sometimes families simply need someone to talk to when they are unsure whether what they are seeing is expected. This is why personalised aftercare and ongoing guidance are central to my service. CQC rated D-Restricted Ltd® Outstanding for Responsive care. The CQC specifically recognised the service's approach to continuity of care, including the six-week tongue-tie package incorporating feeding reviews, tongue-function checks and emotional wellbeing support, as well as the wider support available to families. The service also provides an online Support Portal and access to ongoing support. For me, this is what family-centred care looks like in practice. You shouldn't have to leave a clinic with your baby and then work everything out for yourself. CQC didn't simply take my word for it A CQC rating is not something a provider awards themselves. Before receiving its rating, D-Restricted Ltd® underwent a detailed CQC inspection. Inspectors reviewed evidence about how the service operated and examined the systems and processes supporting the care provided. This included reviewing records, policies, governance arrangements, clinical processes, risk management and evidence of how the service monitored and improved the quality of care. Inspectors also spoke to people who had used the service and considered their experiences. The inspection took place over three days and involved inspectors examining evidence and observing how the service operated in practice. This matters because there is a significant difference between saying: "I provide excellent family-centred care." and having an independent regulator examine the systems, evidence, clinical practice and experiences of families and conclude that the service meets the CQC's standards for an Overall Outstanding rating. Families' experiences matter Patient and caregiver feedback is an important part of understanding whether a healthcare service is delivering the care it aims to provide. During the inspection, CQC considered feedback from people who had used D-Restricted Ltd®. CQC reported that the service had received positive feedback from families and that caregivers interviewed during the inspection spoke highly of the care they had received and said they would recommend the service. For me, this is not simply about collecting five-star reviews. It is about listening. If families tell me that they felt heard, supported and reassured, that helps demonstrate whether the values behind the service are reaching the people they are intended to help. If someone raises a concern, that matters too. Good governance means being willing to listen, learn and improve. Outstanding Well-led: building the systems behind a specialist service D-Restricted Ltd® is a specialist independent service led and delivered by one person. That does not mean that the governance behind the service can be small. As a sole practitioner, I am responsible for the clinical care and for the systems that support it. That includes leadership, governance, policies, risk management, professional development, quality improvement, record keeping, safeguarding, infection prevention and control, feedback and ongoing review of the service. There isn't a large organisation behind me providing separate departments for these things. I have had to build and maintain those systems myself. CQC rated D-Restricted Ltd® Outstanding for Well-led. The inspection considered the leadership, culture, governance, learning, innovation and commitment to continuous improvement within the service. This is also why education is an important part of what I do. Through Tongue-tie School ®, I provide professional education designed to help healthcare professionals and practitioners develop their understanding of tongue-tie awareness, assessment considerations, treatment considerations and wrap-around care. Sharing knowledge and encouraging good practice is part of my commitment to improving the wider care available to families. What does an Outstanding service look like to me? For me, Outstanding care is not about claiming to have all the answers. It is about combining clinical knowledge with compassion. It is about listening before making assumptions. It is about recognising that a baby is part of a feeding dyad and a wider family or support network. It is about understanding that feeding difficulties may have more than one cause. It is about giving families honest information rather than promises. It is about respecting their choices. It is about knowing when to provide support, when to review, when to refer and when to say that a procedure is not the right answer. And it is about remaining available to support the family after the consultation. Why the CQC Outstanding rating matters There are many people providing information, support and services around tongue-tie and infant feeding. For families, it can be difficult to know what level of training, experience, regulation, governance and aftercare sits behind any particular service. A CQC rating cannot tell you whether a particular treatment is right for your baby. It cannot guarantee a particular feeding outcome. But an Overall Outstanding CQC rating does provide independent regulatory recognition of how the service itself is run and delivered. D-Restricted Ltd® received an Overall Outstanding rating at its first CQC inspection, with Outstanding ratings for Caring, Responsive and Well-led. That recognition matters to me because it reflects the things I have worked hard to build into the service: specialist clinical experience evidence-informed infant feeding care appropriate regulation and governance family-centred decision-making personalised aftercare continuity of support ongoing professional education listening to families learning from feedback a commitment to continually improve My vision is to help every feeding dyad feed comfortably and confidently within a nurturing family or wider network. And my guiding principle remains: Every feeding journey deserves support, compassion and reassurance. For families trusting me with their baby, that is what the Outstanding rating is really about. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. Available at: https://doi.org/10.1089/bfm.2021.29179.ams (Accessed: 24 August 2026). Care Quality Commission (2026a) D-Restricted Ltd: Surgical procedures. CQC inspection report. Available at: https://www.cqc.org.uk/location/1-13757340686/reports/LAP-02504/surgery (Accessed: 24 August 2026). Care Quality Commission (2026b) CQC rates specialty tongue-tie service Outstanding at first inspection. CQC press release. Available at: https://www.cqc.org.uk/press-release/cqc-rates-specialty-tongue-tie-service-outstanding-first-inspection (Accessed: 24 August 2026). Care Quality Commission (2026c) D-Restricted Ltd: Caring. CQC inspection report. Available at: https://www.cqc.org.uk/location/1-13757340686/reports/LAP-02504/surgery/caring (Accessed: 24 August 2026). Care Quality Commission (2026d) D-Restricted Ltd: Responsive. CQC inspection report. Available at: https://www.cqc.org.uk/location/1-13757340686/reports/LAP-02504/surgery/responsive (Accessed: 24 August 2026). Care Quality Commission (2026e) D-Restricted Ltd: Well-led. CQC inspection report. Available at: https://www.cqc.org.uk/location/1-13757340686/reports/LAP-02504/surgery/well-led (Accessed: 24 August 2026). National Institute for Health and Care Excellence (2005) Division of ankyloglossia (tongue-tie) for breastfeeding: Interventional procedures guidance [IPG149]. London: NICE. Available at: https://www.nice.org.uk/guidance/ipg149 (Accessed: 24 August 2026). Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 24 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. Available at: https://doi.org/10.1002/14651858.CD011065.pub2 (Accessed: 24 August 2026). UK Government (2008) Health and Social Care Act 2008. Available at: https://www.legislation.gov.uk/ukpga/2008/14/contents (Accessed: 24 August 2026). UK Government (2014) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. SI 2014/2936. Available at: https://www.legislation.gov.uk/uksi/2014/2936/contents (Accessed: 24 August 2026).

A visible lingual frenulum can prompt understandable questions, particularly when an infant is finding feeding difficult. Yet the presence of tissue beneath the tongue is not, by itself, a diagnosis or a treatment plan. High-quality tongue-tie training helps professionals move beyond appearance alone, considering how the infant feeds, how the family is coping and what may be contributing to the difficulty. For families, this approach can feel reassuring. It means concerns are taken seriously without assuming that every feeding challenge, or every oral variation, has one explanation. For professionals, it calls for clinical reasoning: anatomy provides information, but function provides context. Why tongue-tie training needs more than anatomy Ankyloglossia is commonly used to describe a restrictive lingual frenulum that may affect tongue function. However, terminology, definitions and assessment approaches vary across clinical settings and research studies. This variation makes it difficult to compare studies directly and helps explain why a single visual feature should not determine management (Messner et al., 2020). A careful practitioner will consider the whole feeding picture. This may include the infant’s age and health, feeding history, observed feeding behaviours, maternal comfort where relevant, milk transfer concerns, bottle-feeding mechanics, growth, supply, positioning and the family’s goals. It may also include differential considerations such as prematurity, neurological factors, nasal congestion, breast fullness, flow preference, feeding frequency or a need for more tailored feeding support. Training that centres only on identifying oral anatomy can unintentionally narrow this picture. In contrast, education that combines anatomy with feeding observation, communication and reflection supports safer, more individualised care. It also helps practitioners recognise the limits of their role and when referral or multidisciplinary input may be helpful. What evidence-informed training should cover Tongue-tie education should help learners understand normal infant oral anatomy and the range of anatomical variation, rather than presenting one appearance as inherently problematic. It should also address tongue mobility and feeding function without suggesting that any single score or assessment tool can replace skilled clinical judgement. Assessment tools can offer structure and a shared language, but they have limitations. Their reliability, cut-off points and relationship to meaningful feeding outcomes vary. A tool may support documentation and discussion; it should not be used in isolation to decide whether an infant requires a frenulotomy (Ingram et al., 2015; Hatami et al., 2022). A well-rounded course should also explore: the physiology of breastfeeding, chestfeeding and bottle feeding; maternal, infant and environmental contributors to feeding difficulty; how to take a sensitive, useful feeding history and observe a feed; conservative management and the role of skilled feeding support; indications, uncertainties and aftercare considerations surrounding frenulotomy; and communication that supports informed, family-centred decisions. For healthcare professionals, the distinction between learning about a procedure and learning to perform one matters. Professional education may examine the evidence, terminology, decision-making and care surrounding infant frenulotomy without providing procedural training. Safe practice requires appropriate professional scope, governance, competence and local pathways. Evidence and its limits The evidence on infant frenulotomy warrants careful explanation. A Cochrane review found that frenotomy - the term used in the review - was associated with short-term reduction in maternal nipple pain in some studies, while evidence for consistent improvement in infant feeding was less certain. The review also highlighted small sample sizes and methodological limitations (O’Shea et al., 2017). More recent professional statements similarly emphasise that a restrictive frenulum is a functional diagnosis, not simply an anatomical one. They recommend a skilled breastfeeding assessment and consideration of conservative measures before deciding whether frenulotomy is appropriate (Academy of Breastfeeding Medicine, 2021). In the UK, the infant procedure is termed a frenulotomy. This does not mean families should wait without support when feeding is painful, distressing or ineffective. It means the support offered should be proportionate, timely and based on a full assessment. Some families may find feeding support sufficient. Others, after informed discussion, may decide that frenulotomy is an appropriate part of their care plan. Outcomes can vary, and ongoing feeding support remains valuable whichever pathway is chosen. Building clinical reasoning, not a checklist culture The strongest tongue-tie training does not encourage learners to search for a single sign and act on it. Instead, it develops the ability to ask better questions. Is the reported difficulty present across feeds or only at certain times? What happens when positioning, attachment or bottle-feeding pace is adjusted? Is there evidence that feeding effectiveness, comfort or growth is affected? What matters most to this family right now? This reflective approach is particularly important because feeding is relational. A technically detailed assessment has limited value if the parent leaves feeling unheard, blamed or more anxious. Families may be breastfeeding, chestfeeding, expressing, combination feeding or bottle feeding. Each route deserves respectful, practical support without judgement. Training should therefore include communication skills alongside clinical content. Professionals need language that explains uncertainty honestly: a frenulum may be present, but its relevance depends on function; feeding symptoms can have more than one cause; and a decision does not need to be rushed when the infant is well and the family has support. Equally, where there are significant feeding concerns, a clear plan and timely review can reduce the burden of uncertainty. Learning from follow-up Follow-up is often where clinical reasoning becomes most visible. If a family has received conservative feeding support, review can clarify whether comfort, milk transfer or bottle feeding has changed. If frenulotomy has been undertaken, follow-up can focus on feeding, comfort, recovery, parental questions and access to further help where needed. There is insufficient evidence to support routine post-procedural stretching or manual manipulation of the wound, and families should not be advised to undertake painful wound exercises as a standard part of care (Academy of Breastfeeding Medicine, 2021). Supportive oral activities may be discussed in some clinical contexts, but should be individualised, gentle and clearly distinguished from wound manipulation. For practitioners, reviewing outcomes is also a learning opportunity. It can reveal where initial assumptions were incomplete, where additional lactation or feeding support would have helped, and how care pathways might better serve families. This is not about judging previous decisions. It is about maintaining curiosity and improving care. Choosing training that supports safe practice When selecting tongue-tie education, professionals may wish to look for clear learning outcomes, transparent discussion of evidence quality and content that acknowledges uncertainty. Training should address differential diagnosis, conservative management, feeding observation and family-centred communication, rather than positioning surgical release as the default response. It is also reasonable to ask whether the education distinguishes between professional roles and procedural competence. A course should not overstate what a certificate means, or imply that completion alone equips someone to assess or manage every complex feeding presentation independently. Supervision, experience, local governance and appropriate referral networks all matter. D-Restricted Ltd's Tongue-tie School approaches this subject through infant oral anatomy, function, assessment principles, differential diagnosis, conservative management and aftercare considerations. The aim is not to create a formula for intervention, but to help professionals think carefully, communicate clearly and work collaboratively around each infant and family. Good training should leave clinicians more comfortable with nuance. It should help them recognise when a frenulum may be relevant, when other factors need attention, and when a family needs skilled support rather than a quick answer. Every feeding journey deserves to be met with that degree of care. The experience and knowledge of the trainer matters When choosing tongue-tie training, it is important to look beyond the course title and consider who has designed and delivered the training. Tongue-tie is not simply an anatomical finding. Understanding the relationship between oral anatomy, infant function, feeding, breathing, oral motor development and the wider clinical picture requires knowledge developed through education and clinical experience. A trainer should be able to demonstrate relevant professional qualifications, current clinical experience and a genuine understanding of the subject they are teaching. Experience working directly with infants and families is particularly important, as tongue-tie can present differently depending on the infant, feeding method, oral anatomy, compensatory patterns and other contributing factors. A good training course should encourage learners to think critically rather than simply follow a checklist. Anatomy provides information. Function provides context. Look at the accreditation — and understand what it means Accreditation can provide an important indication that a course has undergone external review, but it is worth understanding exactly what has been accredited and what the accreditation represents. D-Restricted Ltd's Tongue-tie School is accredited by 'Advantage' and recognised for 8 L-CERPs through IBLCE. This provides learners with formal continuing professional development recognition alongside the educational content of the course. However, accreditation should not be confused with professional registration, a licence to practise, or a qualification that automatically authorises someone to diagnose or treat tongue-tie. Those responsibilities remain dependent on the learner's own professional registration, scope of practice, competence and relevant legislation or professional requirements. When comparing tongue-tie courses, therefore, look at more than whether the word accredited appears on the website. Consider who has accredited the course, what has been assessed, how many hours or credits are awarded, and whether the content is appropriate for your professional role. Good training should also make clear what it does — and does not — qualify you to do. D-Restricted Ltd Tongue-tie School The Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations course is an evidence-informed online theory programme designed for healthcare professionals and existing tongue-tie practitioners who want to develop, strengthen or update their theoretical knowledge. The trainer’s clinical background directly informs the content and approach of the course. She began her nursing career in 2002 and qualified as a Registered General Nurse in 2005, subsequently working in neonatal nursing before moving into specialist tongue-tie and infant feeding practice. Diana qualified as an International Board Certified Lactation Consultant (IBCLC) in 2018 and has continued to develop her knowledge through specialist education and clinical practice. This combination of nursing, neonatal, infant feeding and specialist tongue-tie experience informs the way the course is taught. The aim is not simply to teach learners to identify an anatomical feature, but to encourage them to understand the clinical context surrounding it. The course takes a function-based approach, exploring the relationship between anatomy, oral function and infant feeding, alongside treatment considerations, conservative management and ongoing support. It encourages learners to look beyond anatomy alone and consider the wider infant–caregiver feeding dyad and the individual circumstances of each family. The six modules cover: Module 1: Anatomy and Physiology Module 2: Potential Impact of Oral Ties and Functional Considerations Over Time Module 3: Tongue Function Assessment Tools and Differential Diagnosis Module 4: Body Therapies, Tongue Exercises and Sensorimotor Oral Activities Module 5: Surgical Release Procedures: Methods, Risks and Clinical Considerations Module 6: Conservative Management and Ongoing Care The programme includes approximately 10 hours of learning, additional reading and self-directed study, a reflective case study and ongoing access to the Tongue-tie School community support hub. Importantly, this is theory and professional education. The course does not teach participants how to perform a tongue-tie assessment using specific assessment tools, nor does it teach frenulotomy technique. It is designed to strengthen theoretical understanding, clinical awareness and informed support, while recognising the importance of working within each professional's own scope of practice. Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations Find out more about the course, modules, accreditation and enrolment: https://www.tongue-tie.info/school References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Hatami, A., Dreyer, C.W., Meier, J.A. and Kuo, C.L. (2022) ‘Assessment tools for ankyloglossia: A systematic review’, Australian Dental Journal, 67(3), pp. 229-239. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2015) ‘The development of a tongue assessment tool to assist with tongue-tie identification’, Archives of Disease in Childhood: Fetal and Neonatal Edition, 100(4), pp. F344-F348. Messner, A.H., Walsh, J., Rosenfeld, R.M. et al. (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.

Searching for a tongue-tie specialist can feel surprisingly difficult. There are many practitioners offering tongue-tie assessment and treatment, but they do not all have the same professional background, specialist training, clinical experience or approach. If you are considering an assessment for your baby, it is worth spending some time researching who you are choosing, rather than simply choosing the closest clinic, the first result that appears in a search, or the practitioner with the soonest availability. Quick availability does not necessarily mean high-quality care, just as a longer waiting time does not necessarily mean that a practitioner is better. Look at the person behind the appointment, not simply how quickly you can get one. A good tongue-tie practitioner should be able to do much more than identify a frenulum. They should understand infant feeding, assess tongue function in the context of the whole baby, recognise when feeding difficulties may have other causes, explain your options clearly and be willing to recommend conservative support or onward referral when appropriate. This guide explains some of the things you can look for when deciding whether a tongue-tie practitioner is right for your baby. 1. Check their professional background One of the first things to establish is who the practitioner actually is. In the UK, a practitioner carrying out tongue-tie assessment and treatment should be an appropriately regulated healthcare professional. Depending on their professional background, this means being registered with the Nursing and Midwifery Council (NMC), General Medical Council (GMC) or General Dental Council (GDC). Professional registration is important because these regulators set professional standards and require practitioners to work within their professional and personal scope of practice, based on their education, training, competence and experience. Look for a practitioner who clearly states: their professional qualification their professional registration or regulatory body their specialist training in tongue-tie assessment and treatment their infant-feeding training how long they have worked with infants and families how much experience they have in assessing feeding difficulties how they maintain their competence and undertake continuing professional development You can check a practitioner's registration independently using the relevant professional register. If this information is difficult to find, you can always ask before booking. 2. Check whether the service is regulated by the CQC If you are choosing a private tongue-tie service in England, UK, it is also worth checking whether the service is required to be registered with the Care Quality Commission (CQC). The CQC regulates health and social care services in England where they provide activities that fall within its regulated activities. Where CQC registration is required, a provider must not carry on that regulated activity without being registered. You can search the CQC website to check whether a service is registered and, where applicable, view information about its regulatory status. It is important to understand that professional regulation and service regulation are not the same thing. For example, a nurse may be professionally regulated by the NMC, while the service they work for may also have CQC registration requirements. Doctors and dentists are professionally regulated by the GMC and GDC respectively. For families choosing private healthcare in England, checking both the individual practitioner's professional registration** and the service's CQC status where applicable can provide valuable reassurance. 3. Find out what specialist training they have undertaken Tongue-tie assessment and infant feeding are specialist areas. A practitioner may have completed a tongue-tie course, but it is worth understanding what that training actually involved. Do not be afraid to ask: What training have you completed in tongue-tie assessment? Who provided the training? How comprehensive was the training? Did it include infant feeding? Did it include both breast and bottle feeding? Did it include practical clinical training? Do you undertake regular continuing professional development? How do you keep your knowledge and clinical skills up to date? There is a considerable difference between attending a short course and developing substantial clinical experience over many years. A good practitioner should be able to explain their training without making exaggerated claims or suggesting that one particular qualification automatically makes them better than every other practitioner. 4. Look for experience in infant feeding This is particularly important. A tongue-tie assessment should not happen in isolation from feeding. A baby may have a visible lingual frenulum and feed well, while another baby may have significant feeding difficulties involving several contributing factors. For this reason, experience in infant feeding is an important consideration when choosing a practitioner. Look for someone who understands breastfeeding and bottle feeding where relevant, and who can recognise issues such as positioning, attachment, milk transfer, milk supply, bottle-flow mismatch, feeding endurance and infant regulation. If breastfeeding is important to your family, you may also wish to look for a practitioner with recognised specialist lactation training. 5. Is the practitioner an IBCLC? You do not have to be an IBCLC to be a tongue-tie practitioner. However, if you are looking for someone to assess your baby's feeding as well as their oral function, it is worth understanding what an IBCLC qualification represents. The International Board Certified Lactation Consultant (IBCLC) credential is the internationally recognised professional certification specifically focused on lactation and infant feeding. The certification requires substantial education in lactation, clinical experience and successful completion of the IBCLC examination. IBCLC is therefore considered the gold standard professional qualification for infant feeding and lactation, regardless of how a family chooses to feed their baby. This does not mean that an IBCLC is automatically a better tongue-tie practitioner, nor that every IBCLC provides tongue-tie assessment or treatment. Instead, it can be a useful additional qualification when choosing a practitioner because it demonstrates a significant level of specialist education and clinical experience specifically relating to infant feeding. When researching a practitioner, consider both areas separately: Are they appropriately trained and experienced in tongue-tie assessment and treatment? and Do they have substantial specialist knowledge of infant feeding? Ideally, you want a practitioner who understands both. 6. Look at their clinical experience Qualifications tell you about training.Experience tells you about clinical exposure. Ask how long the practitioner has been working with babies and families and how frequently they undertake tongue-tie assessments. Experience can be particularly valuable because infant feeding difficulties rarely present in exactly the same way in every baby. A practitioner who has assessed a wide range of infants is more likely to recognise that feeding problems can have multiple contributing factors. A practitioner should also be comfortable saying: "I don't think the frenulum is the main problem." "Let's try some feeding support first." "I would like your baby reviewed by another professional." "I don't think a procedure is appropriate at this stage." These are not signs that an assessment has failed. They can actually be signs of good clinical judgement. 7. Look at their reputation and reviews Online reviews can be extremely useful when choosing a healthcare provider, but it is worth looking beyond the star rating. Read what families actually say about their experience. Look for comments about: whether the practitioner listened to the family's concerns whether the assessment felt thorough whether feeding was considered as part of the assessment whether the practitioner explained their findings clearly whether different options were discussed whether families felt pressured into treatment the quality of aftercare and follow-up how the practitioner responded when things did not go as expected A large number of reviews is not necessarily an indication of clinical quality. Equally, a small number of reviews does not necessarily mean a practitioner is inexperienced. Look for patterns in the feedback, rather than relying on a single review or an overall star rating. It can also be useful to look at reviews across more than one platform where available. 8. Consider professional membership You may come across practitioners who are members of the Association of Tongue-tie Practitioners UK (ATP). ATP membership can be another useful factor to consider when researching a practitioner. The organisation provides professional support, education, networking and resources for practitioners involved in tongue-tie practice. However, ATP membership is not a substitute for professional regulation or CQC registration where applicable. The ATP is a professional organisation rather than a statutory regulator. Its directory should therefore be considered as one source of information rather than a guarantee of clinical quality. Equally, the absence of ATP membership does not automatically mean that a practitioner is unsuitable. Appropriately qualified and regulated practitioners may choose not to be members. Think of professional membership as one piece of the puzzle, alongside professional registration, training, experience, reputation and clinical governance. 9. Check what the assessment actually involves Before booking, ask what the appointment actually includes. A good assessment should involve more than simply looking underneath your baby's tongue. The practitioner should take time to understand your concerns and gather relevant information about your baby's health, birth, feeding history and current feeding pattern. Where appropriate, feeding should be observed. For a breastfed baby this may include observing positioning, attachment, milk transfer and feeding behaviour. For a bottle-fed baby, assessment may include how the baby manages the teat, milk flow, seal, coordination, pacing, comfort and endurance. The baby's oral function should also be considered in an appropriate and gentle way. Most importantly, the assessment should consider the whole feeding picture, rather than assuming that every feeding difficulty is caused by a frenulum. Anatomy provides information. Function provides context. 10. Find out what happens if a tongue-tie is identified Identifying a restrictive lingual frenulum does not automatically mean that a procedure is required. Ask the practitioner what they would recommend if they believe your baby has a tongue-tie. A good practitioner should be able to explain: what they have observed how they believe it relates to your baby's feeding what other factors may be contributing what conservative options are available the potential benefits and limitations of frenulotomy the potential risks what support may be required afterwards what may happen if you decide not to proceed You should have enough information to make an informed decision without feeling rushed or pressured. 11. Be wary of guarantees No responsible clinician can guarantee that a tongue-tie procedure will resolve every feeding, sleep, reflux-like or behavioural problem. Feeding difficulties can have multiple causes, and babies respond differently to intervention. Be cautious of claims suggesting that tongue-tie division will definitely resolve a long list of unrelated problems, or that a procedure is necessary simply because a frenulum is visible. Good clinical care acknowledges uncertainty where uncertainty exists. 12. Ask about aftercare and follow-up Your relationship with a practitioner should not necessarily end when an assessment or procedure is completed. Ask what follow-up is available and who you can contact if you have questions or concerns afterwards. Feeding can take time to adjust, particularly when difficulties have been present for some time. Some families may need further feeding support even when a procedure has been undertaken. A practitioner should be clear about what aftercare they provide, what they expect families to do and when further assessment or referral may be appropriate. 13. Consider clinical governance Healthcare is about more than qualifications and experience. Clinical governance matters too. When choosing a private tongue-tie service, look for clear information about: consent record keeping safeguarding infection prevention and control complaints procedures clinical incidents professional indemnity referral pathways emergency arrangements where appropriate follow-up and continuity of care A professional healthcare service should be willing to explain how these areas are managed. It is also reasonable to ask what happens if your baby is found to need assessment by another healthcare professional. A good practitioner should recognise the limits of their own scope of practice and be willing to refer appropriately. 14. Don't choose solely on price or location Searching for a tongue-tie specialist near me is understandable when you have a young baby and are already struggling with feeding. Convenience matters, particularly when follow-up may be required. However, the closest practitioner is not necessarily the right practitioner for your family. Likewise, the cheapest appointment is not necessarily the best value, and the most expensive service is not automatically the highest quality. And remember: the soonest available appointment is not necessarily the best appointment. Instead, compare what is actually included in the service. Consider the practitioner's: professional background regulatory status specialist training clinical experience infant-feeding knowledge reputation assessment process clinical governance follow-up arrangements This gives you a much better picture of the service than simply comparing prices, distance or availability. Questions to ask before booking If you are unsure, you can contact a practitioner before making an appointment and ask a few straightforward questions: What is your professional background and registration? Are you registered with the NMC, GMC or GDC? Is your service registered with the CQC where applicable? What specialist tongue-tie training have you undertaken? How long have you been working with babies and feeding difficulties? Are you trained in infant feeding or lactation? Are you an IBCLC? What does your assessment involve? Do you observe a breastfeed or bottle feed where appropriate? What happens if you do not think a frenulotomy is appropriate? What support is available after the assessment? What follow-up is available after a procedure? Are you a member of any relevant professional organisations, such as the ATP? What are your arrangements for clinical governance and complaints? The way a practitioner responds can tell you a great deal. You should feel able to ask questions without being made to feel difficult or unreasonable. What should make you pause? There are some warning signs worth considering before booking. The practitioner's qualifications or professional background are unclear. Their professional registration cannot be verified. There is little information about their training or clinical experience. The service's CQC status is unclear where CQC registration may be required. The service focuses almost entirely on the appearance of the frenulum. There is no meaningful discussion of feeding function. You are promised that a procedure will definitely solve your baby's problems. You feel pressured to proceed with treatment immediately. Alternative explanations or conservative options are dismissed. There is little or no information about aftercare. You cannot find out who will actually be assessing or treating your baby. The practitioner appears unwilling to refer or seek additional medical or feeding support when appropriate. One warning sign on its own does not necessarily mean that a practitioner is unsuitable. However, several of these together should prompt you to ask further questions. The evidence around frenulotomy For infants with breastfeeding difficulties and a restrictive lingual frenulum, frenulotomy may be considered following skilled assessment and shared decision-making. The evidence should nevertheless be discussed honestly. A Cochrane review found that frenotomy reduced maternal nipple pain in the short term, while evidence for objective improvements in infant breastfeeding was inconsistent and the studies were relatively small with limitations in design and follow-up (O'Shea et al., 2017). A systematic review similarly found limited evidence for longer-term breastfeeding outcomes (Francis et al., 2015). This does not mean that families' experiences are unimportant, nor that improvement cannot occur. It means that outcomes vary and a responsible practitioner should avoid making guarantees. NICE states that there are no major safety concerns associated with division of ankyloglossia for breastfeeding when normal arrangements are in place for consent, audit and clinical governance, while also recognising that evidence on efficacy is limited (NICE, 2005). For families, the practical message is simple: the decision should be individualised. You should understand what has been observed, what may be contributing to the feeding difficulty, what alternatives are available and what the potential benefits and limitations of intervention are. Choosing care that respects your family Choosing a tongue-tie practitioner is ultimately about much more than finding someone who can perform a procedure. You are choosing someone to assess your baby, interpret what they find and help you make decisions at a time when you may already be tired, worried and unsure about feeding. Look for someone who combines appropriate professional regulation, relevant specialist training, substantial clinical experience, infant-feeding knowledge, good communication, transparent information and a reputation for putting the baby's needs first. A good practitioner should not make you feel that you have arrived simply to obtain a procedure. They should help you understand what is happening, what your options are and whether intervention is actually appropriate. Take your time. Check their qualifications. Check their professional registration. Look at their experience and reviews. Check CQC registration where applicable. Ask about their assessment and aftercare. Consider professional memberships such as the ATP as one additional source of information. Most importantly, choose a practitioner who is prepared to listen, assess, explain and, when necessary, say that a procedure is not the right answer. Your baby's care deserves that level of consideration. Further reading For more information about understanding your baby's oral function: https://www.tongue-tie.info/post/a-guide-to-understanding-your-baby-s-oral-function If you are considering frenulotomy, you may also wish to read: https://www.tongue-tie.info/post/how-to-prepare-for-frenulotomy https://www.tongue-tie.info/post/what-to-expect-after-a-tongue-tie-release 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. doi: 10.1542/peds.2015-0658. 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., Wolf, J.S. and Yellon, R.F. (2020) ‘Clinical consensus statement: ankyloglossia in children’, Otolaryngology-Head and Neck Surgery, 162(5), pp. 597-611. doi: 10.1177/0194599820915457. National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional procedures guidance IPG149. 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. doi: 10.1002/14651858.CD011065.pub2.

A visible lingual frenulum is not, on its own, an explanation for a difficult feed. The value of a thoughtful tongue-tie course lies in helping practitioners move beyond appearance alone: to consider tongue function, feeding observation, parental experience, infant health and the wider clinical picture before discussing management options. For families, this matters because feeding difficulties can feel urgent, exhausting and deeply personal. For professionals, it matters because confident, compassionate care requires more than recognising oral anatomy. It requires clinical reasoning, clear communication and an understanding of what the evidence can - and cannot - tell us. Why a tongue-tie course needs more than anatomy The lingual frenulum is a normal anatomical structure, and its appearance varies. Some infants with a restrictive frenulum feed comfortably and grow well. Others may experience feeding concerns, but those concerns may also relate to positioning, attachment, milk supply, infant prematurity, neurological or medical factors, bottle teat flow, feeding frequency or the cumulative effect of several smaller challenges. A high-quality course should therefore avoid presenting tongue-tie as a diagnosis made by looking alone. Instead, it should teach learners to bring anatomical observations together with functional information. This includes a sensitive feeding history, observation of feeding where appropriate, consideration of maternal or parental comfort, milk transfer and infant wellbeing, and awareness of when another explanation needs exploring. This approach reflects a central principle in specialist practice: anatomy provides information, but function provides context. Assessment tools may support consistency and shared language, but they do not replace professional judgement or a full feeding assessment. The evidence base for tools continues to develop, and their reliability, purpose and limitations need careful consideration rather than checklist-led decision-making (Ingram et al., 2015). What should a good tongue-tie course cover? Infant feeding in its full context A course should begin with normal infant feeding physiology and the realities of early parenting. Learners need to understand that breastfeeding, chestfeeding, bottle feeding, combination feeding and expressed milk feeding are all valid feeding journeys. The clinical question is not whether one route is preferable in principle, but what support will help this particular infant and family feed safely, comfortably and sustainably. For breastfeeding dyads, relevant considerations can include comfort, attachment, audible swallowing, feeding frequency, breast drainage, weight trajectory and the family’s own priorities. For bottle-fed infants, it may include feeding pace, seal, milk loss, coughing, fatigue, comfort and whether the feeding pattern changes with responsive adjustments. No single sign confirms that a frenulum is causing difficulty. Good education also addresses the limits of interpretation. For example, clicking, dribbling, unsettled behaviour or prolonged feeds can have several possible explanations. They may warrant support and further assessment, but they should not be treated as proof of tongue-tie. Oral anatomy, function and differential diagnosis Anatomy teaching should be accurate, respectful and clinically useful. Learners should be able to describe normal oral structures, recognise variation and understand how restriction may affect movement in some infants. Equally, they should understand why labels alone can be unhelpful when they are detached from observed function and feeding outcomes. Differential diagnosis is a defining feature of meaningful education. A course should encourage practitioners to consider factors such as suboptimal positioning and attachment, breast or nipple concerns, oversupply or low supply, infant illness, jaundice, prematurity, reflux-like symptoms, muscular tension, developmental variation and feeding equipment issues. This is not about delaying support. It is about ensuring that support is appropriately targeted. The Academy of Breastfeeding Medicine advises that decisions about ankyloglossia should follow a skilled breastfeeding assessment and should not rely on a tool alone (Academy of Breastfeeding Medicine, 2021). That principle is equally relevant when supporting bottle-feeding families. Conservative care and collaborative decision-making A balanced course makes space for conservative management. Skilled feeding support may be the most appropriate first step for some families, while monitoring, referral or a discussion about frenulotomy may be appropriate for others. The right pathway depends on the infant’s function, feeding impact, clinical findings and the family’s informed preferences. Education should prepare professionals to explain options without pressure. Families deserve clear information about uncertainty, potential benefits, possible risks, aftercare arrangements and the fact that outcomes cannot be guaranteed. A frenulotomy may improve maternal nipple pain in the short term for some breastfeeding dyads, but evidence on longer-term breastfeeding outcomes remains less certain (O'Shea et al., 2017; Francis, Krishnaswami and McPheeters, 2015). This is particularly important where families have already received conflicting advice. A calm explanation such as, “We can see this anatomy, and we also need to understand how feeding is working for your baby and for you,” can reduce anxiety while keeping the conversation clinically grounded. Referral, scope and continuity of care A tongue-tie course should be clear about scope of practice. Identifying concerns, supporting feeding, documenting observations and making an appropriate referral are different from diagnosing independently or undertaking a procedure. Education for infant feeding professionals should not imply that every learner needs to perform, or be trained to perform, a surgical procedure. In the UK, the infant procedure is called a frenulotomy. Where it is considered, families should have access to an appropriately trained clinician, suitable consent processes and a clear plan for follow-up. NICE states that division of ankyloglossia for breastfeeding should be undertaken by trained practitioners with normal arrangements for consent, audit and clinical governance (NICE, 2005). Continuity matters. Whether a family chooses feeding support alone, monitoring, referral or frenulotomy, they may need time to adjust feeding patterns and to raise questions afterwards. A course should teach professionals to work collaboratively with lactation consultants, midwives, health visitors, GPs, paediatric services and other relevant colleagues rather than positioning tongue-tie care as isolated from the rest of infant health. How to judge whether a course is evidence-informed Course descriptions can make broad promises. It is reasonable to look for detail instead. A credible programme should explain its learning outcomes, intended audience, faculty expertise and boundaries. It should distinguish established evidence from areas where evidence is limited or still emerging. Ask whether the teaching addresses critical appraisal. Systematic reviews have found that much of the evidence around treatment is limited by small study sizes, variable definitions and short follow-up periods (Francis, Krishnaswami and McPheeters, 2015; O'Shea et al., 2017). Learners should be supported to understand these limitations, not simply given simplified conclusions. It is also worth considering whether the programme uses respectful, inclusive language and case-based learning. Real clinical situations rarely arrive as neat textbook examples. A parent may have nipple pain and an infant with a visible frenulum, but also a history of a difficult birth, early formula supplementation, delayed lactogenesis or anxiety after previous feeding challenges. Reasoned care means holding these details together. For healthcare professionals, a course should strengthen communication as well as knowledge. Explaining uncertainty is not a lack of expertise. Often, it is the most honest and helpful clinical response. What families can expect from a well-trained professional Families do not need to become experts in oral anatomy to receive good care. They can reasonably expect to be listened to, to have their feeding concerns taken seriously and to receive an assessment that considers both baby and parent. A well-trained professional will not assume that every feeding difficulty is caused by a tongue-tie, nor dismiss a family’s experience because a baby is gaining weight. They will discuss what they observe, explain the available options in plain language and support the family’s decision-making. If a referral is needed, they should explain why and what may happen next. For professionals seeking education, the most useful tongue-tie course is not the one that offers the quickest answer. It is the one that develops the confidence to pause, observe, think critically and offer care that is both evidence-informed and kind. Every feeding journey deserves that level of attention. D-Restricted Ltd Tongue-tie School Fundamentals in Infant Tongue-tie Anatomy, Function and Treatment Considerations D-Restricted Ltd Tongue-tie School is a comprehensive online course designed for healthcare and infant-feeding professionals who want to develop their knowledge and understanding of infant tongue-tie, oral anatomy, function and treatment considerations. The course takes a function-focused and evidence-informed approach, encouraging learners to consider the whole clinical picture rather than relying on anatomical appearance alone. It explores the relationship between anatomy, oral function and infant feeding, while also considering differential diagnosis, conservative management, therapeutic approaches and surgical treatment considerations. What is involved? Tongue-tie School consists of six online modules and is designed to be completed at the learner's own pace. There are approximately 10 hours of reading and learning material. Each module contains educational material followed by an assessment quiz. Learners are required to achieve a minimum 80% pass mark. The course also includes a reflective case study, allowing learners to demonstrate their understanding and reflect on the application of their learning to clinical practice. The course is designed to encourage critical thinking and clinical reasoning rather than simply teaching a checklist-based approach to tongue-tie assessment. Who is the course for? The course is intended for healthcare and infant-feeding professionals who encounter infants with feeding difficulties or who have an interest in developing their knowledge of tongue-tie and related oral function. This may include: Registered nurses Midwives Health visitors Lactation consultants and infant-feeding specialists Speech and language therapists Dentists and dental professionals Other appropriately qualified healthcare professionals working within their professional scope of practice Learners should consider the course in the context of their own professional registration, education, competence and scope of practice. Completion of the course does not independently confer authority to undertake procedures that fall outside a professional's existing scope of practice. What will I learn? The course is divided into six modules, progressively developing knowledge from anatomy and function through to assessment, therapeutic approaches, surgical considerations and ongoing care. Module 1 – Anatomy and Physiology This module explores the relevant anatomy and physiology of the infant oral cavity, including the structures associated with tongue movement and function. It provides the anatomical foundation needed to understand how variations in oral anatomy may relate to function. Module 2 – Potential Impact of Oral Ties and Functional Considerations Over Time This module considers the potential functional implications of oral ties and how these may present at different stages of development. It explores feeding and functional considerations over time and encourages learners to consider the individual infant rather than assuming that an anatomical finding will automatically result in functional difficulty. Module 3 – Tongue Function Assessment Tools and Differential Diagnosis Learners are introduced to approaches to assessing tongue function and the use of structured assessment tools. The module considers the importance of functional assessment and differential diagnosis, including the need to consider other potential contributors to feeding difficulties rather than attributing every feeding problem to tongue-tie. Module 4 – Body Therapies, Tongue Exercises and Sensorimotor Oral Activities This module explores the role of body therapies, tongue exercises and sensorimotor oral activities within the wider management of infants presenting with functional difficulties. It considers the rationale behind different approaches and the importance of appropriate professional boundaries, individual assessment and clinical reasoning. Module 5 – Surgical Release Procedures: Methods, Risks and Clinical Considerations This module examines surgical release procedures and the clinical considerations surrounding them. It considers different methods of release, potential risks and complications, appropriate decision-making and the importance of informed consent. The module places surgical intervention within the wider clinical picture rather than presenting division as an automatic response to the presence of a frenulum. Module 6 – Conservative Management and Ongoing Care The final module considers conservative management and ongoing care, including feeding support, monitoring and the importance of reviewing progress. Learners are encouraged to consider outcomes over time and recognise when further assessment, support or referral may be appropriate. Assessment and certification Knowledge is assessed throughout the course through module quizzes, with an 80% pass mark required. Learners also complete a reflective case study, encouraging them to apply the principles covered throughout the course and reflect on their own clinical reasoning. On successful completion, learners receive certification for completing the programme. The course provides 15 CPD points accredited by Advantage and 8 L-CERPs recognised by IBLCE, supporting ongoing professional development for eligible professionals. How do I enrol? Tongue-tie School is delivered online, allowing professionals to study remotely and work through the material around their existing clinical and professional commitments. To find out more about the course and enrol, visit the D-Restricted Ltd Tongue-tie School. Once enrolled, learners receive access to the online course and can begin working through the six modules. The self-paced format allows learners to revisit the educational material throughout the course and take time to reflect on how the learning relates to their own professional practice. Who is behind Tongue-tie School? The course has been developed by Diana Warren, RGN, IBCLC, founder of D-Restricted Ltd, drawing on extensive clinical experience across nursing, neonatal care, infant feeding and specialist tongue-tie practice. Her clinical background directly informs the content and approach of the course. She began her nursing career in 2002, qualifying as a Registered General Nurse in 2005, followed by experience including neurosurgical and neonatal nursing before moving into specialist tongue-tie and infant-feeding practice. She qualified as an International Board Certified Lactation Consultant (IBCLC) in 2018 and has continued to develop her knowledge through specialist education and clinical practice. This combination of clinical experience, professional education and ongoing practice underpins the course's emphasis on assessment, function, clinical reasoning and individualised care. A course designed to encourage clinicians to think differently Tongue-tie can be a complex and sometimes controversial area of infant healthcare. D-Restricted Ltd Tongue-tie School aims to provide professionals with the knowledge and framework to approach the subject thoughtfully and critically. Rather than focusing solely on whether a frenulum is present or what it looks like, the course encourages learners to ask a more important question: What does the anatomy mean in the context of function, feeding and the individual infant? The underlying principle is simple: Anatomy provides information. Function provides context. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278-281. Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458-e1466. Ingram, J., Johnson, D., Copeland, M., Churchill, C., Taylor, H. and Emond, A. (2015) ‘The development of a tongue assessment tool to assist with tongue-tie identification’, Archives of Disease in Childhood - Fetal and Neonatal Edition, 100(4), pp. F344-F348. National Institute for Health and Care Excellence (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.

A tongue-tie may be identified in the first days or weeks of life, sometimes when a family is already experiencing feeding difficulties, pain or concerns about milk transfer. However, the presence of a lingual frenulum that appears short, tight or restrictive does not, by itself, tell us how a baby will function now or how that child will develop in the future. Not every tongue-tie requires treatment. Some babies feed comfortably and effectively without intervention, while others may experience functional difficulties where restricted tongue movement is one contributing factor. The important question is therefore not simply whether a frenulum is present, but whether restriction is affecting function. It is also important to distinguish between treating a current problem and attempting to prevent a hypothetical future one. Frenulotomy in an infant should be considered in relation to the clinical problems and functional findings that are present at that time. It should not be undertaken simply because a child might develop speech, sleep, breathing, dental, facial or postural difficulties in the future. We do not have a crystal ball: it is not possible to know which infant with a tongue-tie will subsequently develop one of these problems, whether the frenulum will be a contributing factor, or whether the problem would occur regardless of the frenulum. There are also ethical considerations in performing an invasive procedure on an infant for a future outcome that cannot currently be predicted and for which preventative benefit has not been established. If a child develops a functional difficulty later in childhood, that difficulty can be assessed at that time. The child's anatomy, growth, oral structures, function and wider circumstances will then be known, allowing the most appropriate management to be considered based on the problem that actually exists. The same principle applies in the other direction. Releasing a tongue-tie in infancy does not guarantee that a child will never experience speech, breathing, sleep, dental or postural difficulties. These outcomes are influenced by many factors. For example, a child who has undergone frenulotomy may later experience speech difficulties for reasons unrelated to the frenulum. A high palate, dental development, hearing, motor planning, phonological development and other structural or functional factors may all be relevant to speech. The purpose of this article is therefore not to suggest that every untreated tongue-tie will cause problems, nor that every tongue-tie should be released to prevent possible future difficulties. Instead, it considers what is currently known about the potential relationship between restricted tongue function and breastfeeding, bottle feeding, breathing, speech, facial and dental development, posture, sleep, and swallowing and eating. The evidence is not equally strong across these areas. Some associations have been investigated in clinical studies and systematic reviews, while other proposed relationships remain uncertain and require better research. Anatomy provides information. Function provides context. Breastfeeding and chestfeeding The strongest body of evidence concerning infant tongue-tie relates to breastfeeding, although even here the evidence has important limitations. A restrictive lingual frenulum may affect the infant's ability to elevate, extend or move the tongue with the range and coordination required for effective feeding. Depending on the individual infant, this may contribute to difficulty maintaining an effective attachment, generating or maintaining suction, or transferring milk efficiently. Maternal nipple pain and nipple compression or damage may also occur. However, these signs are not specific to tongue-tie. Breastfeeding is a complex interaction involving infant positioning, breast and nipple anatomy, milk flow, gestational age, infant tone, regulation, oral-motor skills, respiratory status and many other factors. A tongue-tie may be one contributing factor rather than the sole explanation. Randomised trials and systematic reviews suggest that frenotomy can reduce maternal nipple pain in the short term for some breastfeeding dyads. However, evidence for consistent improvement in objective breastfeeding outcomes and longer-term breastfeeding duration is less certain. The Cochrane review concluded that frenotomy reduced maternal nipple pain in the short term but did not demonstrate a consistent positive effect on infant breastfeeding, with the evidence limited by small studies and methodological weaknesses (O'Shea et al., 2017). A later systematic review and meta-analysis reported improvements in standardised breastfeeding difficulty and maternal pain following frenotomy, although the authors also noted limitations within the available evidence (Bruney et al., 2022). The UK randomised trial by Emond et al. (2014) is particularly useful when considering whether every tongue-tie should be treated immediately. In infants with mild-to-moderate tongue-tie and breastfeeding difficulties, immediate frenotomy did not produce an objective improvement in breastfeeding at five days compared with standard breastfeeding support. Maternal breastfeeding self-efficacy did improve, and many families in the comparison group subsequently chose frenotomy when difficulties persisted. This supports an individualised approach. A tongue-tie that is present but not causing meaningful functional difficulty does not automatically require intervention. Where significant feeding difficulties persist despite skilled support, however, assessment of whether restricted tongue movement is contributing may be appropriate. Bottle feeding Tongue-tie is less extensively studied in bottle-fed and combination-fed infants than in breastfed infants. Some infants with restricted tongue movement may have difficulty maintaining an effective seal around a teat, generating suction or coordinating tongue movement with the flow of milk. Families may describe milk loss from the mouth, clicking, loss of suction, prolonged feeds, fatigue, coughing or spluttering, unsettled feeding or difficulty taking sufficient volumes. However, these signs are not diagnostic of tongue-tie. Teat flow, feeding position, pacing, respiratory health, neurological or developmental factors, oral-motor coordination and normal individual variation can all influence bottle feeding. The evidence for treating ankyloglossia specifically to improve bottle feeding remains limited. The American Academy of Pediatrics systematic review found insufficient evidence to assess the effects of frenotomy on non-breastfeeding outcomes, including feeding beyond breastfeeding (Chinnadurai et al., 2015). This does not mean that bottle-feeding difficulties should be dismissed when a tongue-tie is present. It means that the feeding problem should be assessed in its own right, rather than assuming that the frenulum is responsible. Breathing and oral posture The relationship between tongue mobility, tongue resting posture and breathing has attracted increasing clinical and research interest. The tongue contributes to the shape and function of the oral cavity and normally rests within the mouth with an interaction between the tongue, palate, jaw and surrounding muscles. Restricted tongue mobility may, in some individuals, influence the range of resting tongue positions that can be comfortably achieved. Researchers have therefore investigated whether ankyloglossia may be associated with altered oral posture, mouth breathing or upper-airway function. However, it is important to distinguish a plausible functional mechanism from evidence of causation. A restricted frenulum does not automatically result in mouth breathing or airway dysfunction, and mouth breathing has many possible causes, including nasal obstruction, allergy, enlarged adenoids or tonsils and other airway factors. Current evidence does not justify predicting that an infant with tongue-tie will develop breathing problems later in childhood. Nor does it establish that infant frenulotomy prevents future breathing difficulties. This is an area where further prospective research is needed, particularly research that assesses tongue function rather than relying solely on the appearance of the frenulum. Speech Speech is one of the areas most frequently raised when discussing possible longer-term effects of an untreated tongue-tie. The tongue is involved in the production of many speech sounds, and adequate movement, speed, precision and coordination are important for articulation. It is therefore biologically plausible that significant restriction of tongue movement could affect speech in some individuals, particularly where the restriction limits the movement required for particular sounds. However, biological plausibility does not establish that tongue-tie causes speech disorders. A systematic review by Wang et al. (2022) identified 16 studies examining ankyloglossia and speech articulation. Most studies were small and the overall quality of evidence was low. The authors found no clear connection between ankyloglossia and speech disorders and concluded that better-designed research using consistent definitions and assessment methods was needed. This is important when considering an infant. It is not possible to look at a baby's frenulum and reliably predict whether that child will have a speech difficulty years later. Speech development is multifactorial. Hearing, phonological development, motor planning, language development, oral structure, palate shape and other developmental factors may all contribute. A high palate, for example, may influence oral structure and speech independently of whether a child has previously had a tongue-tie released. Consequently, infant frenulotomy should not be presented as a guarantee against future speech problems. If a child develops a speech difficulty later, the appropriate response is assessment of the speech difficulty at that time, rather than assuming that the presence or previous treatment of a tongue-tie explains the problem. Facial growth and dental development The possible relationship between tongue restriction and facial or dental development is an area of considerable interest, but it is also an area in which claims can easily become stronger than the evidence supports. The tongue exerts forces within the oral cavity and has an important relationship with the palate, dental arches and surrounding structures. Restricted tongue mobility may alter tongue position or function in some individuals, and researchers have investigated whether ankyloglossia is associated with differences in dental arch dimensions, malocclusion and facial morphology. A 2024 systematic review examining ankyloglossia and facial development identified associations between ankyloglossia and reduced intercanine and intermolar widths, as well as Class III malocclusion and mandibular incisor crowding. However, the authors assessed the quality of the available studies as low and highlighted the lack of good-quality prospective research (Kotarska et al., 2024). These findings are therefore interesting but should not be interpreted as proof that an untreated tongue-tie causes abnormal facial growth. Facial growth is influenced by numerous genetic, skeletal, dental, muscular, respiratory and environmental factors. The palate and dental arches also develop and change throughout childhood. Similarly, there is currently insufficient evidence to conclude that releasing a tongue-tie during infancy prevents later orthodontic problems or ensures normal facial development. If dental or skeletal concerns become apparent as a child grows, they can be assessed by the appropriate dental or orthodontic professional at that stage. The child's actual anatomy and developmental pattern can then be considered rather than attempting to predict the future from an infant frenulum. Posture and whole-body function Claims about tongue-tie and posture are common, but the evidence base is considerably less developed than that relating to infant feeding. The tongue does not function in isolation. It has anatomical and functional relationships with the mandible, hyoid region and surrounding muscles. Changes in tongue position can therefore influence the way other structures are recruited during particular movements. This has led to hypotheses concerning relationships between tongue restriction, head and neck position, cervical muscle activity and wider postural patterns. However, a proposed anatomical or biomechanical relationship is not the same as evidence that an untreated tongue-tie causes poor posture. There is currently insufficient high-quality evidence to conclude that infants with untreated tongue-tie are likely to develop postural problems, or that frenulotomy in infancy prevents such problems. Posture is influenced by growth, musculoskeletal development, vision, balance, strength, motor development, habitual movement patterns and many other factors. If a postural concern develops, it should therefore be assessed in the context of the individual child rather than automatically attributed to a lingual frenulum. This is an important area for future research, particularly studies that use objective functional measures rather than assumptions based on anatomy alone. Sleep and sleep-disordered breathing Sleep is another area where the relationship with tongue-tie is increasingly being investigated. The position and tone of the tongue are relevant to the upper airway, and researchers have therefore considered whether restricted tongue mobility might be associated with sleep-disordered breathing or obstructive sleep apnoea. The research is interesting but not yet definitive. A 2024 systematic review and meta-analysis reported an association between a short lingual frenulum and obstructive sleep apnoea in children. The same review also identified a strong association between a high-arched palate and obstructive sleep apnoea, highlighting the importance of considering more than the frenulum alone (Camañes-Gonzalvo et al., 2024). More recently, a systematic review published in 2026 examined eight studies involving 1,171 children and concluded that the relationship between ankyloglossia and paediatric sleep-disordered breathing remains unclear. The authors also found insufficient evidence to determine whether frenotomy should be used as a treatment for sleep-disordered breathing in children with ankyloglossia (Venugopal et al., 2026). This distinction is important. An association between two conditions does not mean that one causes the other, and evidence that a frenulum is associated with sleep-disordered breathing does not demonstrate that releasing an infant's frenulum will prevent sleep problems years later. If a child develops snoring, mouth breathing, disturbed sleep or other symptoms suggestive of sleep-disordered breathing, these symptoms should be assessed at the time they occur. The child's airway, tonsils, adenoids, palate, craniofacial development, weight, nasal health and other relevant factors can then be considered. Swallowing, eating and digestion As children move from milk feeding to complementary foods, tongue movement becomes important for manipulating food, forming and moving a bolus and coordinating swallowing. A restricted tongue may potentially affect some aspects of oral food management in an individual child, particularly where the range of movement is substantially limited. Some children may develop compensatory strategies that allow them to manage food effectively despite restriction. However, the evidence connecting infant ankyloglossia with later swallowing or eating difficulties remains limited. The available literature includes reports of improvements in some non-breastfeeding feeding functions following treatment, but systematic reviews have concluded that the evidence is insufficient to establish clear longer-term benefits of frenotomy for these outcomes (Chinnadurai et al., 2015). It is also important to distinguish swallowing and oral processing from digestion itself. Digestion involves the gastrointestinal tract and a complex range of physiological processes. It would therefore be inappropriate to state that an untreated tongue-tie causes digestive disorders. Where a child has difficulty chewing, managing textures, swallowing or progressing with eating, the problem should be assessed as a feeding or swallowing concern in its own right. Other causes should be considered rather than assuming that a lingual frenulum is responsible. What does the evidence actually tell us? The evidence surrounding untreated tongue-tie is not a simple question of whether problems will or will not occur. The research suggests that restricted tongue function can be relevant to feeding in some infants, particularly breastfeeding, and there is increasing interest in possible associations between ankyloglossia and later speech, craniofacial development and sleep-disordered breathing. However, the quality of evidence varies substantially between these areas. For speech, current systematic review evidence has not established a clear causal relationship. For facial development, associations have been reported, but the quality of the available studies is low. For sleep-disordered breathing, studies have produced evidence of an association but recent systematic review evidence still describes the relationship as unclear and finds insufficient evidence to recommend frenotomy as a treatment for paediatric sleep-disordered breathing. Evidence concerning posture is particularly limited. This matters because an association does not establish causation. It is also important to recognise a major limitation in the research: there are relatively few high-quality prospective studies following infants with untreated tongue-tie over many years. Without good natural-history research, it is difficult to determine which children would develop problems without treatment, which would not, and what other factors might contribute to those outcomes. This is why it is inappropriate to tell families that an untreated tongue-tie will inevitably cause future speech, sleep, breathing, dental or postural problems. It is equally inappropriate to suggest that releasing every infant tongue-tie will prevent those problems. Treat the problem that exists, not the problem we imagine might happen The distinction between current function and future possibility is central to responsible decision-making. A frenulotomy is an intervention performed on an infant. It should therefore be considered because there is a current clinical reason to consider it, supported by assessment of the infant's function and circumstances, rather than because of a fear that the child might develop a problem years later. We cannot know in infancy whether a particular child will later develop a speech disorder, obstructive sleep apnoea, malocclusion, altered posture or difficulty with eating. We also cannot know whether the lingual frenulum would have contributed to that problem. Anatomy changes with growth and development. The palate develops, the dental arches change, facial structures mature and neuromuscular patterns develop throughout childhood. A problem that does not exist today cannot be assessed accurately as though it already exists. If a clinically significant difficulty develops later, it can be investigated at that time. The child's current anatomy and function can then inform the clinical decision. This approach also avoids the assumption that frenulotomy provides lifelong protection. A child who has undergone frenulotomy may still develop speech difficulties, sleep-disordered breathing, orthodontic problems, postural issues or feeding difficulties for reasons unrelated to the frenulum. Releasing the frenulum does not remove the many other factors that influence development. For example, a high palate may be relevant to speech or airway function regardless of whether a tongue-tie was previously released. The goal should therefore be appropriate care for the child in front of us, rather than attempting to predict and surgically prevent every possible future problem. Observation is not the same as doing nothing Choosing not to undertake frenulotomy does not have to mean ignoring a tongue-tie. Where an infant is feeding comfortably, growing appropriately and functioning well, observation may be entirely appropriate. Families can be supported, information can be provided and the child's function can be reviewed if circumstances change. Similarly, where feeding difficulties are present, conservative support can be an active part of management. This may include skilled feeding assessment, positioning and attachment support, consideration of milk transfer, monitoring growth and hydration, and addressing other potential contributors. If difficulties persist, the assessment can be revisited. This approach allows decisions to remain responsive to the infant's actual needs rather than making an irreversible decision based on what might happen years later. When should families seek further assessment? Families should seek appropriate assessment when there is a current functional concern. In infancy, this may include persistent maternal nipple pain, difficulty maintaining attachment, concerns about milk transfer, prolonged or exhausting feeds, poor weight gain, concerns about hydration or significant difficulty coordinating feeding. As a child develops, concerns may relate to speech, eating, swallowing, sleep, breathing, dental development or other aspects of function. The appropriate professional assessment will depend on the problem. A speech and language therapist may be appropriate for speech concerns; a dentist or orthodontist for dental or facial development; an appropriately qualified clinician for sleep or airway concerns; and a feeding or swallowing specialist where eating or swallowing is problematic. The presence of a tongue-tie can be considered as part of the assessment, but it should not automatically become the explanation for every difficulty. Summary A tongue-tie is an anatomical finding; its significance depends on function. Not every infant with a tongue-tie will experience difficulties, and the presence of a frenulum alone is not a reason to undertake treatment. The evidence surrounding the longer-term effects of an untreated tongue-tie is developing and varies considerably between areas. Research has investigated possible relationships with breastfeeding, bottle feeding, breathing, speech, facial and dental development, posture, sleep and swallowing, but the quality and consistency of the evidence are not the same across these areas. There is stronger evidence that some infants with restricted tongue function may experience breastfeeding difficulties, particularly maternal nipple pain, than there is for many of the proposed longer-term effects. Evidence concerning speech remains inconsistent; research into facial growth and dental development is suggestive but limited by study quality; evidence concerning posture is currently weak; and the relationship between ankyloglossia and sleep-disordered breathing remains uncertain. Importantly, the possibility of a future problem should not be confused with evidence that a future problem will occur. Frenulotomy in infancy should be considered in the context of the problems and functional findings that are present at that time. It should not be undertaken simply to try to prevent a hypothetical future speech, sleep, breathing, dental or postural problem. We do not have a crystal ball. We cannot predict which children will develop these difficulties, whether a tongue-tie will contribute to them, or what other anatomical and functional factors may be involved as a child grows. Anatomy also changes with growth and development. If a clinically significant problem emerges later, it can be assessed and managed at that time, based on the child's current anatomy and function. Equally, a child who has undergone frenulotomy in infancy is not protected from developing future difficulties. Speech, sleep, breathing, dental development, posture and eating are influenced by multiple factors, and problems may arise for reasons unrelated to the lingual frenulum. A high palate, for example, may be relevant to oral function, speech or airway function independently of whether a tongue-tie was previously released. The most appropriate approach is therefore neither to treat every tongue-tie nor to dismiss every tongue-tie. It is to assess function, identify problems that are actually present, consider the available evidence, support the infant and family, and review as the child develops. We do not need to predict the future to provide appropriate care today. Anatomy provides information. Function provides context. References Bruney, T.L., Scime, N.V., Madubueze, A. and Chaput, K.H. (2022) ‘Systematic review of the evidence for resolution of common breastfeeding problems—ankyloglossia (tongue tie)’, Acta Paediatrica, 111(5), pp. 940–947. doi:10.1111/apa.16289. Camañes-Gonzalvo, S., Montiel-Company, J.M., Paredes-Gallardo, V. et al. (2024) ‘Relationship of ankyloglossia and obstructive sleep apnea: systematic review and meta-analysis’, Sleep and Breathing, 28, pp. 1067–1078. doi:10.1007/s11325-024-03021-4. Chinnadurai, S., Francis, D.O., Epstein, R.A., Morad, A., Kohanim, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review’, Pediatrics, 135(6), pp. e1467–e1474. doi:10.1542/peds.2015-0657. Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M. and MacArthur, C. (2014) ‘Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie’, Archives of Disease in Childhood – Fetal and Neonatal Edition, 99(3), pp. F189–F195. doi:10.1136/archdischild-2013-305031. Kotarska, M., Wądołowska, A., Sarul, M., Kawala, B. and Lis, J. (2024) ‘Does ankyloglossia surgery promote normal facial development? A systematic review’, Journal of Clinical Medicine, 14(1), 81. doi:10.3390/jcm14010081. National Institute for Health and Care Excellence (NICE) (2005, updated 2026) ‘Division of ankyloglossia (tongue-tie) for breastfeeding’, HealthTech guidance HTG95. 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. doi:10.1002/14651858.CD011065.pub2. Venugopal, N., Neposlan, J., Bysice, A., Khoury, S., Madou, E., Lee, R., Strychowsky, J.E., St-Laurent, A., Lawlor, C.M. and Graham, M.E. (2026) ‘Is ankyloglossia correlated with pediatric sleep disordered breathing? A systematic review’, The Laryngoscope, 136(3), pp. 1088–1098. doi:10.1002/lary.70134. Wang, J., Yang, X., Hao, S. and Wang, Y. (2022) ‘The effect of ankyloglossia and tongue-tie division on speech articulation: a systematic review’, International Journal of Paediatric Dentistry, 32(2), pp. 144–156. doi:10.1111/ipd.12802.

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.

A pacifier can be a useful tool for some babies and families. Non-nutritive sucking can provide comfort and regulation, and in some clinical circumstances it may support the development of oral feeding skills. At the same time, prolonged or frequent pacifier use can have potential implications for feeding, oral function and developing orofacial structures. The question is therefore not whether pacifiers are simply “good” or “bad”. It is about why a pacifier is being used, when it is being offered, how frequently it is used, and whether it is supporting or interfering with what the individual infant needs. Families deserve balanced information without judgement. A pacifier may be a helpful settling tool for one family while becoming an unhelpful substitute for responsive feeding in another. For healthcare professionals, conversations about pacifier use are also an opportunity for clinical reasoning. Anatomy provides information; function provides context. A pacifier does not diagnose tongue-tie, explain every feeding difficulty or determine a baby's feeding outcome. It is one part of a much wider picture that includes infant health, gestation, feeding method, feeding effectiveness, weight gain, milk supply where relevant, parental comfort, sleep, family circumstances and individual goals. What is non-nutritive sucking? Sucking is an important infant behaviour and does not always have a nutritional purpose. Non-nutritive sucking describes sucking without the transfer of milk and can occur naturally through finger or hand sucking, as well as with a pacifier. Non-nutritive sucking can have a role in infant regulation and settling. It also involves coordinated activity of the lips, cheeks, tongue and jaw. In premature infants, non-nutritive sucking has been studied as part of supporting the development and progression of oral feeding. Research has reported potential benefits for outcomes such as progression to oral feeding and hospital stay, although the quality and findings of individual studies vary. This is an important positive aspect of pacifier use. A pacifier is not simply an object that “stops a baby crying”. Sucking is a physiological behaviour with developmental and regulatory functions. However, the fact that non-nutritive sucking can be beneficial does not mean that more sucking is necessarily better. The context, duration and frequency of use matter. When can pacifier use become unhelpful? Pacifier use may become unhelpful when it repeatedly delays or replaces feeding, masks feeding cues, becomes a constant source of soothing, or limits opportunities for other oral experiences. In the early weeks, frequent feeding is biologically normal. For babies feeding at the breast, milk removal also plays an important role in establishing and maintaining milk production. If a pacifier is repeatedly used to settle a baby who is actually hungry, the feed may be delayed and opportunities for breast stimulation and milk removal may be reduced. This does not mean that every pacifier use outside a feed is problematic. A baby who has fed effectively and is then offered a pacifier for comfort is very different from a baby who is repeatedly given a pacifier instead of being offered a feed. The same principle applies to bottle-fed and combination-fed infants. A bottle or teat can be an entirely appropriate means of providing nutrition. The concern is not that bottle feeding is harmful, but that prolonged sucking on a teat or pacifier beyond nutritional need may become a habitual oral behaviour. Clinical assessment should therefore consider what the infant is communicating rather than assuming that the pacifier itself is the cause of a feeding difficulty. Pacifiers and breastfeeding The relationship between pacifier use and breastfeeding is more complicated than a simple statement that pacifiers “cause breastfeeding problems”. Observational research has reported associations between pacifier use and shorter breastfeeding duration, but association does not establish causation. In some situations, pacifier use may contribute to reduced feeding opportunities; in others, pacifier use may have been introduced because breastfeeding was already difficult, the baby was unsettled or the family was experiencing feeding challenges. A Cochrane review of healthy, term infants whose mothers intended to breastfeed found that restricting pacifier use did not significantly increase breastfeeding rates at three or four months compared with unrestricted use. This does not mean that timing and context are irrelevant, particularly when a baby is struggling to transfer milk or when milk supply is being established. For families establishing breastfeeding, the priority should therefore remain responsive feeding, effective milk transfer, appropriate monitoring of weight and output, and timely support when feeding is difficult. If a pacifier is being used, families can be encouraged to consider whether it is being offered after an effective feed or whether it is being used to postpone a feed. This distinction is particularly important when there is already concern about milk transfer, infant weight gain, maternal nipple pain or milk supply. Where tongue-tie is suspected, a frenulum should not be considered in isolation. Assessment should consider tongue function alongside feeding history, observation and the individual infant's circumstances. The tongue's resting position One consideration that is sometimes overlooked is what happens to the tongue while a pacifier is in the mouth. A pacifier occupies space within the oral cavity and influences where the tongue can rest. Rather than having unrestricted opportunity to adopt a natural resting position within the mouth, the tongue is required to accommodate the pacifier. Occasional use is unlikely to have the same implications as frequent or prolonged use. However, when a pacifier is present in the mouth for substantial periods of the day, the infant has correspondingly less time experiencing other oral postures and movements. Research into prolonged pacifier sucking has identified associations with changes in resting tongue position, lip posture, swallowing patterns and the shape of the hard palate. However, the evidence needs to be interpreted cautiously because much of the available research is observational and methodological quality varies. This is therefore not an argument that pacifiers cause abnormal tongue posture in every infant. It is a reason to consider duration and frequency of use, particularly where there are already concerns about oral function. Pacifiers, dentition and developing orofacial structures The developing mouth is responsive to repeated patterns of muscle activity and pressure. A systematic review examining pacifier sucking and orofacial structures identified associations with anterior open bite and posterior crossbite. However, the authors also found that most of the available studies had serious or moderate risk of bias and concluded that high-level evidence was lacking. This is an important example of why evidence should not be overstated. It would be inappropriate to tell a family that using a pacifier will inevitably cause dental problems. Equally, it would be inappropriate to suggest that prolonged sucking habits have no potential effect on developing oral structures. Duration and frequency appear to be important considerations. The longer and more frequently a sucking habit continues, the greater the opportunity for it to influence developing oral structures. This principle also applies to prolonged use of feeding teats. Bottle feeding itself should not be presented as harmful, particularly because bottles may be an essential and appropriate means of providing nutrition. The consideration is whether an infant continues to suck habitually on a teat for prolonged periods beyond the nutritional requirements of the feed. As children grow, reducing prolonged sucking habits can therefore be considered as part of supporting healthy oral development. Pacifier use following frenulotomy Pacifier use following frenulotomy is an area where clinical practice and evidence do not always align neatly. Following a frenulotomy, the wound needs to heal while the newly released tongue is able to move functionally. Some clinicians advise avoiding pacifiers during the healing period because of concerns about the sucking pattern, tongue positioning and the possibility that these could influence wound healing or contribute to re-adhesion. However, it is important to distinguish clinical reasoning from established evidence. There is currently no robust evidence demonstrating that pacifier use causes re-adhesion following frenulotomy. Research into post-frenotomy care remains limited and variable. There is substantial variation in postoperative care practices, and the evidence examining the relationship between postoperative care and outcomes remains limited. More research is needed to establish whether particular postoperative practices influence wound healing, functional outcomes or re-adhesion. For this reason, families should be given clear, individualised postoperative advice by the clinician responsible for their baby's care. A pacifier should not automatically be described as causing re-adhesion when the evidence does not establish that relationship. Pacifiers and SIDS: what does the evidence really tell us? Pacifier use has been associated with a reduced risk of sudden infant death syndrome (SIDS) in observational research. This association has led to recommendations in some safer-sleep guidance to consider offering a pacifier at sleep times. However, there is no robust evidence that pacifier use prevents SIDS. A Cochrane review specifically examining pacifiers for SIDS prevention found no eligible randomised controlled trials and concluded that there was no randomised trial evidence on which to support or refute pacifier use for the prevention of SIDS. This distinction matters. An association identified in observational research does not demonstrate that the pacifier itself prevents SIDS. Other factors associated with pacifier use may contribute to the observed relationship. A pacifier should therefore not be presented to families as a proven protective measure against SIDS. This is particularly important for babies who are not breastfed. A baby being formula-fed, bottle-fed or combination-fed should not automatically be offered a pacifier because they are not breastfeeding, on the assumption that the pacifier will compensate for the absence of breastfeeding or provide established protection against SIDS. Breastfeeding itself is associated with a reduced risk of SIDS. This does not mean that families who do not breastfeed should feel blamed, or that a pacifier should never be used. It means that pacifier use should not be presented as a substitute for the protective association associated with breastfeeding. For a breastfed baby, there is also a practical feeding consideration. If a pacifier is repeatedly used to settle a baby who is hungry, it may delay feeding and reduce opportunities for milk removal. Protecting responsive feeding and effective milk transfer should therefore remain a priority, particularly while breastfeeding is being established. Safer sleep advice should always be considered as a whole rather than reduced to one intervention or product. Ear health Frequent pacifier use has also been associated with an increased risk of acute otitis media. This does not mean that every infant who uses a pacifier will develop ear infections. However, where a child experiences recurrent middle-ear infections, the frequency and duration of pacifier use may be worth considering as part of a wider clinical picture. Families should be supported to make gradual changes where appropriate rather than being given blanket advice or made to feel that they have caused their child's ear problems. When might reducing pacifier use be helpful? There is no single age at which every baby needs to stop using a pacifier. Instead, it can be useful to consider the role that the pacifier is playing. Questions to consider include: Is the baby feeding effectively? Is the pacifier being used after feeds or to delay feeds? Is the baby gaining weight appropriately? Are feeding cues being recognised and responded to? Is the pacifier being used occasionally or for substantial periods of the day? Is it being used primarily for sleep, or throughout waking hours? Is the infant developing other ways of settling and regulating? Are there concerns about tongue function, oral posture or feeding? Is the child experiencing recurrent ear infections? Is prolonged sucking continuing as the child develops a primary dentition? Has the infant recently undergone a frenulotomy and been given specific postoperative advice? For some families, reducing pacifier use may be straightforward. For others, it may be an important source of comfort and regulation and need to be reduced gradually. A family-centred approach recognises both realities. A balanced approach for families A pacifier can be useful. It can support non-nutritive sucking, comfort and regulation, and in particular clinical circumstances non-nutritive sucking may have a role in supporting oral feeding development. But useful does not mean necessary, and occasional use is different from prolonged habitual use. The potential concerns relate particularly to what happens when a pacifier becomes a frequent or constant presence: feeds may be delayed, feeding cues may be missed, opportunities for milk removal may be reduced, the tongue's unrestricted resting position may be limited, and prolonged sucking habits may influence developing oral structures. The evidence around these effects is not equally strong. Some areas have better evidence than others, and some commonly repeated clinical claims remain insufficiently studied. This is especially important following frenulotomy. Concerns about pacifier use during wound healing may be clinically reasonable, but there is not currently robust evidence demonstrating that pacifier use causes re-adhesion. Families should therefore receive individualised advice rather than absolute statements presented as established fact. The same balanced approach should be applied to SIDS. There is no robust evidence that pacifier use prevents SIDS. An observational association should not be transformed into a guarantee of protection, and a baby who is not breastfed does not need a pacifier as a substitute for breastfeeding or as an established SIDS-prevention measure. Ultimately, the most useful question is not: > “Are pacifiers good or bad?” It is: > “Is this pacifier helping this baby and family, and is anything important being missed?” That question allows families to make informed decisions without fear, guilt or judgement. A pacifier can be a useful tool. It can also become unhelpful when its use is prolonged, excessive or substituted for something the infant actually needs. As with so many aspects of infant feeding and development, context matters. References Hauck, F.R., Thompson, J.M.D., Tanabe, K.O., Moon, R.Y. and Vennemann, M.M. (2011) ‘Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis’, Pediatrics, 128(1), pp. 103–110. doi: 10.1542/peds.2010-3000. Jaafar, S.H., Ho, J.J., Jahanfar, S. and Angolkar, M. (2016) ‘Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding’, Cochrane Database of Systematic Reviews, 2016(8), CD007202. doi: 10.1002/14651858.CD007202.pub4. Psaila, K., Foster, J.P., Pulbrook, N. and Jeffery, H.E. (2017) ‘Infant pacifiers for reduction in risk of sudden infant death syndrome’, Cochrane Database of Systematic Reviews, 2017(4), CD011147. doi: 10.1002/14651858.CD011147.pub2. Schmid, K.M., Kugler, R., Nalabothu, P., Bosch, C. and Verna, C. (2018) ‘The effect of pacifier sucking on orofacial structures: a systematic literature review’, Progress in Orthodontics, 19, 8. doi: 10.1186/s40510-018-0206-4.

A latch can look close from across the room yet still feel pinching, leave a nipple misshapen after a feed, or make feeding feel like an anxious negotiation rather than a moment of connection. Learning how to improve infant latch is not about achieving a picture-perfect position. It is about helping an individual baby feed as comfortably and effectively as possible, while protecting the wellbeing of the person feeding them. For some families, a few small changes can make a meaningful difference quite quickly. For others, persistent difficulty is a sign that the whole feeding picture needs skilled attention. This may include the baby’s health and development, feeding history, milk supply, breast or chest comfort, bottle-feeding technique, oral function and the circumstances surrounding the feeding difficulties. Anatomy provides information. Function provides context. How to breastfeed: begin with the feed, not a diagnosis A single symptom does not always have a single cause. Sometimes there is one clear contributing factor, but often several factors overlap. Nipple pain, frequent feeding, clicking, slipping from the breast, unsettled behaviour or concerns about milk transfer can all have different explanations, and the same symptom may have more than one possible cause. This is why it can be more useful to observe an entire feed where possible rather than immediately focusing on the latch itself. The baby’s age, gestation, weight, health, feeding history and development all provide important context, as does the caregiver’s experience, comfort and feeding goal. Before bringing the baby to the breast or chest, look for early feeding cues. These can include stirring, waking, turning towards touch, bringing their hands towards their mouth, licking and opening the mouth. Responding to these cues gives the baby an opportunity to begin feeding before they become very distressed. If a baby is already crying hard, you may have missed the earlier feeding cues. Crying is a late feeding cue, and a baby who is highly distressed may find it more difficult to organise their movements and coordinate feeding. Trying repeatedly to latch a very upset baby can make the experience stressful for both of you. Instead, calm first. Holding the baby close, offering skin-to-skin contact, cuddling or simply allowing them a moment to settle can help. Once the baby is calmer and showing signs that they are ready to feed, you can try again. This is not a failure or a missed opportunity; it is responding to what the baby needs at that moment. Positioning your baby for breastfeeding There is no single correct breastfeeding position. The caregiver needs to be comfortable and well supported, while the baby needs to be close enough to remain stable and secure. Keeping the baby’s whole body in contact with the caregiver can help them feel anchored and supported while feeding, rather than having to use energy to stabilise themselves. Where possible, bring the baby’s body towards you rather than leaning your breast or chest towards the baby. Their head, neck and body should be positioned so that they can approach the breast or chest without having to twist their head. Supporting the shoulders and upper back, rather than pressing on the back of the head, allows the baby freedom to move their head and neck as they open their mouth and attach. The exact position will vary according to the baby’s size, gestation, tone, development and health, as well as the caregiver’s body, breast or chest shape, comfort and feeding history. Positioning should therefore be adapted to the individual baby and caregiver rather than treated as a rigid set of instructions. How to latch a baby: head and chin first, then up and over Once your baby is calm, close to you and showing feeding readiness, position them so that their nose is in line with your nipple. The next part is not about putting the nipple directly into the centre of the baby’s mouth. Instead, the nipple can be used to gently stimulate the baby’s upper lip and encourage the gape reflex, giving the baby an opportunity to open their mouth widely before attachment. As the mouth opens, think about the baby’s head and chin coming towards the breast or chest first. The nipple should be angled upwards towards the roof of the baby’s mouth rather than pointing directly forwards into the centre of the mouth. A useful way to visualise the direction is to think about pointing the nipple upwards towards the baby’s nose, almost as though you were going up towards the eye, rather than straight forwards. This encourages an asymmetrical approach to the breast or chest rather than trying to position the nipple like a bullseye in the centre of the mouth. As the baby’s mouth opens wide, allow their head to tip back into extension and bring the baby up and over the nipple and breast or chest. The chin comes into contact with the breast or chest first, followed by the mouth coming up and over to take in a mouthful of breast or chest tissue. One way of picturing the movement is to imagine someone taking a drink from a pint glass. Their head tips back, their chin comes forward and their mouth comes up and over the rim of the glass. The baby’s attachment has a similar up-and-over quality. This is very different from trying to place the nipple directly into the centre of the baby’s mouth, as though the baby were sucking through a straw. The baby is not simply being positioned over the nipple; they are using their own movements to open, approach and attach. If the baby misses the latch, nothing has gone wrong. They can try again. Newborn babies are learning how to breastfeed, and caregivers are learning how to support them. It can take practice for both parties to become familiar with the movements involved. There is no need for either of you to get it right first time. The aim is not to make the baby hit a precise target, but to give them the opportunity to open widely, approach the breast or chest effectively and develop a comfortable, functional attachment. The asymmetrical latch A comfortable latch does not necessarily look symmetrical. Rather than aiming the nipple directly into the centre of the baby’s mouth, an asymmetrical attachment allows the baby to take breast or chest tissue into the mouth, with the nipple positioned towards the roof of the mouth. This is why trying to achieve a “bullseye” latch can be unhelpful. The aim is not for the nipple to sit centrally in the baby’s mouth, nor is the aim for the baby to suck only on the nipple as though it were a straw. The baby needs to take an appropriate amount of breast or chest tissue into their mouth so that they can maintain attachment, generate suction and transfer milk. The baby’s chin may be deeply into the breast or chest while the nose remains relatively clear. Exactly how this looks will vary according to the individual baby’s mouth, the caregiver’s anatomy and the feeding position. What matters is not whether the latch looks identical to a textbook image, but whether the baby is feeding effectively and comfortably. A latch can look unusual and still function very well. Equally, a latch can look close to the expected picture and still be painful or ineffective. Appearance provides information, but function provides the context. What should a comfortable and effective latch feel like? A comfortable latch generally feels different from a pinching, rubbing or biting sensation. Breastfeeding can feel unfamiliar, particularly during the early days, and some caregivers may experience brief tenderness, but persistent sharp or pinching pain should not simply be accepted as something that has to be endured. After a feed, the nipple should not routinely be severely compressed, creased or misshapen. You may see the baby’s jaw moving as they feed, with periods of quicker sucking followed by deeper, slower sucking and pauses. Swallowing may be visible or audible, although it is not always easy to recognise. The baby may come off the breast or chest looking relaxed and satisfied, but behaviour alone cannot tell us whether milk transfer has been adequate. Feeding frequency, urine and stool output, weight gain and the baby’s general wellbeing all form part of the wider picture. Milk transfer cannot be judged by latch appearance alone. A baby may feed frequently for many different reasons, and frequent feeding does not automatically mean that there is not enough milk. Equally, a baby appearing settled after a feed does not, by itself, confirm effective milk transfer. If breastfeeding hurts, try again If the latch feels pinchy or shallow, gently breaking the suction and trying again can be more helpful than continuing through pain. Place a clean finger into the corner of the baby’s mouth to release the suction, then allow both of you to reset before offering the breast or chest again. A reset is not a setback. It gives the baby another opportunity to practise and gives the caregiver another opportunity to adjust the baby’s position and attachment. Sometimes a small change is enough, such as bringing the baby’s body closer, allowing the head to tip back, waiting for a wider gape or changing the angle at which the baby approaches. If pain continues despite adjustments, or if the baby repeatedly slips towards the nipple or cannot maintain the attachment, it is worth looking beyond positioning alone. Persistent nipple pain, cracking, bleeding or repeated nipple compression deserves attention rather than simply being accepted as part of breastfeeding. Protecting your milk supply Effective and frequent milk removal is an important part of establishing and maintaining milk supply. Milk production is regulated by the process of milk removal and the physiological signals associated with demand. If milk is consistently removed less effectively, this can reduce the stimulation to produce milk. However, concerns about milk supply should not automatically be attributed to latch. Supply can be influenced by many factors, including feeding frequency, infant milk transfer, breast or chest physiology, previous breastfeeding experiences, supplementation, expressing or pumping, medications and caregiver health. This is why protecting milk supply is not about making every feed look perfect. It is about understanding what is happening and ensuring that milk is being removed appropriately for the family’s feeding goals. If milk transfer is a concern, a feeding assessment can help determine whether the issue relates to attachment, the baby’s ability to transfer milk, milk flow, feeding frequency or another factor. When latch difficulties need a wider assessment Sometimes changing positioning solves a breastfeeding problem. Sometimes it does not. If difficulties persist, it is important to consider the whole feeding picture rather than repeatedly changing the position of the baby and hoping that something eventually works. A baby’s gestation, birth experience, health, jaundice, nasal congestion, tone, oral function, neurological development and previous feeding experiences may all influence feeding. Breast or chest fullness, nipple anatomy, milk flow and the caregiver’s physical comfort can also affect the experience. Emotional wellbeing matters too. When every feed has become an anxious negotiation, families may need more than another instruction to “get a deeper latch”. They may need someone to observe what is actually happening, listen to their experience and consider the possible contributing factors with them. A single symptom should therefore not automatically lead to a single diagnosis. Clicking, pain, frequent feeding, slipping from the breast, unsettled behaviour or concerns about milk supply are all useful pieces of information, but none should be interpreted in isolation. What about tongue-tie? A lingual frenulum is an anatomical structure. Its presence does not automatically mean that a baby has a functional feeding problem or requires treatment. Tongue-tie may be one consideration when feeding difficulties persist, but it should not be used as a catch-all explanation for pain, poor attachment, clicking, frequent feeding or concerns about milk transfer. Many babies with a visible lingual frenulum feed effectively, while babies with feeding difficulties may have other contributing factors. Assessment should consider tongue movement and oral function in the context of feeding, alongside the infant’s history, development, weight and clinical wellbeing. Anatomy provides information. Function provides context. Where tongue-tie is considered clinically relevant, decisions about frenotomy should be based on the individual infant and feeding circumstances rather than the appearance of the frenulum alone. Evidence from randomised trials remains limited, although frenotomy may provide short-term relief of maternal nipple pain in some circumstances (O’Shea et al., 2017). Breastfeeding support should include bottle feeding too Infant feeding support should not stop at the breast or chest. Some families exclusively breastfeed, while others combination feed, express milk, use donor milk or formula, or bottle feed their baby. Feeding plans can also change over time as the needs of the baby and family change. Bottle feeding is a skill too. A baby may have difficulty maintaining a seal around the teat, coordinating sucking, swallowing and breathing, managing milk flow or remaining regulated throughout a feed. Signs such as clicking, dribbling, repeated loss of the teat, coughing, spluttering, prolonged feeds or distress may provide useful information, but none of these signs alone identifies a particular cause. Responsive bottle feeding can help caregivers follow the baby’s cues. Holding the baby close and semi-upright, allowing pauses and avoiding pressure to finish a feed can help the baby have greater control over the pace and volume of the feed. Skilled infant-feeding support should therefore reflect the feeding method a family is actually using rather than assuming that every family is exclusively breastfeeding. When should you seek skilled breastfeeding support? You do not need to wait until feeding has become unbearable before asking for help. Skilled support may be useful if breastfeeding remains painful, nipples are cracked or bleeding, the nipple is repeatedly misshapen after feeds, the baby repeatedly slips off the breast or cannot maintain attachment, feeds are consistently very long or exhausting, or there are concerns about milk transfer, milk supply or weight gain. Support can also be valuable for families who are combination feeding, expressing or pumping, introducing bottles or managing a change in their feeding plan. If you have concerns about your baby’s oral function, or feeding has become stressful and is affecting your wellbeing, a detailed assessment can help identify what support may be appropriate. If a baby is difficult to wake for feeds, has signs of dehydration, is becoming increasingly lethargic, has significant jaundice or there are concerns about inadequate intake or weight gain, prompt assessment by an appropriate healthcare professional is important. Early, individualised breastfeeding support is recommended by the World Health Organization and NICE, particularly when pain, milk-transfer concerns or feeding difficulties are present. Evidence suggests that breastfeeding support can improve breastfeeding outcomes, particularly when support is appropriately targeted and tailored to the needs of the individual family (McFadden et al., 2017; World Health Organization, 2018). The value of skilled breastfeeding and infant-feeding support An International Board Certified Lactation Consultant (IBCLC) is a specialist in lactation and infant feeding who has met the education, clinical experience and examination requirements established by the International Board of Lactation Consultant Examiners. The IBCLC Commission describes the IBCLC credential as the “gold standard in lactation care”. Maintaining the credential requires ongoing professional development and recertification, supporting continuing competence as evidence, professional standards and infant-feeding practice develop (IBCLC Commission, 2026). Skilled IBCLC support extends well beyond demonstrating a particular latch technique. An IBCLC can take a detailed feeding history, observe a feed, consider infant and caregiver factors, assess breastfeeding and milk transfer, discuss milk supply, support expressing and pumping, and help families who are breastfeeding, combination feeding or bottle feeding. A skilled practitioner should also recognise the limits of their own scope of practice and identify when medical, paediatric, speech and language therapy, dietetic, dental, oral-motor or other specialist assessment may be appropriate. Good infant-feeding care is not about finding one explanation for every difficulty; it is about assessing the individual feeding situation and knowing when further expertise is needed. Professional certification is not the end of learning. IBCLCs are required to maintain their credential through continuing professional development and recertification requirements. This provides a framework for maintaining professional competence throughout practice (IBCLC Commission, 2026). For families, this matters because infant feeding is not static. A newborn’s needs can change rapidly, and prematurity, illness, growth, developmental changes, changes in milk supply, returning to work, introducing bottles, expressing or changing feeding goals can all alter the support that is needed. The most useful support is therefore individualised, evidence-informed and responsive to the family rather than based on a single snapshot of feeding. There is no single way to breastfeed The goal is not to make every baby look the same while feeding. It is to help each baby and caregiver find a way of feeding that is comfortable, effective and sustainable for them. Sometimes that means a small positioning adjustment. Sometimes it means calming a baby before trying again. Sometimes it means changing the way the baby approaches the breast or chest and allowing an asymmetrical attachment. Sometimes persistent difficulties require a much broader assessment. And sometimes the most helpful thing a family can hear is that they are learning together. Missing the latch on the first attempt does not mean that either the baby or caregiver is doing anything wrong. Breastfeeding is a skill that develops through repeated opportunities, observation and adjustment. The most useful question is not simply whether a latch looks right. It is whether the baby is feeding effectively and comfortably, whether milk transfer and supply are being supported, and whether the approach is sustainable for the person feeding them. That is where calm, skilled and individualised breastfeeding and infant-feeding support can make a real difference. References Colson, S., Meek, J. and Hawdon, J. (2008) ‘Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding’, Early Human Development, 84(7), pp. 441–449. doi: 10.1016/j.earlhumdev.2007.12.003. IBCLC Commission (2026) Start your IBCLC journey. Available at: https://ibclc-commission.org/how-to-become-an-ibclc/ (Accessed: 31 August 2026). IBCLC Commission (2026) Step 1: Prepare for IBCLC recertification. Available at: https://ibclc-commission.org/how-to-become-an-ibclc/step-1-prepare-for-ibclc-recertification/ (Accessed: 31 August 2026). McFadden, A., Gavine, A., Renfrew, M.J., Wade, A., Buchanan, P., Taylor, J.L., Veitch, E., Rennie, A.M., Crowther, S.A., Neiman, S. and MacGillivray, S. (2017) ‘Support for healthy breastfeeding mothers with healthy term babies’, Cochrane Database of Systematic Reviews, 2, CD001141. doi: 10.1002/14651858.CD001141.pub5. 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: 31 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. World Health Organization (2018) Guideline: counselling of women to improve breastfeeding practices. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789241550468 (Accessed: 31 August 2026).

A baby who sleeps with their mouth open, makes a clicking sound while feeding, or seems unable to maintain a latch can prompt understandable questions about infant resting tongue posture. Families may be told that the tongue should sit in one particular place at all times, or that a low tongue automatically indicates a tongue-tie. Neither is quite that simple. An infant's oral posture is variable and changes with feeding, breathing, sleep, alertness, positioning and development. A single observation rarely explains a feeding experience. For clinicians, resting tongue posture can be one small piece of functional information. For families, noticing patterns can be useful, particularly when they occur alongside feeding concerns. It is not, however, a diagnostic test for tongue-tie, nor does it predict whether a baby will need treatment. What do we mean by infant resting tongue posture? Resting tongue posture describes where the tongue appears to sit when an infant is calm and not actively feeding or crying. Depending on the baby's state, the tongue may be visible at the lips, lie forward in the mouth, rest lower in the oral cavity, or have more contact with the palate. Infants are not small adults. Their airway anatomy, suck-swallow-breathe coordination, arousal state and feeding patterns are developing rapidly, particularly during the early weeks and months. A photograph, a brief look during a consultation, or an observation while a baby is unsettled may therefore provide limited information. Tongue posture may change after a feed, during light sleep, with nasal congestion, after crying, when the baby is tired, or simply as their head and body position changes. There is no well-established evidence-based ‘ideal’ resting position that can be used alone to diagnose restricted tongue function. Statements that every infant should permanently hold the whole tongue against the palate go beyond the available evidence. The more helpful question is not simply, ‘Where is the tongue at this moment?’ but, ‘How does this baby use their tongue, jaw, lips and breathing pattern during feeding and at rest?’ Why is resting tongue posture important? Although the tongue is most noticeable when it is moving, it spends much of its time at rest. Its relationship with the palate, lips, cheeks and jaw therefore forms part of the wider oral environment. The tongue is not an isolated structure. It works as part of a coordinated muscular system, and its position can influence how space is occupied within the mouth and how forces are distributed around the developing oral structures. At the same time, the tongue's resting position can itself be influenced by the shape of the palate, nasal breathing, muscle tone, oral habits, tongue mobility and other anatomical or functional factors. This makes resting posture relevant, but not in the sense of there being one perfect position that every infant must maintain. A baby who has a comfortable resting posture, effective nasal breathing and efficient feeding may have no reason for intervention simply because their tongue does not resemble an image seen online. Conversely, a persistent low or forward tongue posture may be worth exploring when it occurs alongside other functional findings. The important distinction is between observing a posture and understanding what has contributed to it. The tongue and the developing palate The relationship between the tongue and palate begins very early in development. During the early embryonic period, the tongue occupies the developing oral cavity and forms part of the mechanical and functional environment in which the palate develops. The timing described in clinical and embryological teaching varies, with the tongue-palate relationship developing during the early weeks of gestation, commonly described within approximately weeks 4–8. As the baby develops, the tongue continues to provide an important muscular and mechanical influence on the developing palate and maxilla. Normal tongue elevation and contact with the palate are therefore relevant to the developing oral environment. Where a restrictive lingual frenulum genuinely limits tongue elevation, the tongue may be unable to achieve the same contact with the developing palate. This can contribute to altered palatal development, including a higher or narrower palatal shape in some infants. A tongue-tie can therefore be one contributing factor to a high or narrow palate. It is not, however, the only possible cause. Palatal shape is influenced by multiple factors, including genetics, craniofacial development, airway and breathing patterns, muscle function, oral habits and individual anatomical variation. The relationship is therefore not as simple as saying that every high palate is caused by tongue-tie. How can restricted tongue function affect the developing mouth? The tongue plays an important role in feeding and in the developing orofacial system. When tongue elevation is restricted, an infant may compensate by recruiting other structures to achieve the movements required for feeding. Compensatory patterns can include increased jaw movement, altered mandibular positioning, increased activity of the mentalis and other perioral muscles, changes in lip behaviour and wider muscular tension patterns. These adaptations do not occur in every infant with a tongue-tie, and their significance depends on the degree of restriction and how the individual infant compensates. However, if the tongue is unable to elevate and contact the palate effectively, the normal tongue-to-palate stimulus involved in the developing oral environment may also be altered. This is one reason why assessing tongue function is about more than looking at the frenulum. The question is not simply whether a frenulum is visible, but whether it is restricting function and whether the infant is compensating for that restriction. What are the potential consequences of a persistent low tongue posture? A low tongue posture is not automatically a problem. An infant may temporarily adopt a lower tongue position depending on their state, breathing, positioning or developmental stage. The concern is more about persistent patterns, particularly when a low tongue posture occurs alongside other findings. Research has identified associations between altered or low resting tongue posture and dental, occlusal and speech-related outcomes, although much of this evidence comes from older children and adults rather than infants. A 2026 systematic review found associations between lingual resting posture and anterior open bite, crossbite and articulation errors, while also highlighting limitations in the available evidence and a lack of standardised assessment methods. Research in older children has also identified relationships between mouth breathing, altered tongue posture and craniofacial development. These findings should not be transferred directly to infants as though the same outcomes have been proven in babies. Infant craniofacial development is dynamic, and there is currently much less research specifically examining the long-term consequences of infant resting tongue posture. Nevertheless, a persistently low tongue posture may be associated with: reduced tongue-to-palate contact an open-mouth resting posture altered oral containment changes in swallowing patterns difficulty maintaining an effective oral seal compensatory activity of the lips, jaw and perioral muscles changes in the balance of muscular forces around the developing teeth and jaws altered palatal or dental development over time These associations do not mean that a low tongue posture causes all of these outcomes, nor that every infant with a low tongue posture will develop them. For example, an infant who cannot breathe comfortably through their nose may naturally adopt an open-mouth posture and lower their tongue to facilitate airflow. In this situation, the low tongue posture may be an adaptation to an underlying airway problem. This is why it is important to ask why the tongue is resting low rather than simply trying to force it upwards. Resting tongue posture and breathing Tongue posture and breathing are closely connected. When nasal breathing is comfortable, the lips can remain gently closed and the tongue can occupy the oral cavity without needing to move forward to facilitate airflow. When nasal breathing is compromised, an infant may adopt an open-mouth posture and the tongue may sit lower within the mouth. Nasal congestion, enlarged adenoids or tonsils, allergies and other upper-airway factors can affect breathing. Persistent mouth breathing therefore deserves assessment rather than being attributed automatically to tongue posture or tongue-tie. If your baby is struggling to breathe, this is an emergency. Call 999 or seek emergency medical care immediately. Do not wait for a GP appointment, feeding assessment or tongue-tie assessment, and do not assume that breathing difficulty is caused by tongue posture or tongue-tie. For persistent mouth breathing, noisy breathing or concerns about the upper airway when your baby is otherwise well, discuss this with your GP, health visitor or paediatric team. Resting posture is not the same as tongue function A tongue can appear to rest in an apparently favourable position and still have functional difficulties. Equally, an infant may demonstrate a tongue posture that does not conform to an idealised picture but feed effectively and demonstrate appropriate oral function. The two should therefore not be confused. Tongue function includes the ability to move, elevate, lateralise and coordinate appropriately for the individual's developmental stage. During feeding, the tongue works with the jaw, lips, cheeks and palate to help create an effective feeding pattern. Studies using ultrasound have demonstrated the dynamic nature of infant feeding, including tongue movement and intra-oral vacuum during breastfeeding (Geddes et al., 2008). A resting observation therefore tells us something different from observing the tongue during feeding. Both may be useful, but neither should be interpreted in isolation. What else can influence resting tongue posture? Resting tongue posture can be influenced by many factors, including: nasal airway patency nasal congestion feeding method prematurity and developmental stage muscle tone neurological development head and body positioning oral habits tongue mobility palatal shape jaw position lip competence swallowing pattern sensory factors fatigue and arousal state Feeding itself can also influence what is observed. During breastfeeding, breast fullness, milk flow, positioning and the baby's ability to maintain an effective seal can all affect oral behaviour. During bottle feeding, teat flow, teat fit, bottle angle and pacing can influence the coordination of sucking, swallowing and breathing. A clicking sound, milk leakage or difficulty maintaining a seal may therefore have several possible explanations. What can a practitioner do to help? If an assessment identifies a functional issue, your chosen practitioner may offer exercises or activities that are appropriate for your baby's age and individual presentation. These may be designed to support tongue movement, tongue elevation, oral coordination, lip closure, tongue-to-palate contact or wider postural control. Exercises should not be prescribed simply because a tongue appears low at rest. The reason for the posture needs to be considered first. For some infants, appropriate support may involve feeding positioning, pacing, addressing bottle flow, supporting nasal breathing or working on wider oral and postural function rather than focusing specifically on tongue posture. Where tongue restriction is contributing to functional difficulties, exercises may form part of a wider programme of support before or after specialist assessment. Functional exercises should also be distinguished from postoperative wound-stretching. These are not the same thing, and families should follow the specific postoperative advice provided by the clinician undertaking any procedure. There is currently limited high-quality evidence for many specific infant oral exercises, so they should be individualised and used as part of an overall functional assessment rather than presented as a guaranteed way to change the palate or facial structure. What does this have to do with tongue-tie? A lingual frenulum is normal anatomy. In some infants, its characteristics may be associated with restricted tongue movement and feeding difficulties. This is commonly described as symptomatic ankyloglossia or tongue-tie. However, the appearance of a frenulum does not establish functional restriction, and not every visible frenulum causes problems (Messner et al., 2020; Academy of Breastfeeding Medicine, 2021). The same applies to resting tongue posture. A low tongue position is not proof of a tongue-tie, and a tongue that appears elevated does not rule one out. If tongue-tie is suspected, assessment by a practitioner with specific experience in functional infant oral assessment is preferable. An IBCLC can assess feeding function whether a baby is breastfed, bottle-fed or combination-fed, and an IBCLC with specific experience in tongue-tie and infant oral function can bring feeding assessment together with consideration of oral anatomy. When should you seek support? If feeding is painful or persistently difficult, your baby seems unable to maintain an effective latch or seal, there is frequent milk leakage, clicking is persistent, feeds are unusually long or frequent, or you have concerns about milk transfer, hydration or weight gain, it is reasonable to seek professional support. An IBCLC can support families whether their baby feeds at the breast, from a bottle, or through a combination of feeding methods. They can assess feeding as a whole and help identify whether further assessment is appropriate. If tongue-tie is suspected, choosing an IBCLC who also has specific experience in functional infant oral assessment and tongue-tie can be particularly helpful. Where a medical or surgical opinion is required, appropriate referral should form part of the care pathway. For persistent mouth breathing, noisy breathing or other concerns about the airway in an otherwise well baby, speak with your GP, health visitor or paediatric team. If your baby is struggling to breathe, however, this is not a routine GP or tongue-tie referral. Call 999 or seek emergency medical care immediately. How does breastfeeding relate to facial and palatal development? Breastfeeding is a dynamic oral activity requiring coordinated movement of the tongue, jaw, lips and facial muscles. Unlike a passive activity, effective breastfeeding provides repeated neuromuscular and mechanical stimulation to the developing orofacial structures. Research has found associations between breastfeeding and aspects of dental and occlusal development, including lower rates of some malocclusions. This supports the concept that feeding method can form part of the wider functional environment influencing craniofacial development. It is important, however, not to suggest that breastfeeding alone determines facial growth or guarantees a particular palatal shape. Genetics, airway, anatomy, muscle function and many other factors contribute to craniofacial development. Where tongue restriction interferes with the normal mechanics of breastfeeding, the infant may be unable to use the tongue, jaw and perioral musculature in the same way as an infant without functional restriction. This is another reason why feeding difficulties should be assessed functionally rather than assuming that the appearance of a frenulum tells us everything we need to know. Can frenulotomy change a high palate? A frenulotomy releases a restrictive lingual frenulum. It can improve tongue mobility where the frenulum is genuinely restricting movement, and evidence supports its use in appropriately selected infants with symptomatic ankyloglossia. Research has demonstrated benefits particularly in reducing maternal nipple pain, and systematic-review evidence has also reported improvements in measures of breastfeeding effectiveness. However, the degree of improvement varies between individuals and between outcomes. A frenulotomy is not guaranteed to alter the shape, width or height of an established palate. This distinction is important. If restricted tongue function has contributed to altered palatal development, releasing the restriction does not mechanically reshape the palate. The procedure removes the restriction and creates the potential for improved tongue movement and function. What happens developmentally afterwards will depend on the individual infant and the many factors influencing craniofacial growth. The earlier a functional restriction is identified does not mean that a particular palatal outcome can be guaranteed. Nor does it mean that every infant with a high palate requires frenulotomy. The decision to undertake a frenulotomy should be based on evidence of functional restriction and relevant symptoms, rather than on the appearance of a frenulum, a high palate or a low resting tongue posture alone. How is a decision about frenulotomy made? The Academy of Breastfeeding Medicine advises that no single assessment tool should be used as the sole basis for deciding whether a frenulotomy is indicated. A comprehensive assessment should consider the infant's history, the feeding experience, oral function, anatomy and direct observation of feeding where appropriate (Academy of Breastfeeding Medicine, 2021). This approach recognises that feeding difficulties can have multiple causes. For some families, skilled feeding support may resolve the difficulty without a procedure. For others, where there is clear functional restriction associated with persistent feeding difficulties, frenulotomy may be an appropriate option. Families should receive clear information about why the procedure is being considered, what benefits may reasonably be expected, its limitations and potential risks, and what support is available afterwards. A frenulotomy can release a restriction. It cannot guarantee a particular feeding outcome, tongue posture, palatal shape or facial development. What can families observe at home? If you are concerned about your baby's mouth or tongue, try to notice patterns rather than repeatedly checking their tongue position. You might make a brief note of when feeding feels easier or harder, whether there is pain or leakage, how long feeds usually take, whether your baby frequently loses their seal, and any concerns raised during routine weight checks. A short video of a typical feed can sometimes help a clinician understand the concern, provided you feel comfortable sharing it securely. Try not to compare your baby's mouth with images online. Still photographs rarely show feeding function and cannot account for your baby's age, developmental stage, feeding method, health or individual anatomy. Your observations matter, but they are most useful when explored alongside a full assessment. Looking at the whole picture Resting tongue posture can provide useful information, but it is only one part of infant oral function. A low tongue posture does not automatically mean something is wrong. A high palate does not automatically mean a tongue-tie is present. An open mouth does not prove that the tongue is restricted, and a clicking sound does not have a single cause. At the same time, persistent low tongue posture, restricted tongue elevation or altered tongue-to-palate contact can be clinically relevant, particularly when they occur alongside feeding difficulties, compensatory muscular patterns, altered breathing or other functional findings. The important question is therefore not simply where the tongue is resting. It is why it is resting there, what the tongue can do, how the baby is feeding and breathing, and whether the pattern is affecting function or development. A thoughtful assessment brings these observations together rather than focusing on one anatomical feature. For families, the goal is not to achieve a picture-perfect tongue position. The goal is safe, effective and comfortable function for that individual baby, while supporting healthy development. Anatomy provides information. Function provides context. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. Geddes, D.T., Kent, J.C., Mitoulas, L.R. and Hartmann, P.E. (2008) ‘Tongue movement and intra-oral vacuum in breastfeeding infants’, Early Human Development, 84(7), pp. 471–477. McFarland, C.J., Hashemi Hosseinabad, H. and Schafer, E.C. (2026) ‘Still Tongue, Silent Cues: A Systematic Review of Lingual Resting Posture’, Communication Disorders Quarterly. First published online 3 March 2026. doi: 10.1177/15257401261425962. Messner, A.H., Walsh, J., Rosenfeld, R.M. et al. (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. et al. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. Thomas, J., Bunik, M., Holmes, A. et al. (2024) ‘Identification and management of ankyloglossia and its effect on breastfeeding in infants: Clinical report’, Pediatrics, 154(2), e2024067605. Peres, K.G., Cascaes, A.M., Leão, A.T. et al. (2015) ‘Exclusive breastfeeding and risk of dental malocclusion’, Acta Paediatrica, 104(8), pp. e393–e398.

Nipple pain is not something you simply have to put up with when breastfeeding. While some tenderness can occur during the early days, breastfeeding should not remain painful, and persistent or worsening pain is a sign that something needs looking at. If your nipples hurt at every feed, or they are cracking or bleeding, it is important to seek help early rather than waiting for the problem to become more severe (NHS, 2026). Nipple trauma can range from soreness and irritation through to cracks, bleeding, blisters and open wounds. One of the most common causes is ineffective positioning or attachment, which can result in the nipple being compressed during feeding (NHS, 2026). Sometimes the cause is relatively simple and a small adjustment can make a significant difference. At other times, there may be several factors contributing to the problem, including infant oral function, pumping, skin conditions, vasospasm or infection (Berens et al., 2016). The important thing is to identify what is causing the trauma rather than simply trying to manage the pain. Why an IBCLC can be helpful An International Board Certified Lactation Consultant (IBCLC) is a specialist in breastfeeding, lactation and infant feeding. Their role involves assessing the feeding process as a whole, rather than simply looking at the nipple in isolation. An IBCLC can assess how your baby is attaching and feeding, how milk is being transferred, your baby's oral function, your pumping technique and flange fit where relevant, as well as factors affecting your breasts, nipples and milk supply. Persistent nipple pain is recognised as something that requires assessment of both maternal and infant factors, including feeding dynamics and possible causes of nipple trauma (Berens et al., 2016). An IBCLC can also consider the wound itself and suggest supportive measures that may help create the right environment for healing. There are a range of non-prescription wound-care options available, and a lactation specialist may be aware of approaches that a parent, or a healthcare professional who does not routinely work in lactation and nipple trauma, may not have considered. The choice of approach should be based on the condition of the nipple, the nature of the wound, the suspected cause and the individual feeding circumstances. The aim is not simply to find something to put on the nipple, but to support healing while also addressing whatever is causing the trauma. Treat the wound, but don't forget to treat the reason the wound happened. Creating the right environment for healing Nipple wounds, like other wounds, need the right environment to heal. Wound-healing principles support maintaining an appropriately moist environment for epithelialisation, but appropriately moist does not mean constantly wet. There is an important difference between supporting a wound with enough moisture to prevent it from drying out and allowing the skin to remain saturated. Excessive moisture can soften the skin and contribute to maceration, leaving damaged tissue more vulnerable to further irritation. This is particularly relevant when nipples are already cracked or injured. Anything that creates prolonged friction, pressure or excessive moisture needs to be considered as part of the overall picture. Gentle nipple care is therefore important. Avoid unnecessary washing of the nipples, particularly with harsh soaps or products that can strip the natural protective barrier of the skin. If breast pads become damp, changing them regularly can help prevent prolonged exposure to moisture. Reducing friction against clothing and allowing the nipple to remain comfortable between feeds can also help. The goal is not to keep the nipple completely dry at all costs, but to create an environment in which damaged tissue can heal without being repeatedly irritated or traumatised. Silver Nipple Cups and Shells Silver nipple cups have become increasingly popular as a way of protecting sore or damaged nipples between feeds. The use of silver in wound care has generated interest, and some research has reported improvements in nipple trauma with silver nipple protectors. However, the evidence remains limited and does not establish silver nipple cups as a superior or guaranteed treatment for nipple wounds. The evidence base for silver products is still developing, and stronger comparative research is needed before firm conclusions can be drawn about their effectiveness. There is also an important practical consideration: the environment created underneath a silver cup matters. Because a cup sits over the nipple, moisture can become trapped. If the nipple remains wet for prolonged periods, the skin can become macerated rather than supported in healing. This does not mean that silver cups are inappropriate for everyone, but prolonged moisture needs to be considered when a nipple wound is failing to heal. Silver cups and shells may also collect milk. For someone who is already producing more milk than their baby needs, repeatedly collecting milk or providing additional breast stimulation may be relevant when considering the wider feeding picture. This does not mean that silver cups cause oversupply, but it is something worth considering if oversupply is already an issue. The quality and composition of silver products can also vary. The fact that a product contains silver does not, by itself, guarantee that it will provide a particular clinical benefit. If you are using silver cups and they are comfortable and your nipples are healing, there is no reason to assume that you are doing something wrong. However, if healing is not progressing, it is worth looking at the whole situation rather than simply adding another product. The NHS currently advises that silver nipple cups can be used between feeds when nipples are cracked, while also noting that breast shells can affect attachment (NHS, 2026). What about lanolin? Lanolin is one of the products parents are most commonly asked about when they have sore or damaged nipples. It is derived from sheep's wool and is widely used as an emollient in moisturising and skin-care products. Highly purified lanolin is generally well tolerated by people who are not allergic or sensitive to it. It has been used extensively in breastfeeding care, and many breastfeeding parents use it without problems. However, lanolin can cause irritant or allergic contact dermatitis in some people. Wool alcohols are recognised sensitising substances, and reactions can cause symptoms such as itching, burning, redness, swelling, scaling or increasing soreness. A reaction can therefore make an already damaged nipple feel worse or appear not to be healing. This does not mean that everyone using lanolin will develop a reaction. If you are already using lanolin, it feels comfortable, and your nipples are healing, there is no need to panic or assume that the product is harming you. There is also limited evidence that lanolin is particularly effective at reducing nipple pain compared with other approaches. In a randomised controlled trial involving 186 breastfeeding women with nipple pain or damage, lanolin did not significantly reduce pain compared with usual postpartum care, although both groups experienced clinically relevant improvement over time (Jackson & Dennis, 2017). A 2026 systematic review and meta-analysis of randomised trials also found no clear advantage of lanolin over expressed breast milk for reducing nipple cracks or pain, with the certainty of the evidence remaining low (Barja-Ore et al., 2026). The important question is therefore not whether lanolin is universally "good" or "bad", but whether it is appropriate for your individual skin and circumstances. If your nipples become increasingly itchy, burning, red, swollen, flaky or sore after using a product, stop and seek professional advice rather than assuming that you simply need to apply more. When the nipple changes shape after a feed The appearance of your nipple immediately after a feed can provide useful information about what is happening during feeding. A nipple that comes out of your baby's mouth flattened, wedged, compressed or unusually pale or white may indicate that it has been compressed during the feed. When attachment is ineffective, the nipple can be held towards the front of the baby's mouth and compressed against the hard palate, causing pain and potentially contributing to nipple damage (NHS, 2026). A small adjustment to positioning or attachment can sometimes make a significant difference. This is one reason why having a feeding assessment can be much more useful than simply being told to apply a cream. The shape of the nipple is not, however, a diagnosis by itself. It needs to be considered alongside the baby's oral movements, attachment, sucking pattern, milk transfer and the parent's symptoms. Nipple blanching, vasospasm and colour changes Not all nipple pain is caused by a wound. Some breastfeeding parents experience vasospasm, where the blood vessels in the nipple constrict. This can cause the nipple to become white or blanched, sometimes followed by a change to purple or red as blood flow returns. The pain may be sharp, burning or shooting and can occur during or after a feed. Cold temperatures can also trigger or worsen symptoms (Berens et al., 2016). Vasospasm can occur alongside nipple trauma, particularly when the nipple has already been subjected to compression. This means that simply treating the visible crack or wound may not resolve the underlying pain if there is another contributing factor. Persistent nipple pain therefore deserves proper assessment rather than automatically being attributed to "just breastfeeding". Could tongue-tie be contributing? Tongue-tie is often discussed when a breastfeeding parent is experiencing nipple pain, but the presence of a frenulum does not, by itself, mean that tongue-tie is causing a feeding problem. A frenulum is normal anatomy. The important question is what effect, if any, it is having on tongue function and feeding. Some infants with restricted tongue function may have difficulty achieving or maintaining an effective attachment, which can contribute to nipple compression and pain. The NHS recognises tongue-tie as one possible factor contributing to difficulty attaching and sore or cracked nipples (NHS, 2026). This is why assessment should consider function rather than simply the appearance of the frenulum. Anatomy provides information. Function provides context. If a frenulotomy is undertaken, the procedure itself is not necessarily the end of the feeding assessment. The tongue is a muscular hydrostat made up of eight paired muscles: four intrinsic and four extrinsic muscles. These muscles work together to create the complex movements required for tongue function. Following release, there may still be issues relating to movement, strength, tone, coordination or compensatory patterns that need to be considered. Addressing residual tensions and helping the tongue develop appropriate strength, tone and coordinated movement can therefore be an important part of supporting functional feeding. If an underlying mechanical or functional factor continues to contribute to nipple compression or poor attachment, simply waiting for the wound to heal may not solve the problem. The nipple can continue to be traumatised with every feed, making healing slower and potentially prolonging pain. This is why treating the wound and treating the reason for the wound need to happen together. Pain after the cause has been corrected Even when the underlying cause of nipple trauma has been identified and corrected, pain may not disappear immediately. Damaged tissue needs time to repair. A nipple that has been cracked, grazed or bleeding may remain tender while the wound heals, even if feeding mechanics have already improved. The important distinction is between pain from healing tissue and ongoing trauma. If each feed continues to cause fresh damage, the nipple repeatedly cracks or bleeds, the wound is getting larger, or pain is becoming progressively worse, the original cause may not have been fully addressed. You should not feel that you simply have to endure severe pain while waiting for your nipples to heal. Persistent nipple pain is recognised as a clinical problem requiring assessment of potential underlying causes rather than simply continued tolerance of the symptoms (Berens et al., 2016). Keeping your milk supply going while your nipples heal When nipples are extremely painful, it can be tempting to stop breastfeeding completely. Sometimes a temporary change in how milk is removed can be helpful while the nipple begins to heal, particularly if direct feeding is causing significant trauma. Hand expression can provide a gentle alternative for some people and may be easier on a damaged nipple than repeated feeding or pumping. However, completely stopping milk removal without a plan can reduce milk production because milk supply is closely linked to milk removal. The NHS therefore recommends continuing to breastfeed where possible or expressing milk by hand if feeding is too painful, while seeking help to address the underlying cause (NHS, 2026). The aim is to find a way of maintaining milk removal while reducing further trauma. The best approach will depend on your circumstances, your baby's age and feeding needs, your milk supply and the severity of the nipple injury. A temporary adjustment does not mean that you have failed at breastfeeding, nor does it mean that you have to stop breastfeeding permanently. When a wound may need medical assessment Not every cracked nipple is infected, and not every persistent nipple problem is caused by infection. However, damaged skin can provide an opportunity for infection to develop, and infection is one of the possible causes of persistent nipple and breast pain (Berens et al., 2016). Seek medical assessment if you develop increasing redness, warmth or swelling, discharge or pus, significant deterioration in the wound, or systemic symptoms such as fever or feeling generally unwell. Persistent pain that is not improving also deserves assessment, particularly if the cause is unclear or the wound is failing to heal. Sometimes the answer is not another product. Sometimes the important step is identifying something that has been missed. The most important step is finding the cause There are many products, techniques and pieces of advice available for sore nipples. It can be tempting to keep trying different creams, cups, shells or other approaches in the hope that one of them will finally solve the problem. But nipple trauma is a wound, and a wound that is repeatedly being injured will struggle to heal. If attachment is causing compression, attachment needs to be addressed. If infant oral function is contributing, that needs to be assessed. If pumping or flange fit is causing trauma, that needs attention. If there is a skin condition, vasospasm, infection or another contributing factor, that needs to be considered too (Berens et al., 2016). Healing is not simply about what you put on the nipple. It is about creating the right conditions for healing while removing the reason the injury keeps happening. Treat the wound, but don't forget to treat the reason the wound happened. If you are experiencing nipple pain, cracking or bleeding, you do not have to wait until the problem becomes severe before seeking help. Early assessment can sometimes identify a relatively simple change that prevents a small injury from becoming a persistent problem (NHS, 2026). References Barja-Ore, J., Vargas-Fernández, R., Comandé, D., Santero, M. & Hernández-Vásquez, A. (2026). Efficacy and safety of topical application of breast milk compared with lanolin for reducing nipple cracks and pain in breastfeeding mothers: systematic review and meta-analysis. Breastfeeding Medicine. doi:10.1177/15568253261470292. Berens, P., Eglash, A., Malloy, M. & Steube, A.M. (2016). ABM Clinical Protocol #26: Persistent Pain with Breastfeeding. Breastfeeding Medicine, 11(2), pp.46–53. doi:10.1089/bfm.2016.29002.pjb. Jackson, K.T. & Dennis, C.-L. (2017). Lanolin for the treatment of nipple pain in breastfeeding women: a randomized controlled trial. Maternal & Child Nutrition, 13(3), e12357. doi:10.1111/mcn.12357. National Health Service (NHS). (2026). Sore or cracked nipples when breastfeeding. Reviewed 16 June 2026. National Health Service (NHS). (2026). Breast pain and breastfeeding. Reviewed March 2026.

A feed can look settled from across the room while feeling painful, exhausting or deeply worrying to the person doing it. Lactation support is about helping families understand what is happening with feeding, identify where difficulties may be arising and make informed choices about what feels right for them. It is not limited to breastfeeding, and it is not only something to consider in the first few days after birth. Support may be relevant whether an infant is breastfeeding or chestfeeding, receiving expressed milk, bottle feeding, combination feeding, or moving between different feeding methods. What is a lactation consultant? The term “lactation consultant” is widely used, but it is important to understand that in the UK it is not a legally protected professional title. This means that the words “lactation consultant” alone do not tell you what qualification, education or clinical experience someone has. Different professionals may provide lactation or infant-feeding support, with very different levels of education, training, experience and scope of practice. This does not mean that one type of support is automatically right for every family. Peer supporters, breastfeeding counsellors, healthcare professionals and lactation consultants can all have valuable roles. However, their qualifications and scope are not interchangeable. For families seeking specialist lactation care, it is therefore worth asking what qualification the person holds rather than relying solely on the job title they use. Understanding the different levels of support There are several different routes through which families may access feeding support. Peer support Peer supporters are often people with their own breastfeeding experience who have undertaken training to provide support within a defined role. Their lived experience can be particularly valuable because they understand many of the practical and emotional challenges that feeding can bring. Personal breastfeeding experience, however, is not the same as professional lactation education or clinical training. Someone who has breastfed for six months, for example, may have valuable personal experience, but that experience alone does not provide the same knowledge, assessment skills or clinical scope as a professional lactation qualification. Peer support is an important part of the wider support network and can work alongside more specialist care when this is needed. Breastfeeding counsellors Breastfeeding counsellors undertake training through individual organisations, and the level and structure of that training can vary. They commonly provide support with everyday breastfeeding challenges, antenatal education, groups and helplines, with more complex situations referred on when appropriate. Healthcare professionals with additional feeding education Midwives, health visitors, nurses, doctors and other healthcare professionals may have additional education and experience in infant feeding alongside their primary professional qualification. Their knowledge can be particularly valuable because they can consider feeding alongside the wider health and wellbeing of the infant and caregiver. However, having a healthcare qualification does not automatically mean that someone has specialist lactation training. IBCLC IBCLC stands for International Board Certified Lactation Consultant. The IBCLC credential is the highest level of internationally recognised professional certification specifically focused on lactation care. Certification is awarded by the International Board of Lactation Consultant Examiners (IBLCE) following defined education, clinical experience and examination requirements. IBCLCs work with families experiencing a wide range of feeding situations and may also work as part of a wider maternal and infant healthcare team, making referrals and collaborating with other professionals when appropriate. The distinction is important: being an IBCLC is not simply another way of saying “lactation consultant”. An IBCLC has demonstrated that they have met the requirements for this specific professional certification. What does it take to become an IBCLC? IBCLC certification has defined eligibility requirements covering health sciences, lactation-specific education and clinical experience. Current IBLCE pathways require candidates to demonstrate substantial lactation-specific clinical experience through one of three routes. Depending on the pathway, this includes 1,000 hours of lactation-specific clinical practice, 300 hours of directly supervised clinical practice through an accredited lactation academic programme, or 500 hours of directly supervised lactation-specific practice through an IBLCE-verified pathway. Candidates also need lactation-specific education, including education in communication skills, and must pass the IBCLC examination. Certification does not end with passing the examination. IBCLCs are required to maintain their professional knowledge and meet ongoing recertification requirements. This is why the letters “IBCLC” provide useful information to families: they identify a specific professional credential rather than simply a job title. When can lactation support be helpful? Lactation support is often associated with the immediate postnatal period, but there is no requirement for difficulties to be severe or for a baby to be very young before seeking help. Support can begin during pregnancy, when a caregiver wants to understand feeding options, prepare for breastfeeding or chestfeeding, learn about expressing, or simply know what to expect. After birth, support may be helpful when: feeding is painful or uncomfortable an infant is struggling to attach or stay attached feeds are very long, very frequent or feel particularly exhausting there are concerns about milk transfer or milk supply an infant appears unsettled during or after feeds expressing or pumping is difficult a caregiver is unsure about flange fit or expressing technique bottle feeding is proving difficult combination feeding is being considered a family is moving between breast, bottle and expressed milk an infant is having difficulty coordinating feeding there are concerns about an infant's oral function, including where tongue-tie may be part of the clinical picture a caregiver is returning to work or planning changes to their feeding routine feeding goals have changed a caregiver wants to reduce or stop breastfeeding or expressing a family simply wants reassurance that feeding is going well. Sometimes the most useful intervention is not changing the feeding method at all. It may simply be understanding what is happening, confirming that feeding is progressing normally and giving a caregiver the confidence to continue. Lactation support is not just about breastfeeding The word “lactation” can sometimes make people assume that support is only relevant to breastfeeding. In reality, infant feeding can take many forms, and families may move between methods over time. A lactation professional may support a caregiver who is: exclusively breastfeeding or chestfeeding expressing milk providing expressed milk by bottle or another method combination feeding formula feeding transitioning from one feeding method to another introducing or increasing bottle feeds returning to breastfeeding after a period of expressing or bottle feeding gradually reducing feeds or stopping altogether. Bottle feeding is therefore not outside the scope of infant-feeding support. Appropriate support may include understanding feeding cues, responsive bottle feeding, pacing, positioning and helping a caregiver feel confident with their chosen feeding method. The aim should not be to make every family feed in the same way. Good support helps families understand their options and make informed decisions that work for their own circumstances. Support can begin in pregnancy and continue for as long as it is wanted There is a common perception that lactation support is something needed only when breastfeeding is first established. In reality, feeding can change considerably over the weeks and months following birth. A caregiver may want support during pregnancy, in the first days after birth, several weeks or months later, when returning to work, when introducing bottles, when increasing or reducing expressing, when combination feeding, or when preparing to stop feeding. There is no single point at which a family is expected to stop needing support. The World Health Organization recommends breastfeeding counselling during pregnancy and after birth, continuing throughout the period of breastfeeding. NICE also recommends feeding support before and after birth and continued discussion of feeding as part of ongoing health contacts. The important thing is that support should remain appropriate to the family's current feeding goals rather than assuming that those goals will remain unchanged. Where can families find infant-feeding support? Specialist lactation care is only one part of the wider infant-feeding support network. Families may also receive support from: midwives health visitors NHS infant-feeding teams maternity and community services trained peer supporters local breastfeeding groups, cafés and drop-ins national breastfeeding helplines breastfeeding counsellors IBCLCs and other appropriately trained infant-feeding professionals. These different forms of support can complement one another. A peer supporter may be exactly what a caregiver needs for reassurance and practical encouragement. A health visitor or midwife may identify a wider health concern. An IBCLC may be appropriate when a feeding situation is complex or requires more specialist lactation assessment. Knowing where each type of support sits within the wider picture helps families access the right level of help without suggesting that one service has to replace another. What does good lactation support look like? Good lactation support should feel supportive rather than judgemental. It should start by listening to what the caregiver wants to achieve rather than assuming that there is one “correct” way to feed an infant. A skilled professional should take time to understand the feeding history, observe what is happening where appropriate, consider the infant and caregiver together, explain their findings clearly and discuss options rather than simply giving instructions. Good support should also recognise when something falls outside the professional's scope and when another healthcare professional or specialist assessment is needed. Most importantly, receiving feeding support should never feel like a test that a caregiver has either passed or failed. Feeding can be complicated. Families may have strong hopes and expectations before their baby arrives and find that their experience is very different afterwards. Feeding plans may change repeatedly as circumstances change. Professional support should help families navigate those changes without judgement. Choosing a lactation professional If you are looking for lactation support, it is reasonable to ask: What qualification do you hold? Are you an IBCLC? What lactation-specific education have you completed? What clinical experience do you have? What types of feeding situations do you support? What falls outside your scope of practice? How do you work alongside other healthcare professionals when needed? What happens if further assessment or support is required? If someone describes themselves as a lactation consultant, remember that the title itself does not tell you their level of training. If you specifically want to see an IBCLC, you can verify whether someone currently holds the credential by checking the IBCLC Registry through IBLCE. The Lactation Consultants of Great Britain also publishes a useful guide, Who's Who in Breastfeeding Support and Lactation in the UK, which explains the differences between IBCLCs, breastfeeding counsellors, peer supporters and other forms of breastfeeding support. The right support is the support that meets your needs There is no shame in asking for help with feeding, whether the difficulty is significant or you simply want reassurance. You do not have to wait until feeding has become overwhelming before seeking support, and you do not have to be experiencing a problem at all. Sometimes support is about preparation. Sometimes it is about solving a specific difficulty. Sometimes it is about understanding your options when your original feeding plan has changed. And sometimes it is simply having someone knowledgeable sit with you, listen to what is happening and help you make sense of it. The most important thing is that families know what type of support is available, understand the qualifications behind the person providing it, and feel able to choose the level of support that is appropriate for them. References International Board of Lactation Consultant Examiners (IBLCE) (2026) About IBLCE. International Board of Lactation Consultant Examiners (IBLCE) (2026) Clinical Experience Requirements and Pathways to the IBCLC. Lactation Consultants of Great Britain (LCGB) (2025) Who's Who in Breastfeeding Support and Lactation in the UK. Lactation Consultants of Great Britain (LCGB) (2025) What is an IBCLC? National Institute for Health and Care Excellence (NICE) (2021) Postnatal care, NG194. National Institute for Health and Care Excellence (NICE) (2025) Postnatal care, NG247. NHS (2025) Breastfeeding and help with breastfeeding. World Health Organization (WHO) (2021) Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. World Health Organization (WHO) (2026) Ensuring competency for providers of breastfeeding support and care: a toolkit.

IBCLC stands for International Board Certified Lactation Consultant. It is an internationally recognised, board-certified professional credential for practitioners specialising in lactation and infant feeding. Becoming an IBCLC requires a defined combination of health-science education, lactation-specific education, substantial clinical experience and successful completion of the IBCLC examination. The credential is maintained through ongoing recertification requirements. An IBCLC can support a feeding dyad from before birth, through the establishment and development of feeding, and for as long as the dyad chooses to seek support. Their expertise encompasses far more than breastfeeding alone and can include breastfeeding or chestfeeding, expressing, bottle feeding, infant formula feeding, combination feeding, relactation, changing feeding methods and weaning. Importantly, IBCLC is a professional credential rather than a primary healthcare profession. IBCLCs come from a range of professional backgrounds, and their scope of practice is determined by their IBCLC scope alongside any other professional registration, qualifications, legislation and local requirements. Understanding what the IBCLC credential represents can help families distinguish between the different types of breastfeeding and infant-feeding support available and choose support appropriate to their needs. What does it take to become an IBCLC? The IBCLC credential is not awarded simply because someone has experience breastfeeding their own children or has attended a short breastfeeding course. There are defined eligibility requirements. Candidates must complete health-sciences education, lactation-specific education and substantial lactation-specific clinical experience before they can sit the examination. The current certification requirements include 95 hours of lactation-specific education, comprising 90 hours of lactation education, including education relating to the WHO Code, together with communication education. Candidates must also meet the clinical-experience requirements of one of the recognised pathways to certification. There are three routes to gaining the required clinical experience: Pathway 1: at least 1,000 hours of lactation-specific clinical practice in an appropriate supervised setting within the required timeframe. Pathway 2: completion of an accredited lactation academic programme, including at least 300 hours of directly supervised lactation-specific clinical practice. Pathway 3: completion of a verified, pre-approved mentorship route, including at least 500 hours of directly supervised lactation-specific clinical practice. Clinical hours must involve providing lactation care; simply observing or shadowing another practitioner does not meet the requirement. Personal breastfeeding experience, or supporting family and friends informally, also does not count as clinical practice. Candidates must then successfully complete the IBCLC examination before being awarded the credential. This means that an IBCLC has undertaken a substantial and structured programme of education, clinical experience and examination specifically related to lactation and infant feeding. Who are IBCLCs? IBCLCs come from different professional and educational backgrounds. Some are nurses, midwives, doctors, dietitians, speech and language therapists or other healthcare professionals. Others enter the profession through recognised lactation-specific routes. What they have in common is the additional education, clinical experience and examination required for the IBCLC credential. An IBCLC may therefore have another professional registration alongside their IBCLC credential. This is important because their additional professional registration may give them a separate scope of practice that is different from their IBCLC scope. For example, an IBCLC who is also a registered nurse may have nursing responsibilities and competencies that another IBCLC does not. Similarly, an IBCLC who is also a doctor, midwife or another regulated professional will have the scope of that profession alongside their lactation expertise. The IBCLC credential itself, however, relates specifically to specialist lactation and infant-feeding knowledge and clinical practice. “Lactation consultant” does not necessarily mean IBCLC Families should also be aware that the term lactation consultant is not, in itself, a legally protected professional title in the UK. This means that someone describing themselves as a lactation consultant is not necessarily an IBCLC. There are many knowledgeable and experienced people providing valuable breastfeeding and infant-feeding support who hold different qualifications. These may include breastfeeding counsellors, peer supporters and practitioners with other lactation or feeding qualifications. The important distinction is that IBCLC identifies a specific internationally recognised, board-certified credential with defined eligibility, examination and recertification requirements. For families, it is therefore reasonable to ask what qualification a person holds, what their clinical background is, and what experience they have with the particular feeding issue they are seeking help with. What can an IBCLC help with? IBCLC care is not limited to breastfeeding. An IBCLC can support families with a wide range of infant-feeding situations, including: preparing for breastfeeding before birth getting feeding established after birth positioning and attachment painful feeding and nipple pain concerns about milk transfer milk supply concerns expressing and breast-pump use flange fitting and pumping technique responsive bottle feeding feeding expressed breast milk infant formula feeding combination feeding transitioning between breast, bottle and other feeding methods relactation feeding after a period of separation changing or reducing breastfeeding weaning and ending breastfeeding This means that seeing an IBCLC does not mean that a family has to be exclusively breastfeeding, or that the aim of support is necessarily to increase breastfeeding. The role of the IBCLC is to provide specialist assessment, information and support around lactation and infant feeding while working with the family's individual circumstances, choices and goals. IBCLC care and medical care An IBCLC is a specialist in lactation and infant feeding. They are not a replacement for a GP, paediatrician or other medical professional. However, this distinction does not mean that an IBCLC should only deal with simple feeding problems. IBCLCs are trained to take a detailed history and undertake comprehensive maternal, infant and feeding assessments within their scope of practice. Through this assessment they may identify signs, symptoms or patterns that warrant further medical assessment. For example, an IBCLC may recognise that a persistent milk-supply concern could warrant investigation of factors such as insufficient glandular tissue, hormonal or endocrine factors, medication effects or other underlying issues. They may recognise symptoms consistent with mastitis or another condition requiring medical assessment. The IBCLC can explain their findings to the family and recommend that they discuss the concern with an appropriate healthcare professional. However, a recommendation from an IBCLC does not oblige a GP or another healthcare professional to undertake a particular investigation or treatment. A GP remains responsible for making their own clinical assessment and decisions within the scope, standards and regulatory requirements of their own profession. This is an important part of multidisciplinary care. The IBCLC contributes specialist lactation and infant-feeding expertise; the GP or other medical professional contributes their own medical expertise and clinical responsibility. The two roles should complement one another rather than one professional being expected to undertake the role of the other. What about tongue-tie? Tongue-tie is a good example of why specialist infant-feeding assessment can be valuable. An IBCLC does not have authority to diagnose tongue-tie simply because they hold the IBCLC credential. The IBCLC scope allows comprehensive maternal, infant and feeding assessment related to lactation, but diagnosis of a disease or medical condition is outside the IBCLC scope unless the practitioner has separate professional authority to do so. An IBCLC can, however, assess feeding function, observe how an infant is using their mouth and tongue during feeding, document relevant findings and identify when further assessment may be appropriate. This is particularly important with tongue-tie because the presence of a frenulum is an anatomical finding; it does not, by itself, establish that feeding is impaired or explain the whole clinical picture. Anatomy provides information. Function provides context. Tongue-tie-related feeding concerns can be multifactorial, involving oral function, feeding mechanics, infant regulation, maternal factors, positioning, milk transfer and other aspects of the feeding relationship. This is one reason specialist lactation knowledge can be particularly valuable when assessing a feeding concern in which tongue-tie may be part of the picture. It also demonstrates why a multidisciplinary approach can be more appropriate than expecting one professional to assess every aspect of an infant's health and development. An IBCLC may therefore identify a concern, undertake the aspects of assessment that fall within their scope, explain what they have observed and refer or recommend further assessment where appropriate. The IBCLC credential itself does not authorise frenulotomy. Where an IBCLC also performs tongue-tie division, that must arise from separate professional registration, training and legal authority applicable to the practitioner and jurisdiction. Why multidisciplinary care matters Good infant-feeding care does not depend on one professional having all the answers. An IBCLC may work alongside a GP, paediatrician, midwife, health visitor, speech and language therapist, dietitian, pharmacist, physiotherapist, occupational therapist, dentist or another appropriately qualified professional, depending on the needs of the infant and family. Each professional brings a different area of expertise. The IBCLC contributes specialist knowledge of lactation and infant feeding. A medical professional contributes medical assessment and management. A speech and language therapist may contribute expertise in communication and swallowing. A dietitian may contribute nutritional assessment. Other professionals may assess musculoskeletal, developmental, oral-health or other factors. The purpose is not to pass responsibility from one professional to another. It is to bring together the appropriate expertise while keeping the infant and feeding dyad at the centre of care. How do you choose an IBCLC? If you are considering an IBCLC, it is reasonable to look beyond the letters after someone's name. First, check that their IBCLC credential is current. Current IBCLCs can be verified through the international IBCLC professional register. In the UK, the Lactation Consultants of Great Britain (LCGB) also provides a directory of IBCLCs who are current LCGB members. LCGB is the professional association for IBCLCs in Great Britain and provides education and professional support for its members. It can also be helpful to consider: the practitioner's professional background and additional qualifications their experience with the type of feeding issue you are experiencing whether they regularly work with infants of your baby's age and needs whether they offer the type of feeding support you are looking for recommendations from other families independent reviews and feedback about their service whether they work collaboratively with other healthcare professionals when this is appropriate Reviews and recommendations can provide useful insight into a practitioner's communication, accessibility and families' experiences, but they should not replace checking the person's actual professional credentials and experience. LCGB's “Who's Who in Breastfeeding Support and Lactation in the UK” is also a useful resource for understanding the differences between IBCLCs, breastfeeding counsellors, peer supporters and other forms of breastfeeding support. The important thing to remember An IBCLC is a specialist in lactation and infant feeding who has met defined education, clinical-experience and examination requirements to obtain an internationally recognised board-certified credential. Their expertise can extend from before birth through the entire feeding journey — whether that journey involves breastfeeding, chestfeeding, expressing, bottle feeding, formula feeding, combination feeding, relactation, changing feeding methods or weaning. They do not replace other healthcare professionals, nor should they be expected to. Instead, an IBCLC can provide specialist assessment and support within their scope while working alongside other professionals when additional expertise is needed. For families, understanding what the IBCLC credential actually represents makes it easier to distinguish between different types of feeding support and to choose a practitioner whose qualifications, experience and approach are appropriate for their individual needs. References IBCLC Commission (2026) Step 1: Prepare for IBCLC Certification. Available from: https://ibclc-commission.org/step-1-prepare-for-ibclc-certification/ IBCLC Commission (2026) Certification FAQs. Available from: https://ibclc-commission.org/certification-faqs/ IBCLC Commission (2026) Lactation Specific Clinical Experience. Available from: https://ibclc-commission.org/step-1-prepare-for-ibclc-certification/lactation-specific-clinical-experience/ IBCLC Commission (2026) Scope of Practice for International Board Certified Lactation Consultant (IBCLC) Certificants. Available from: https://ibclc-commission.org/ibclc-information/ International Board of Lactation Consultant Examiners (2017, updated 2023) Advisory Opinion: Assessment, Diagnosis, and Referral. Available from: https://ibclc-commission.org/wp-content/uploads/2023/05/2017advisory-opinion-assessment-diagnosis-referralFINAL.pdf International Board of Lactation Consultant Examiners (2018) Advisory Opinion on Frenulotomy. Available from: https://ibclc-commission.org/ibclc-information/ Lactation Consultants of Great Britain (2025) Who's Who in Breastfeeding Support and Lactation in the UK. Available from: https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/ Lactation Consultants of Great Britain (2026) Find an IBCLC. Available from: https://lcgb.org/find-an-ibclc/

Choosing a breast pump flange is not simply about finding a size that feels comfortable. The right fit should support comfortable milk expression, effective milk removal and a good milk yield, while also working with the individual breast, nipple, pump and the circumstances in which expressing takes place. Flange fitting has also changed in recent years. Traditional advice has often been based on measuring the nipple at its base and then adding a specified number of millimetres to determine the flange size. More recent guidance and research have moved towards measuring the nipple tip and using that measurement as a starting point for assessing fit during pumping. The Flange FITS™ Guide is one example of this approach. There is a guide for parents and separate professional guidance, and the approach focuses on assessing the flange during pumping rather than relying on measurement alone. A flange fit assessment should therefore ask a much broader question than: > “What size flange do I need?” It should ask: > “What flange, pump settings and expressing approach allow this individual to express comfortably and effectively?” What is a flange fit assessment? A flange, also called a breast shield, is the part of a breast pump that sits against the breast and surrounds the nipple. During pumping, the nipple is drawn into the flange tunnel. Although flange fitting is often discussed in terms of millimetres, diameter is only one part of the assessment. A comprehensive assessment considers: nipple size and shape how the nipple moves within the tunnel during pumping whether the nipple can glide comfortably within the tunnel how much surrounding breast tissue is drawn into the tunnel changes in nipple colour, shape or swelling breast and nipple comfort the flange's shape and material pump suction and cycle settings milk flow and milk yield expressing frequency and duration the pump being used whether the two breasts respond differently previous experiences with pumping and the person's individual goals for expressing. Where appropriate and with consent, observing part of a pumping session can provide information that cannot be obtained from measurement alone. The aim is not to identify one universally “correct” flange size. It is to find an arrangement that works for that individual. Start with the history, not the measurement Before measuring a nipple, it is important to understand why the person is expressing. For some, pumping may be occasional and practical. For others, expressing may be central to maintaining their milk production because their baby is not currently transferring milk effectively at the breast. Others may be exclusively expressing, combination feeding, returning to work, expressing during separation from their baby, or expressing for another individual reason. These different circumstances mean that the goals of expressing can be very different. A useful assessment therefore explores: What are you hoping to achieve through expressing? How often are you currently pumping? How long does each session take? What pump are you using? Which flange or flanges are you currently using? What pump settings are you using? How much milk are you typically expressing? Does milk flow easily? Does milk flow change during the session? Do you experience discomfort or nipple changes? Have you already tried different flange sizes or designs? Does one breast respond differently from the other? Has anything changed recently? This history matters because a flange cannot be assessed in isolation from the person using it. Someone who is expressing once a day has different requirements from someone expressing eight times a day. Someone trying to maintain milk production while their baby temporarily feeds elsewhere has different priorities from someone expressing occasionally after a breastfeed. Individual goals should therefore form part of the flange assessment. Nipple measurement is a starting point — not a prescription Nipple measurements can be useful, but they are not fixed measurements. Nipple diameter can change throughout the day and can be influenced by factors including temperature, stimulation, lactation stage and what has happened immediately beforehand. Nipple tissue can also change during and after pumping. The left and right nipples may not be the same size either. It is therefore important to assess each side individually rather than assuming that one flange size will necessarily work for both breasts. Current approaches to flange fitting have also moved away from automatically adding a predetermined number of millimetres to a nipple measurement. The Flange FITS™ Guide recommends measuring the nipple tip, with the nipple gently stimulated or tugged so that it is everted, and using that measurement as a starting point. It then recommends trying nearby flange sizes during pumping to identify which provides the best combination of comfort and milk flow. https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Services/Maternity/The-Flange-FITS-Guide-for-optimal-comfort-efficiency-and-milk-yield.pdf This is an important change from older approaches that commonly measured the nipple at its base and added a fixed number of millimetres. A recent comparative pilot study found that smaller-fit flanges selected using the Flange FITS™ approach resulted in greater comfort and, on average, greater milk output than the standard sizing approach used in the study. Importantly, the researchers concluded that flange fitting should be individualised and may require trialling more than one size. https://pubmed.ncbi.nlm.nih.gov/39614713/ This does not mean that everyone should automatically use a smaller flange. It means that measurement should be used as a starting point for assessment rather than as a rigid prescription. What should happen inside the tunnel? During pumping, the nipple should be positioned centrally and should be able to glide comfortably within the tunnel. The sides of the nipple may gently contact the tunnel walls, but the nipple should not be tightly compressed or repeatedly rubbing against the tunnel. Signs that the fit may need reassessment can include: rubbing or friction blanching or marked colour change swelling during pumping nipple trauma discomfort or pain restricted nipple movement excessive areolar tissue being drawn into the tunnel reduced or interrupted milk flow. The Flange FITS™ Guide describes an optimal fit as one where the nipple gently glides within the tunnel, pumping is comfortable and milk comes out easily. https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Services/Maternity/The-Flange-FITS-Guide-for-optimal-comfort-efficiency-and-milk-yield.pdf This is why simply looking at a measurement chart cannot replace observing what happens during pumping. Flange shape matters too Flanges are not simply different sizes of the same shape. Different manufacturers produce breast shields with different tunnel lengths, angles, contours and materials. Some have a more traditional rigid design, while others use softer silicone or different breast-shield shapes. Maymom, for example, now offers several breast-shield designs with different shapes and dimensions, illustrating why two flanges with the same stated tunnel diameter may not feel or perform in the same way. https://www.maymom.com/index.php/products-menu/breastshield-selection-guide This is particularly relevant when a person has tried several sizes but still does not feel that their flange is working well. A flange fitting service should therefore involve trying different flange sizes and, where appropriate, different flange shapes and designs, rather than simply measuring and recommending one size. The material can also make a difference. Some silicone flanges and in-bra pump inserts may benefit from a small amount of suitable lubrication to reduce friction. The Flange FITS™ Guide specifically notes that a thin layer of coconut oil or nipple balm can increase comfort, and some silicone-flange manufacturers provide specific guidance on lubrication. https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Services/Maternity/The-Flange-FITS-Guide-for-optimal-comfort-efficiency-and-milk-yield.pdf Any product used should be compatible with the equipment and appropriate for use around the nipple and breast, and manufacturer instructions should be followed. Pump settings matter Finding the right flange does not necessarily solve every pumping problem. Pump settings also influence the experience and effectiveness of expressing. Many pumps have a stimulation or let-down mode followed by an expression mode. However, relying on the pump's automatic programme for the entire session does not necessarily provide the best response for every individual. It can be useful to move between stimulation and expression modes during a session, depending on what is happening with milk flow. For example, if milk flow slows after an initial let-down, returning temporarily to a faster stimulation pattern may help stimulate another milk ejection before returning to a slower expression pattern. The aim is not simply to use the highest suction or follow a predetermined programme from beginning to end. Pump settings can be adjusted according to comfort, milk flow and the individual's response. Research has demonstrated that vacuum level influences milk flow and yield, with maximum comfortable vacuum producing greater milk removal than softer settings in one study. This supports the principle of finding an effective level that remains comfortable rather than simply choosing the strongest possible suction. https://pubmed.ncbi.nlm.nih.gov/18333764/ Pumping is not the same as breastfeeding at the breast The volume obtained during a pumping session should not be interpreted as though it were a direct measurement of how much milk the breast can produce for a baby feeding at the breast. Breastfeeding involves a complex physiological and hormonal process, including infant suckling, sensory stimulation and neuroendocrine responses that contribute to milk ejection. A pump provides a mechanical stimulus, and its effectiveness depends on the pump, flange, settings, timing, breast fullness, milk ejection response and the individual's response to the equipment. Consequently, the amount expressed by a pump does not necessarily represent the amount of milk that would be available to, or removed by, a baby feeding directly at the breast. This distinction is particularly important when supporting someone who is worried that a low pumping volume automatically means they have low milk production. Pump output needs to be interpreted in context. Comfort matters — but yield and milk removal matter too Comfort is an important part of flange fitting, but it should not be the only outcome considered. A person may experience comfortable pumping but obtain very little milk. Another may obtain a reasonable volume but develop swelling or nipple trauma. Someone else may find that one breast responds well to a particular flange while the other requires a different size or shape. A useful assessment therefore considers: Is it comfortable? Is the nipple moving appropriately? Is the breast shield working with the person's anatomy? Is milk flowing effectively? Is milk being removed efficiently? Is the set-up sustainable for the person's expressing goals? This is the value of a proper flange fit assessment: it considers the whole expressing experience rather than treating flange size as an isolated measurement. Why professional assessment can be valuable There is a growing amount of information online about flange sizing, but self-measurement and self-selection cannot always identify why pumping is difficult. An IBCLC has advanced education and clinical experience in lactation and breastfeeding care. The IBCLC credential requires substantial lactation-specific education and clinical practice in addition to passing an international examination, and IBCLCs work within defined professional competencies and scope of practice. https://iblce.org/about-iblce/ For flange fitting specifically, it is also worth asking whether the professional has undertaken advanced education in breast pump and flange fitting and has practical experience observing pumping sessions and working with different pumps, flange sizes, shapes and materials. This is important because flange fitting is not simply something that can be learned from a manufacturer's size chart or through occasional self-study. A skilled clinician should be able to consider the flange alongside the wider lactation picture and recognise when a pumping difficulty may require further assessment or referral. When flange fit may not be the whole explanation Changing the flange can be helpful, but not every pumping problem is caused by flange size. Persistent nipple pain can have a range of possible causes, including trauma, dermatitis, infection, vasospasm and pumping-related mechanical problems. A careful assessment is preferable to repeatedly changing flange sizes without considering the wider picture. Similarly, a low expressed volume does not automatically mean low milk production. Pump output can be influenced by: timing of the pumping session breast fullness milk ejection frequency of milk removal pump effectiveness flange fit pump settings stress and comfort individual response to the pump and the reason the person is expressing. If breastfeeding is also part of the feeding plan, it may be important to consider breast and nipple comfort, infant positioning and attachment, milk transfer and infant feeding function. Anatomy provides information. Function provides context. What happens during a flange fitting service? A flange fitting service should be more than measuring a nipple and recommending a size. The assessment may involve: 1. Taking a detailed history and establishing the person's expressing goals. 2. Assessing each nipple individually. 3. Measuring the everted nipple tip as a starting point. 4. Observing pumping where appropriate and with consent. 5. Trialling different flange sizes. 6. Trying different flange shapes and designs where indicated. 7. Reviewing suction and cycle settings. 8. Considering stimulation and expression modes and how the person responds to them. 9. Assessing comfort, nipple movement, breast tissue movement and milk flow. 10. Agreeing a practical plan that the person can realistically use at home. 11. Reviewing the response and making further adjustments where necessary. The outcome may be a different flange size, a different shape or material, a different pump setting, a change in pumping technique — or a combination of these. Sometimes the assessment may also identify that the flange is not the main problem. When to seek further support Please seek prompt medical advice for fever or flu-like symptoms, a hot or increasingly painful area of the breast, rapidly worsening redness, pus, significant bleeding or severe pain. Further lactation support may also be appropriate when pumping remains uncomfortable, nipples are repeatedly damaged, milk expression changes unexpectedly, or there are concerns about an infant's feeding, hydration, growth or wellbeing. Flange fitting is most useful when it forms part of skilled, individualised lactation care rather than being treated as a quick equipment fix. There is no single flange size that is right for everyone. Measure as a starting point. Observe what happens during pumping. Consider the shape and material of the flange. Listen to the person's goals and experience. Then assess comfort and effective milk removal together. That is the difference between simply choosing a flange size and actually assessing flange fit. References Academy of Breastfeeding Medicine (2016) ‘ABM Clinical Protocol #26: Persistent pain with breastfeeding’, Breastfeeding Medicine, 11(2), pp. 46–53. Anders, L.A., Mesite Frem, J. and McCoy, T.P. (2025) ‘Flange Size Matters: A Comparative Pilot Study of the Flange FITS™ Guide Versus Traditional Sizing Methods’, Journal of Human Lactation, 41(1), pp. 54–64. doi:10.1177/08903344241296036. Kent, J.C., Prime, D.K. and Garbin, C.P. (2012) ‘Principles for maintaining or increasing breast milk production’, Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(1), pp. 114–121. Mesite Frem, J. (2023) The Flange FITS™ Guide for Optimal Comfort, Efficiency and Milk Yield. Babies in Common. Mitoulas, L.R., Lai, C.T., Gurrin, L.C., Larsson, M. and Hartmann, P.E. (2002) ‘Efficacy of breast milk expression using an electric breast pump’, Journal of Human Lactation, 18(4), pp. 344–350. Prime, D.K., Geddes, D.T., Spatz, D.L., Robert, M. and Hartmann, P.E. (2011) ‘Using milk flow rate to assess milk ejection and breast milk removal during pumping’, Journal of Human Lactation, 27(2), pp. 159–166. Prime, D.K., Garbin, C.P., Hartmann, P.E. and Kent, J.C. (2012) ‘Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression’, Breastfeeding Medicine, 7(6), pp. 442–447. Witt, A.M., Bolman, M., Kredit, S. and Vanic, A. (2016) ‘A systematic review of the effects of breast milk expression methods on milk volume and milk composition’, Journal of Human Lactation, 32(3), pp. 495–504. World Health Organization (2009) Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization. ```

A search for tongue-tie England UK CQC requirement often comes from a sensible question: if an independent service assesses an infant and may offer tongue-tie division, what regulation and professional oversight should families expect? In England, there is a specific answer. Frenulotomy (tongue-tie division) is classed by the Care Quality Commission (CQC) as the regulated activity of Surgical procedures. CQC confirmed this specifically in its guidance to tongue-tie providers. It states that frenulotomy, when carried out by or under the supervision of a healthcare professional, falls within the regulated activity Surgical procedures. CQC also clarified that frenulotomy is not covered by the regulated activity of maternity and midwifery services simply because the procedure is undertaken by a midwife. [1] Where a provider is carrying on this regulated activity in England, CQC registration is a legal requirement, unless a specific legal exemption applies. CQC states that registration is a statutory obligation and that carrying on a regulated activity without the required registration is an offence. [1] CQC registration is therefore not simply an optional quality mark that a tongue-tie provider may choose to obtain. It forms part of the legal regulatory framework for providing the procedure. Why is frenulotomy a regulated activity? The CQC classification relates to what is actually being done. Frenulotomy involves surgically cutting the lingual frenulum using an instrument. CQC therefore classifies the procedure as 'Surgical procedures'. [1] The fact that a frenulotomy may be a relatively quick procedure does not remove it from the regulatory framework. It is also important to distinguish the regulated surgical procedure from other services that a tongue-tie provider may offer. For example, infant feeding support, lactation support or professional education may not themselves be regulated activities under CQC. A provider can therefore offer several different services while only some of those services fall within CQC regulation. Does every tongue-tie practitioner need their own CQC registration? Not necessarily. The important question is "who is carrying on the regulated activity and who is responsible for the service?". Some tongue-tie practitioners operate their own independent service and therefore have their own CQC registration. Others may be employed by, or contracted to, a CQC-registered provider. In those circumstances, the regulated activity may be carried out under the registration of the organisation responsible for the service rather than through a separate CQC registration held by the individual practitioner. There are also arrangements involving 'practising privileges', where a practitioner provides care within another organisation under that organisation's governance and regulatory arrangements. The precise legal position depends on the individual arrangement and who is legally carrying on the regulated activity. This means that asking simply whether an individual practitioner is "CQC registered" may not give the complete picture. For families, the more useful question is: Who is the CQC-registered provider responsible for the regulated activity being delivered to my baby? A transparent provider should be able to explain this clearly. CQC registration is not the same as professional registration There are several different layers of accountability, and it is important not to confuse them. Professional regulation applies to the individual practitioner. For example, a nurse is regulated by the Nursing and Midwifery Council (NMC), a doctor by the General Medical Council (GMC), and a dentist by the General Dental Council (GDC). CQC regulation applies to the provider and the regulated activity being carried on. Professional registration does not replace CQC registration where the provider is legally required to register. The Association of Tongue-tie Practitioners (ATP) has its own membership requirements, which are separate again. ATP Full Membership is specifically for current tongue-tie practitioners who provide surgical release. The current Full Membership criteria require the practitioner to be a registered health professional with the Nursing and Midwifery Council (NMC), General Medical Council (GMC) or General Dental Council (GDC) and to be registered with CQC or the equivalent regulator where applicable. Full Membership is available to both independent and NHS release providers. [2] Therefore, for ATP Full Membership, the three professional regulators currently specified for providers are: Nursing and Midwifery Council (NMC) General Medical Council (GMC) General Dental Council (GDC) These ATP membership requirements should not be confused with the wider list of professional regulators recognised within CQC legislation. CQC registration and ATP membership are separate regulatory and professional-association frameworks. ATP membership is optional and is not required in order to provide tongue-tie services. However, practitioners who choose to apply for ATP Full Membership must meet the organisation's specified requirements, including professional registration and CQC or equivalent registration where applicable. Registration is not the end of CQC oversight It can sometimes be assumed that once a provider has obtained CQC registration, the regulator has effectively approved the service and there is no further scrutiny. That is not how CQC regulation works. CQC can assess registered services after registration. Assessments may be planned or undertaken in response to information, concerns, risk or other regulatory intelligence. The purpose is to establish whether the service is meeting the relevant regulatory requirements and providing safe, effective and person-centred care. CQC therefore looks for evidence to support the care and treatment people actually receive, rather than simply checking whether a provider has written policies. For a tongue-tie service, this may include reviewing clinical records, observing assessments and procedures, speaking with caregivers, reviewing policies and governance systems, considering staff competence and training, and examining evidence of outcomes, incidents, complaints and learning. Registration is therefore not a one-off approval that means a service will never be reviewed again. What does CQC look for? CQC's assessment framework is structured around five key questions: Safe Effective Caring Responsive Well-led These areas need to be evidenced through the provider's practice. CQC gathers evidence from a range of sources, including people's experiences, feedback from staff and leaders, feedback from partners, observation, processes and outcomes. [3][4] Safe CQC considers whether people are protected from avoidable harm and whether there are safe systems for delivering care. This can include infection prevention and control, safeguarding, risk management, safe staffing, clinical records, incident reporting and learning from safety events. [5] Effective CQC considers whether care and treatment are effective and based on people's assessed needs, relevant evidence and good practice. Evidence can include assessment processes, clinical records, care and treatment planning, consent, monitoring of outcomes and quality improvement activity. [6] For a tongue-tie service, this means there should be evidence supporting the assessment and care and treatment provided, rather than decisions being based solely on the appearance of a frenulum. Caring CQC considers whether people are treated with kindness, compassion, dignity and respect and whether their choices are taken into account. [7] For an infant service, this includes the experience of the infant and the caregivers involved in their care. Responsive CQC considers whether services respond appropriately to people's needs and whether care is accessible, personalised and responsive. Well-led CQC considers whether leadership, management and governance support the delivery of high-quality care, learning and improvement. This includes systems for managing risk, maintaining accountability, monitoring performance and learning from information and experience. [8] These five areas are not simply headings on a CQC report. A provider needs to be able to evidence the quality of its service against the relevant assessment framework. What does a CQC rating mean? Where CQC rates a service, the rating reflects its assessment of the evidence available about the quality of that service. The four ratings are: Outstanding Good Requires improvement Inadequate A rating therefore represents more than the fact that a provider has successfully registered. It provides information about what CQC found when it assessed the service. For example, D-Restricted Ltd has an overall CQC rating of Outstanding. Its latest CQC assessment rated the service Outstanding overall, with the surgical service rated Outstanding overall. The individual key questions were rated Safe – Good, Effective – Good, Caring – Outstanding, Responsive – Outstanding and Well-led – Outstanding. [9] This rating followed CQC assessment activity that included evidence gathered from the service and its delivery of care. An Outstanding rating therefore represents the regulator's assessment of the evidence gathered about the service. It is considerably more than simply having obtained CQC registration. CQC ratings must be displayed Once a provider has received a CQC performance rating, there is a legal requirement to display that rating. Under Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, providers that have received a CQC performance assessment must display their current rating conspicuously and legibly at the relevant premises and on their website if they have one. [10] CQC provides a 'ratings widget' for providers to display on their websites. CQC recommends using the widget because it displays the information required by the regulation, links to the relevant CQC profile and automatically updates if the rating or inspection result changes. [11] The widget is therefore more than a promotional graphic. It provides a direct link between the provider's website and the regulator's current information. CQC states that ratings must be displayed on websites within 21 calendar days after publication. [12] This is not simply a marketing choice. Once a provider has received a CQC rating, displaying that rating is a legal requirement. A provider that has not yet received a rating may still be legitimately registered. The absence of a rating therefore does not automatically mean that a provider is unregistered. What about regulation elsewhere in the UK? CQC regulates England only. Scotland, Northern Ireland and Wales have different regulatory arrangements, and the English CQC requirements should not automatically be applied to services operating elsewhere in the UK. Scotland Independent healthcare in Scotland is regulated through Healthcare Improvement Scotland (HIS). The scope of registration in Scotland differs from the CQC framework in England. Providers should therefore establish whether their particular service falls within the applicable Scottish registration requirements rather than assuming that the English model applies. [13] Northern Ireland In Northern Ireland, the Regulation and Quality Improvement Authority (RQIA) registers and regulates specified independent healthcare services, including independent clinics, independent hospitals and independent medical agencies. [14] Again, the regulatory framework is separate from CQC and providers should consider the requirements that apply to their particular service. Wales Wales has its own healthcare regulator, Healthcare Inspectorate Wales (HIW). However, tongue-tie providers do not fall within the scope of HIW registration. HIW's registration framework applies to specified independent healthcare services, but tongue-tie providers do not fall within the scope of registration simply because they provide tongue-tie assessment and division. [15] This is an important distinction when comparing the UK nations. A tongue-tie provider in Wales does not require HIW registration simply because they provide tongue-tie assessment and division. What should families look for? Families do not need to become regulatory experts before arranging tongue-tie care. However, it is reasonable to ask: Who is providing the assessment and procedure? Which professional regulator is the practitioner registered with? Who is legally responsible for the service? If the service is in England, is the provider registered with CQC for Surgical procedures? If the provider has received a CQC rating, is the current rating displayed on its website? Can the provider explain who is responsible for follow-up and complaints? Can the provider explain which regulatory framework applies if the service is outside England? A transparent provider should be able to answer these questions clearly. Regulation is one part of choosing a service Regulation should not be confused with a clinical recommendation. CQC registration means that a provider is legally registered to carry on the relevant regulated activity. Ongoing CQC assessment considers evidence about the quality and safety of the service. Professional registration provides accountability for the individual practitioner's professional practice. ATP membership provides an additional professional-association framework. These are different things. For families, the most useful approach is to look at the whole picture: who is providing the care, who regulates the practitioner, who regulates the service, what evidence supports the care provided and what independent regulatory information is available. Anatomy provides information. Function provides context. Why regulation matters Tongue-tie division may be a brief procedure, but in England it is a regulated surgical activity. CQC has specifically confirmed that frenulotomy is the regulated activity Surgical procedures, and that registration is a statutory obligation for providers carrying on that activity. [1] Regulation therefore provides an important layer of accountability around the service delivering the procedure. For families, the question is not simply whether someone offers tongue-tie division, but: Who is accountable for the service, which regulator oversees it, and what evidence demonstrates the quality of the care being provided? That distinction matters. D-Restricted Ltd operates a CQC-registered tongue-tie clinical service and currently has an overall CQC rating of Outstanding. [9] References 1. Care Quality Commission (2022) Briefing for providers: Registration requirements for tongue-tie procedures. Newcastle upon Tyne: Care Quality Commission. 2. Association of Tongue-tie Practitioners (ATP) (2026) Membership Application – Full Membership. Available from: https://www.tongue-tie.org.uk/membership-application 3. Care Quality Commission (2025) Assessment framework. Newcastle upon Tyne: Care Quality Commission. 4. Care Quality Commission (2025) Evidence categories. Newcastle upon Tyne: Care Quality Commission. 5. Care Quality Commission (2025) Single assessment framework: Safe. Newcastle upon Tyne: Care Quality Commission. 6. Care Quality Commission (2025) Single assessment framework: Effective. Newcastle upon Tyne: Care Quality Commission. 7. Care Quality Commission (2025) Single assessment framework: Caring. Newcastle upon Tyne: Care Quality Commission. 8. Care Quality Commission (2025) Single assessment framework: Well-led. Newcastle upon Tyne: Care Quality Commission. 9. Care Quality Commission (2026) D-Restricted Ltd – Inspection summary. Newcastle upon Tyne: Care Quality Commission. Published 3 June 2026. 10. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20A: Requirement as to display of performance assessments. SI 2014/2936. 11. Care Quality Commission (2025) How to use the CQC widget and posters. Newcastle upon Tyne: Care Quality Commission. 12. Care Quality Commission (2025) How providers must display ratings. Newcastle upon Tyne: Care Quality Commission. 13. Healthcare Improvement Scotland (2026) Independent healthcare and registration guidance. Edinburgh: Healthcare Improvement Scotland. 14. Regulation and Quality Improvement Authority (2026) Registration Guidance. Belfast: RQIA. 15. Healthcare Inspectorate Wales (2026) Registration FAQs and guidance on independent healthcare services. Cardiff: Healthcare Inspectorate Wales. Every family considering tongue-tie care deserves to know not only what a service offers, but who regulates it, who is responsible for the care and what evidence sits behind the quality of that service.

A clicking sound can be surprisingly worrying, particularly when feeding already feels uncomfortable, unsettled or exhausting. Parents often ask, “Why does my baby click when feeding?” The short answer is that clicking usually means the seal between the baby’s mouth and the breast, bottle teat or both is briefly breaking. The sound alone does not tell us why this is happening, or whether it is affecting feeding. Clicking itself is not necessarily a problem. It can be surprisingly loud and irritating to listen to, but the sound does not automatically mean that something is wrong. If your baby is comfortable, feeding effectively and growing appropriately, occasional clicking may simply be something you notice rather than something that needs correcting. It becomes more relevant when it occurs alongside other feeding difficulties. There are several possible reasons for clicking, and more than one factor may be involved. The most helpful approach is therefore not to diagnose from the sound, but to consider the whole feeding picture. Why does a baby click while feeding? During feeding, a baby needs to coordinate sucking, swallowing and breathing while maintaining an effective oral seal. Clicking can occur when that seal or vacuum is briefly lost and then regained. This can happen at the breast, with a bottle, or during both. The underlying reason may be quite different from one baby to another. Clicking can be associated with: a changing or shallow latch loss of suction or vacuum difficulty maintaining an effective oral seal a fast or changing milk flow positioning or attachment a high palate or other differences in oral anatomy tongue or jaw function fatigue or developmental immaturity nasal congestion feeding coordination the shape, size, flow rate, material or flexibility of a bottle teat There is limited research specifically examining clicking as an isolated symptom. Clinically, it is therefore best understood as an observation rather than a diagnosis. Its significance depends on what accompanies it: your baby’s comfort, feeding efficiency, milk intake, weight pattern, your comfort and the practical details of how feeds are going. Position, attachment and changing milk flow At the breast, a shallow or changing latch can make it harder for a baby to maintain a stable seal. You can read more about this in the D-Restricted Ltd guide to how to improve infant latch. Babies may change their position as they become sleepy, as the breast softens during a feed, or when milk flow changes. A faster flow can lead some babies to pull back, cough, splutter or briefly lose their seal. A slower flow may lead to more active sucking and repeated adjustments. This is not about achieving one “perfect” position. Families feed in many different ways, and what is comfortable and effective for one caregiver and baby may not suit another. Small, responsive adjustments to support and positioning can sometimes reduce clicking, but they will not address every possible cause. Bottle feeding, teat choice and flow Clicking can also occur during bottle feeding. A baby needs to maintain a seal around the teat while coordinating sucking, swallowing and breathing. If that seal is repeatedly lost, a clicking sound may result. The bottle teat itself can sometimes be relevant. Its shape, size, flow rate, material or flexibility may affect how comfortably a particular baby can maintain a seal. There is not necessarily one universally “correct” teat for every baby; suitability depends on the individual baby, their oral skills and how they are managing the feed. The way the bottle is offered can also influence feeding. A flow that is too fast or difficult for a baby to manage may result in gulping, coughing, spluttering, milk leakage or repeated breaks in sucking. A baby who is very hungry, tired or unsettled may also have more difficulty maintaining a consistent seal. The D-Restricted Ltd guide to how to pace bottle feeds explains more about supporting a calm and responsive bottle-feeding experience. It can be useful to notice whether clicking happens from the beginning of every bottle or only later in the feed. Does milk leak from the mouth? Does your baby cough or gulp? Does the teat collapse? Do they appear relaxed between bursts of sucking? These observations are generally more useful than the clicking sound itself. Nasal congestion, tiredness and feeding coordination Babies generally coordinate nasal breathing with sucking and swallowing during feeding. Nasal congestion can therefore make feeding more difficult and may contribute to frequent pauses or loss of seal. Tiredness, overstimulation and developmental immaturity can also affect feeding coordination, particularly in younger or preterm babies. Some babies may click more at particular times of day. A pattern like this may relate to fatigue, changing milk flow or a period when the baby is becoming less organised, rather than indicating a fixed oral problem. Oral anatomy and tongue function Differences in oral anatomy can sometimes contribute to clicking. A high palate, for example, may influence how a baby is able to maintain an effective seal. A restricted lingual frenulum, often called tongue-tie, may also be relevant for some babies. However, a visible frenulum is common and anatomy alone cannot establish whether it is causing a feeding difficulty. Equally, a baby may have feeding difficulties without tongue-tie. A meaningful assessment considers tongue function alongside the feeding relationship and the baby's wider health. It should include a careful history and observation of feeding where possible, rather than relying on clicking, appearance or a score in isolation. This reflects an essential principle in infant feeding care: anatomy provides information; function provides context. The Academy of Breastfeeding Medicine states that a decision about frenotomy should follow a skilled clinical breastfeeding assessment and shared decision-making, rather than being based solely on the presence of a frenulum (LeFort et al., 2021). Evidence from systematic reviews suggests that frenotomy may reduce maternal nipple pain in some breastfeeding dyads, but evidence for consistent improvement in infant breastfeeding and longer-term breastfeeding outcomes remains limited (Francis, Krishnaswami and McPheeters, 2015; O’Shea et al., 2017). This means that clicking alone cannot tell us whether a baby has a functionally significant tongue-tie or whether frenotomy would be beneficial. When clicking may need further assessment Clicking does not automatically mean that something is wrong. If your baby is comfortable, feeding effectively, producing appropriate wet nappies and growing as expected, occasional clicking may not require any intervention. Further assessment may be appropriate when clicking is persistent or occurs alongside other feeding concerns, such as: nipple pain or damaged nipples persistent milk leakage from the mouth frequent coughing, choking or spluttering very frequent or unusually prolonged feeds repeatedly coming off the breast or bottle difficulty maintaining a seal frustration or distress during feeds concerns about milk transfer concerns about weight gain or feeding effectiveness These signs do not automatically point to one particular cause. Pain, for example, may relate to attachment, breast fullness, skin conditions, infection or other factors. A baby who repeatedly comes off the breast may be responding to milk flow, fatigue, congestion, discomfort or a need for a different feeding approach. Looking at the wider picture helps avoid both missed concerns and oversimplified explanations. If your baby has significantly fewer wet nappies than expected, signs of dehydration, is becoming unusually sleepy or difficult to wake, is not waking for feeds, is struggling to feed, or you are otherwise concerned that your baby is becoming unwell, seek urgent medical advice. If your baby is not waking or is difficult to rouse, seek emergency medical care. What can a feeding assessment clarify? A feeding assessment should feel calm, respectful and practical. It begins with listening. When did the clicking start? Does it happen at the breast, bottle or both? How are feeds affecting the baby and caregiver? Has anything changed? What has already been tried? A practitioner may also consider birth history, gestation, health, growth and the family's feeding goals. Observing a feed can add valuable context. Depending on the type of feeding, a practitioner may look at the baby's cues, body support, latch or teat placement, audible swallowing, milk loss, pauses, parental comfort and how feeding changes over the course of the feed. If oral function appears relevant, it can be considered as one part of this broader assessment. For some families, simple changes to positioning, attachment, bottle feeding technique or teat choice may be enough. Others may benefit from a period of review or input from another healthcare professional. Who can help with clicking? If clicking is persistent or you are concerned about how your baby is feeding, discussing your concerns with your midwife or health visitor can be a useful starting point. They can listen to your concerns and help identify whether further assessment or specialist support may be appropriate. An IBCLC (International Board Certified Lactation Consultant) is a specialist in infant feeding and can support families with breastfeeding, bottle feeding, expressed milk and combination feeding. IBLCE provides the international register of currently certified IBCLCs, which can be used to verify an individual's current certification. In the UK, the Lactation Consultants of Great Britain (LCGB) also provides a directory of IBCLCs. It is worth understanding who you are asking for infant feeding support. There are different roles and qualifications within infant feeding, with different levels of education, training, scope and professional accountability. LCGB provides a Who’s Who in Breastfeeding Support and Lactation in the UK resource to help families understand these differences. A peer supporter, for example, may have undertaken a short programme of peer-support training, whereas an IBCLC has completed specialist education, clinical experience and an international examination-based certification process. These roles can both have value, but they are not equivalent qualifications. When choosing someone to support you, it is therefore reasonable to ask about their qualification, training, professional registration or certification, experience and scope of practice. Helpful observations to bring to an appointment You do not need to fix clicking before seeking help. A few notes can make an assessment more productive: Does clicking happen at every feed or only occasionally? Does it happen at the breast, bottle or both? Does it begin at a particular point during the feed? Does it change depending on the time of day? Is milk leaking from your baby's mouth? Does your baby cough, gulp or splutter? Does the clicking increase when your baby becomes tired? Is feeding comfortable for you? Does your baby appear comfortable and settled? Are feeds effective and is your baby growing as expected? If you are concerned about growth, share the dates and weights recorded by your healthcare team rather than trying to interpret a single measurement alone. A short video of a typical feed may sometimes help a clinician understand what you are seeing, provided it does not replace an in-person assessment when one is needed. Most importantly, your experience matters. Feeding does not need to be painful or persistently stressful for you to deserve support. Clicking is a clue, not a verdict Clicking can be surprisingly loud, and it can certainly become frustrating when you hear it throughout a feed. But the sound itself is not necessarily a sign that something is wrong. A baby may click because they are temporarily losing suction, adjusting to milk flow, struggling to maintain a seal, becoming tired, dealing with nasal congestion, adapting to a bottle teat or because of differences in oral anatomy or function. Sometimes more than one factor is involved. The important question is not simply “Why is my baby clicking?” but “What else is happening during feeding?” Whether your baby is breastfeeding, bottle feeding, combination feeding or receiving expressed milk, the aim is the same: safe, effective feeding that protects comfort, growth and the family's confidence. Clicking is a useful clue, not a verdict. Looking at the whole feeding picture can help turn an unsettling sound into a clearer, kinder plan. References Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’, Breastfeeding Medicine, 16(4), pp. 278–281. Francis, D.O., Krishnaswami, S. and McPheeters, M. (2015) ‘Treatment of ankyloglossia and breastfeeding outcomes: a systematic review’, Pediatrics, 135(6), pp. e1458–e1466. International Board of Lactation Consultant Examiners (IBLCE) (n.d.) ‘Public IBCLC Registry’. Available at: https://iblce.org/ (Accessed: 9 September 2026). Lactation Consultants of Great Britain (LCGB) (n.d.) ‘Who’s Who in Breastfeeding Support and Lactation in the UK’. Available at: https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/ (Accessed: 9 September 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.